Elbow Conditions
Tennis Elbow
Tennis elbow is inflammation of the muscles and tendons on the outer part of the elbow. There is usually a bony prominence where the tendons attach. If one were to look at the muscles of the forearm they coalesce into a series of tendons which come to insert over the outer bony prominence of the elbow in an area which is no bigger than a 50p coin. Thus there is a very great amount of force over a small area which results in tearing and inflammation ie tennis elbow. The majority of tennis elbow sufferers do not play tennis.
Tennis Elbow
Features on history
Typical history consists of pain on shaking hands, wringing a cloth, opening jar tops, straightening the elbow first thing in the morning and squeezing toothpaste tubes. These bring about pain.
Features on Examination
Physical signs consist of tenderness over the outer end of the elbow which is made worse by resisted movements of the tendons at the wrist and the knuckles on the back of the hand.
Investigations
Investigations can consist of x-rays and ultrasound/MRI.
Treatment
The vast majority of cases of tennis elbow are treated conservatively with modification of activities of daily living, mobilisations with physiotherapy, splintage, heat and ultrasound. In cases that do not respond injections are considered at the common extensor origin. If after 2 to 3 injections and in association with the above measures no progress is forthcoming surgery can be considered but it is always a last resort rather than a first port of call.
Nuggets of Wisdom
ELBOW AND WRIST ARTHROSCOPIES:
These play an important role in the management of these two joints. Debridement and removal of loose bodies from the elbow lend themselves very well to arthroscopy.
Similarly, interventional wrist arthroscopy is becoming mainstream and commonplace. Typical conditions for which wrist arthroscopy is deployed are debridement/repair of triangulofibrocartilage, styloidectomy, arthroscopic excision of dorsal and volar ganglia are some examples of interventional wrist arthroscopy.
Recovery
We always like to try simple things first such as injections, splinting modification of lifestyle and physiotherapy. Surgery is a last resort. Like any intervention it carries small risks which include wound infection, reflex sympathetic dystrophy (pain and stiffness in the wrist), recurrence rate, tenderness in the scar. It can take up to 6-9 months for the ultimate plateau of recovery to come through.
The procedure involves an incision on the outer side of the elbow by the common extensor origin. The common extensor tendon is dissected, lifted on and lengthened. Any debris is removed as well. The wound is closed and the elbow is splinted.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
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Golfer’s Elbow
Golfer’s elbow is inflammation in the muscles and tendons which take origin from the bony prominence on the inner aspect of the elbow. This area is referred to as the funny bone. The cause of golfer’s elbow is often repetitive movements as occurs in exercise, sustained physical work or repetitive tasks. These symptoms can be associated with stiffness. Despite the name of the condition the majority of suffers do not play golf.
Features on history
Features consist of pain on the inside of the elbow and the forearm accentuated by resisted and sustained activities.
Golfer’s Elbow
Features on Examination
There is tenderness over the area and pain on stressing the muscles.
Investigations
These usually consist of x-rays and an ultrasound/MRI scan. It is often important to distinguish between Golfer’s Elbow and an ulnar neuritis which is pressure on the nerve behind the bony prominence where the inflammation of golfer’s elbow occurs. This gives numbness and tingling in the little finger. It is not always easy to identify the demarcation line between a Golfer’s Elbow and an ulnar neuritis as the two can co-exist. Thus, nerve conduction tests may be necessary to clarify the diagnosis.
Treatment
The vast majority of cases of golfer’s elbow are treated conservatively with modification of activities of daily living, mobilisations with physiotherapy, splintage, heat and ultrasound. In cases that do not respond injections are considered at the common flexor origin. If after 2 to 3 injections and in association with the above measures no progress is forthcoming surgery can be considered but it is always a last resort rather than a first port of call. Like any intervention it carries small risks which include wound infection, reflex sympathetic dystrophy (pain and stiffness in the wrist), recurrence rate, tenderness in the scar. It can take up to 6-9 months for the ultimate plateau of recovery to come through. The procedure will involve incision on the inside aspect of the elbow. The common flexor mass is identified by the medial epicondyle and that is lifted off and lengthened. Any inflammation in the area is cleared. The wound is closed and the elbow splinted
Recovery
It can take up to 6-9 months for the ultimate plateau of recovery to come through. Post operative physiotherapy is always necessary.
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Full 5 star rating for Mr Yanni, could not fault anything in my procedure at the Sloane Hospital.
Elbow Arthritis/Elbow Locking
Arthritis is a condition which involves the loss of articular cartilage lining a joint. In some cases there is no causative reason for it but in a significant proportion of patients the cause of arthritis can be linked either to a systemic inflammatory arthropathy, repeated attritional exercise, manual work over many years and previous trauma/fractures. Patients complain of loss of range of movement, weakness and pain. It is often associated with stiffness and loss of range of movement. Loose bodies can detach from the articular surfaces which become loose in the joint. These can get jammed between the joint surfaces resulting in elbow locking.
