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Lateral Epicondylitis, Tennis Elbow, and Tennis Elbow Release

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Lateral epicondylitis, or tennis elbow, is the most common cause of pain on the lateral, outside part of your elbow.  The most common symptom is pain on the side of your elbow and back of your forearm any time you lift something with your palm facing DOWNWARD.  As time goes on, that pain can happen all the time, even when you are resting, or the pain can cover an even larger portion of your arm.  Tennis elbow is very similar to tendonitis, which is an inflammation of the attachments of muscles to bone.  With tennis elbow, the muscle involved is the Extensor Carpi Radialis Brevis, or ECRB, and rather than just inflammation, there is usually an element of degeneration and breakdown within that tendon.  That breakdown of the tendon looks like a hole or tear within the tendon that can be seen with a MRI or during surgery. 

Alternative causes of pain at that same location include a posterolateral plica which causes painful clicking on the back-outside portion of your elbow; posterolateral rotary instability, or PLRI, which is usually the result of a fall or trauma to your elbow, and radiocarpal arthritis, which is a wearing away of the smooth covering of the elbow joint and usually has stiffness along with pain.  Your history, examination, and radiographs will help you and you doctor determine what the exact cause of your pain is.  Tennis elbow is a self-limiting disease, meaning the pain will go away on its own, but that usually takes 24 months, or 2 years.  Your doctor will discuss a range of treatments to alleviate the pain of lateral epicondylitis.

Initial treatment of lateral epicondylitis and tennis elbow is usually nonoperative.  This treatment may include wrist or elbow braces, physical therapy, anti-inflammatory medication, or a cortisone injection into your elbow.  These might completely resolve your symptoms.  Physical therapy for tennis elbow begins by focusing on the muscles around your shoulder blade and core, and then works into strengthening the muscles around your elbow.  Your therapist might use modalities such as ultrasound and iontopheresis to alleviate your pain as well.  After several visits with the therapist here or near your home, you can complete much of the therapeutic exercises on your own at home.  Anti-inflammatory medicine can reduce the swelling and pain.  Both over-the-counter and prescription medications are useful and effective.  Additionally, your doctor may offer you a cortisone shot on the day of your visit in an attempt to bring you pain relief right away.  The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection.  The injection is placed at the insertion of the muscle on the bone.  This injection may relieve your pain permanently.  If not, the injection can be repeated.  Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment. 

Arthroscopic and Open Tennis Elbow Release

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If you continue to have pain or if you cannot get back to your normal activities, your doctor may offer you a surgery known as “arthroscopic tennis elbow release” or “open tennis elbow release.”  During both of these procedures, the surgeon uses specially designed instruments to remove the degenerated portion of the ECRB tendon and sew the torn tendon and muscle back to the bone.  The arthroscopic surgery is completed using three or four ¼ inch incisions around the elbow, while the open procedure is carried out through a single ¾ inch incision directly over the injured tendon.  There are benefits to both procedures, and your surgeon will discuss which option is best for you.

This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your arm so that your whole arm goes to sleep prior to the surgery and stays asleep for 12 to 24 hours afterwards.  Additionally, you will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes less than 1 hour.  When you wake up, you will have a sling and possibly a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.

During both the arthoscopic and open operations, your surgeon will remove the degenerative, pain causing portion of the tendon and then use sutures to sew the torn muscle and tendon back down to the bone where it was originally attached.  Those stitches hold the ECRB muscle down to bone for the next three months while the two grow and heal back together.  It takes three months for that to happen, and that is why your activities will be quite limited during that same time span. 

Medial Epicondylitis, Golfer’s Elbow, and Medial Epicondylitis Release

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Medial epicondylitis, or golfer’s elbow, is the most common cause of pain on the medial, inside part of your elbow.  The most common symptom is pain on the inside of your elbow and front of your forearm any time you lift something with your palm facing UPWARD.  As time goes on, that pain can happen all the time, even when you are resting, or the pain can cover an even larger portion of your arm.  Golfer’s elbow is very similar to tendonitis, which is an inflammation of the attachments of muscles to bone. 

Alternative causes of pain at that same location include an cubital tunnel syndrome or ulnar nerve intrapment which usually also sends nerve like pain down to your ring and small fingers; ulnar collateral ligament injury which usually comes as the result of a fall or repetitive throwing; and ulnohumeral elbow arthritis, which is a wearing away of the smooth covering of the elbow joint and usually has stiffness along with pain.  Your history, examination, and radiographs will help you and your doctor determine what the exact cause of your pain is.  Golfer’s elbow is a self-limiting disease, meaning the pain will go away on its own, but that usually takes 24 months, or 2 years.  Your doctor will discuss a range of treatments to alleviate the pain of medial epicondylitis.

Initial treatment of medial epicondylitis and golfer’s elbow is usually nonoperative.  This treatment may include wrist or elbow braces, physical therapy, anti-inflammatory medication, or a cortisone injection into your elbow.  These might completely resolve your symptoms.  Physical therapy for golfer’s elbow begins by focusing on the muscles around your shoulder blade and core, and then works into strengthening the muscles around your elbow.  Your therapist might use modalities such as ultrasound and iontopheresis to alleviate your pain as well.  After several visits with the therapist here or near your  home, you can complete much of the therapeutic exercises on your own at home.  Anti-inflammatory medicine can reduce the swelling and pain.  Both over-the-counter and prescription medications are useful and effective.  Additionally, your doctor may offer you a cortisone shot on the day of your visit in an attempt to bring you pain relief right away.  The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection.  The injection is placed at the insertion of the muscle on the bone.  This injection may relieve your pain permanently.  If not, the injection can be repeated.  Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment. 

Open Medial Epicondylitis Release

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If you continue to have pain or if you cannot get back to your normal activities, your doctor may offer you a surgery known as “open medial epicondylitis release.”  During this procedure, the surgeon uses specially designed instruments to detach the wrist flexor muscles from the elbow, remove the degenerated portion of the tendon, and then sew the tendon and muscle back to the bone.  This open procedure is carried out through a single ¾  inch incision directly over the injured tendon.

This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You will be seen by an anesthesiologist prior to surgery.  You will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes less than 1 hour.  When you wake up, you will have a sling and possibly a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.

During the operation, your surgeon will remove the degenerative, pain causing portion of the tendon and then use sutures to sew the muscle and tendon back down to the bone where it was originally attached.  Those stitches hold the wrist flexor muscles back down to bone for the next three months while the two grow and heal back together.  It takes three months for that to happen, and that is why your activities will be quite limited during that same time span.

Cubital Tunnel Syndrome and Ulnar Nerve Release

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Cubital Tunnel Syndrome is also known as ulnar nerve compression at the elbow, and is another cause of numbness and tingling in the hand, very similar to carpal tunnel syndrome.  In distinction from carpal tunnel syndrome, the numbness and tingling felt with cubital tunnel syndrome is usually felt in the small and ring fingers.  Additional symptoms include pain around the elbow and weakness or muscle wasting around the hand.  You may have difficulty holding on to small items or weakness with gripping.  The symptoms you feel are similar to those usually described as “hitting your funny bone,” only they last a lot longer.

Your hand and elbow surgeon will likely be able to diagnose cubital tunnel syndrome with a thorough history and focused physical exam.  You will likely have X-rays made on the day of your visit as well.  Frequently, your doctor may obtain a nerve study, known as a Nerve Conduction Study/Electromyelogram or NCS/EMG, from a neurologist to confirm the diagnosis.

Initial treatment options for cubital tunnel syndrome include physical therapy and elbow bracing.  Occasionally medicines such as anti-inflammatory medications or nerve stabilizing medications may alleviate your pain.

Ulnar Nerve Release or Ulnar Nerve Transposition

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The purpose of this surgery is to relieve the numbness and tingling you feel in your hands.  Your hand and elbow surgeon will accomplish this by releasing the constricting bands of tissue that surround the ulnar nerve at the elbow.  This is an open surgery, meaning you will have an incision and scar on the inside portion of your elbow.  Your surgeon may relocate the nerve to the front of your elbow to prevent it from getting compressed again after the surgery.