Features on history
Patients complain of loss of range of movement, weakness and pain. It is often associated with stiffness loss of range of movement and locking.
Elbow Arthritis/Elbow Locking
Features on Examination
Examination is to identify any inflammatory fluid within the joint. It also identifies the state of the muscles surrounding the joint and determines the range of movement.
Investigations
Investigations consist of x-rays and scans.
Treatment
Treatment will vary according to severity. Very often patients are troubled by locking features in the history as some bits of bone come off from the arthritic surfaces and get to jam the elbow joint itself. Treatment will consist of rest and physiotherapy although if there are significant problems the next port of call would be to consider the patient for elbow arthroscopy the purpose of which is to debride the elbow and remove any loose bodies which very often give a feel of locking.
Recovery
Elbow arthroscopies have been reported as having a higher complication rate amongst all the arthroscopies which are undertaken in orthopaedic surgery. There are well described & recognised risks in particular to the posterior interosseous nerve anteriorly and also there are definite recognised risks in relation to the nerves and vessels around the elbow. Whereas arthroscopy in all other joints in the body can be described as practically complication free that is not necessarily the case with elbow arthroscopy as evidenced in the literature. Every precaution is taken to avoid this by preoperative marking and careful identification of the anatomical landmarks. The rationale for surgery is removal of loose bodies, debridement of the elbow surfaces and the tissues of rest of the joint. We would hope to improve the symptoms considerably although there may be some irreversible changes as well as pointing out that some of the opacities which appear as loose bodies on X-ray can in fact turn out to be embedded within synovium and are not loose.
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Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123
Ulnar Neuritis/Cubital Tunnel Syndrome
Ulnar neuritis is a condition which affects the nerve behind the inner aspect of the elbow. This is often nominated as the funny bone for children.
This nerve runs from behind the elbow all the way down to the arm and it usually supplies the sensation to the little finger and the part of the ring finger closest to the little finger. It also performs an important role in supplying the motored power to the small muscles of the hand which are involved in fine movements.
This is a relatively common problem in people involved in sustained physical activity, exercise or who by virtue of their jobs cause pressure on the nerve.
In addition to over use it can also be related to posture and at times sleeping position.
Nuggets of Wisdom
ULNAR NEURITIS:
There is anecdotal evidence that there is an increase in the incidence. This is ascribed to the widespread availability of gymnasia and the modern habit of walking around holding a mobile phone to the ear with the elbow hyperflexed. Whereas the thresholds for intervention in carpal tunnel syndrome are low (the results of carpal decompression are very good), the same cannot be applied to ulnar neuritis. Surgery is a last resort. Modification of ADL, splintage and avoidance of precipitating daily activities are the mainstay of treatment.
Features on history
Dependent upon the severity of the compression at the elbow patients report varying symptoms. Thus in mild conditions the symptoms can be confined to numbness/tingling along the side of the hand by the little finger as well as the little finger itself and part of the ring finger. As the compression increases then these changes become more or less permanent with loss of feeling. If the compression progresses from there then it can cause more motor symptoms and these usually involve weakness of the hand, clumsiness and inability to do any sustained fine activity. Patients often notice wasting in the hand with so called guttering which can be observed over the back of the hand and wasting in other muscle parts supplied by the nerve.
Features on Examination
Physical examination consists of testing the nerve and its reactivity behind the elbow by the performance of a tinel test followed by an examination of the sensation and also the motor function of the small muscles of the hand.
Investigations
A conduction test is usually required to quantify the severity. The nerves are the biological cables of the body and they conduct electricity. When they are compressed then the velocity of conduction is diminished thus resulting in a delay which can be measured neurophysiologically. The purpose of the nerve conduction test is to measure this delay and thereby quantify the degree of severity.
Treatment
Treatment depends upon the degree of involvement. In mild cases this will require splinting, physiotherapy and nerve tension releasing exercises. If the condition is severe and where conservative measures have failed then this requires surgery at the elbow to decompress the nerve.
Recovery
Whereas the results of carpal tunnel syndrome decompression at the wrist can be very predictable, the results in relation to ulnar nerve decompression are mixed. Surgery is a last resort. It is best regarded as an intervention to arrest further deterioration rather than to completely reverse the symptoms as they are.
Furthermore, the ulnar nerve is a mixed nerve, which again is a factor against a complete recovery. Doing surgery to prevent deterioration is something that is not always discerned by the patient. If motor signs exist in relation to the ulnar neuritis, then there is always the risk of irreversible nerve damage ie an incomplete recovery following surgery. Notwithstanding, we would never embark upon surgery unless we felt we had an excellent chance of improving the clinical situation.
It takes about one year for the ultimate plateau of recovery to come through following . There are small risks in relation to wound infection, reflex sympathetic dystrophy which is pain and stiffness, recurrence of symptoms, persistent pain and neuroma of the cutaneous branch of the medial part of the forearm.
The surgery involves the release of the arcade, which covers the ulnar nerve and which is causing compression. Any abnormal muscle bands are also released.
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Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123