This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You will be seen by an anesthesiologist prior to surgery.  You will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes about 1 hour.  When you wake up, you will have a sling and possibly a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.

Elbow Instability, Ulnar Collateral Ligament Tear, and UCL Reconstruction

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Ulnar Collateral Ligament (UCL) tears of the elbow are common cause of medial elbow pain and disability in overhead throwers.  This is usually baseball players, but they also occur in football players, tennis players, and any athlete after a fall on an outstretched arm.  They are also known as Medial Collateral Ligament (MCL) tears of the elbow.  They may occur suddenly with a fall or with a single pitch, or they may come on gradually after months or years of throwing.  The most common symptom is pain on the medial, inside portion of the elbow.  Throwers or other athletes usually have difficulty competing at their usual level and will describe a decrease in their speed or accuracy.  The function of the UCL is to stabilize the two main bones at the elbow, the ulna and humerus, as you throw an object or as you try to lift or push anything.  When the ligament is torn, the bones and the muscles around the elbow help to provide stability, but sometimes this is not enough support.

Diagnosis of UCL tears can be made with a detailed history of your symptoms and a physical exam focused on your elbow.  Valgus stress X-rays during that same visit can demonstrate laxity of the UCL.  A MRI with intra-articular gadolinium is frequently used to confirm the diagnosis by noninvasively looking at the UCL to find partial or complete tears of the ligament.

The vast majority of partial and complete tears of the UCL can be treated nonoperatively.  Initial treatment includes bracing with a hinged elbow brace and an aggressive physical therapy program that works on the entire kinetic chain, which starts with the body’s core muscles, extends through the shoulder blade and shoulder joint, and then works across the muscles of the elbow joint, and finally to the forearm and hand.  Corrections of throwing technique are made at this same time.  Bracing and therapy, along with a brief period of rest from throwing or sports, will frequently allow a complete return to sports and all activities.

UCL Reconstruction/Tommy John Surgery

The purpose of this surgery is to restore stability to your elbow so that you can return to full activities and throwing.  Your sports medicine elbow surgeon will recreate a new ligament to replace the torn UCL.  UCL reconstruction is also known as Tommy John surgery, named after the first professional pitcher who underwent this surgery and made a triumphant return to pitching.  During UCL reconstruction surgery, a tendon is used to recreate or replace your torn UCL.  That tendon is either from an organ donor, known as an allograft, or your surgeon can use an extra tendon from your forearm or thigh, known as an autograft.  Both graft options have benefits and risks which your surgeon will discuss with you.

This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your arm so that your whole arm goes to sleep prior to the surgery and stays asleep for 12 to 24 hours afterwards.  Additionally, you will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes less than 1 hour.  When you wake up, you will have a sling and a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.

Recovery from a UCL reconstruction is highly dependent upon a focused, sport specific physical therapy program.  Initially, you will work on getting the motion back in your elbow.  In the 6 to 12 months following the surgery, you will go forward with a therapy program which will start by strengthening the core muscles of your trunk, and then work on your shoulder and elbow strength.  Proper throwing mechanics will be emphasized.  Studies have shown that high level throwers and baseball pitchers can return to elite level play after they recover from UCL reconstruction.

Elbow Arthritis and Arthroscopic Radial Head Resection and Ulnohumeral Arthroplasty

Elbow arthritis is a far less frequent cause of pain than the other problems already discussed.  Stiffness may be more of a problem than pain.  Just like arthritis in other joints, arthritis in the elbow is a wearing away of the smooth cartilage covering on the ends of bones where they come together to form a joint.  The result is two roughened surfaces rubbing up against each other.  Arthritis can be the result of osteoarthritis, the most common cause of arthritis in other joints; previous trauma or fracture around the elbow; or less common inflammatory arthritis such as rheumatoid arthritis.

Initial treatment of elbow arthritis is usually nonoperative.  This treatment may include a brief period of immobilization in an elbow splint, physical therapy, anti-inflammatory medication, or a cortisone injection into your elbow.  These might completely resolve your symptoms.  Physical therapy for elbow arthritis focuses on regaining motion and strength around your elbow.  Your therapist might use modalities such as ultrasound and iontopheresis to alleviate your pain as well.  After several visits with the therapist here or near your home, you can complete much of the therapeutic exercises on your own at home.  Anti-inflammatory medicine can reduce the swelling and pain.  Both over-the-counter and prescription medications are useful and effective.  Additionally, your doctor may offer you a cortisone shot on the day of your visit in an attempt to bring you pain relief right away.  The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection.  The injection is placed within the arthritic elbow joint itself.  This injection may relieve your pain permanently.  If not, the injection can be repeated.  Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment.

Arthroscopic Radial Head Resection and Arthroscopic Ulnohumeral Arthroplasty/Arthroscopic Outerbridge-Kashiwagi Procedure

Numerous surgical options exist for people affected by elbow arthritis who have persistent elbow pain, elbow stiffness, or disability despite a course of nonoperative treatment.  Both arthroscopic and open procedures have a place in the treatment of elbow arthritis.  Your treatment options will be tailored specifically to your type of arthritis and your desired goals. 

Arthroscopic radial head resection is an option if your arthritis is primarily on the lateral side of the elbow, known as radiocapitellar arthritis.  This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your arm so that your whole arm goes to sleep after the surgery and stays asleep for 12 to 24 hours afterwards.  Additionally, you will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes less than 1 hour.  When you wake up, you will have a sling and possibly a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.  During this operation, your surgeon will place an arthroscope within your elbow to view the entire joint.  This arthroscope is a pencil sized digital camera that stays in place during the course of the surgery.  The diagnosis of arthritis is confirmed by direct visualization prior to any other invasive actions being taken.  At this point in the surgery, a shaving burr is introduced within your elbow and the arthritic portion of the radial head is removed.  This prevents the roughened, arthritic surfaces from rubbing together any more, and alleviates the pain you felt as a result of this elbow arthritis.  At the conclusion of the surgery, you will have a single stitch in each of 3 or 4 ¼ inch incisions around your elbow.  Please keep your elbow dry until those stitches are removed several days later.  You will likely attend physical therapy following the surgery to regain the motion in your elbow.  You can anticipate good pain relief from your arthritis pain after the pain of the surgery subsides.

Arthroscopic ulnohumeral arthroplasty is an option for people with arthritis in the main portion of the elbow joint as the result of primary osteoarthritis or post-traumatic arthritis for whom stiffness and pain within the elbow joint limits their activities.  This procedure is also described as the Outerbridge-Kashiwagi ulnohumeral arthroplasty, which originally was performed through a large open technique, but can now be accomplished arthroscopically.  This is an inpatient procedure which goes on here at the hospital.  You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your arm so that your whole arm goes to sleep after the surgery and stays asleep for 12 to 24 hours afterwards.  Additionally, you will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes about 1 hour.  When you wake up, you will have a sling and possibly a splint stabilizing your elbow.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home.  During this operation, your surgeon will place an arthroscope within your elbow to view the entire joint.  This arthroscope is a pencil sized digital camera that stays in place during the course of the surgery.  The diagnosis of arthritis is confirmed by direct visualization prior to any other invasive actions being taken.  At this point in the surgery, a shaving burr is introduced within your elbow and the arthritic portion of the humerus is removed.  This facilitates you regaining motion within your elbow and alleviates the pain you felt as a result of this elbow arthritis.  At the conclusion of the surgery, you will have a single stitch in each of 3 or 4 ¼ inch incisions around your elbow.  Please keep your elbow dry until those stitches are removed several days later.  You will likely attend physical therapy immediately following the surgery to regain the motion in your elbow.  You can anticipate increased elbow motion and good pain relief from your arthritis pain after the pain of the surgery subsides.