Elbow Surgery Overview
Bones of Elbow Joint
The elbow is a hinge joint consisting of three bones. The upper part of the hinge is at the end of the upper arm bone (humerus), and the lower part of the hinge is at the top of the two forearm bones (radius and ulna) which are side by side. When the elbow is bent, the ends of the two forearm bones rub against the end of the humerus.
Elbow Surgery Layout:
Elbow Joint Pain and Problems
In a healthy elbow joint, the surfaces of these bones are very smooth and covered with a tough protective tissue called cartilage. Arthritis causes damage to the bone surfaces and cartilage where the three bones rub together. These damaged surfaces eventually become painful.
Tendinitis
- Lateral Epicondylitis (Tennis Elbow)
The lateral epicondyle is the outside bony portion of the elbow where large tendons attach to the elbow from the muscles of the forearm. These tendons can be injured, especially with repetitive motions of the forearm, such as using a manual screwdriver, washing windows, or hitting a backhand in tennis play.
Tennis elbow results with inflammation of the tendons causing pain over the outside of the elbow, occasionally with warmth and swelling, but always with local tenderness. The elbow maintains its full range of motion, as the inner joint is not affected, and the pain can be particularly noticed toward the end of the day. Repeated twisting motions or activities that strain the tendon typically elicit increased pain. X-rays are usually normal, but can reveal calcium deposits in the tendon or reveal other unforeseen abnormalities of the elbow joint.
The treatment of lateral epicondylitis includes ice packs, resting the involved elbow, and anti-inflammatory medications. Anti-inflammatory medications typically used include aspirin and other non-sterodial anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn), diclofenac (Voltaren), and ibuprofen (Motrin). Bracing the elbow can help. Simple braces for tennis elbow can be found in community pharmacies and athletic goods stores. Local cortisone injections are given for persistent pain. Activity involving the elbow is resumed gradually. Ice application after activity can reduce or prevent recurrent inflammation. Occasionally, supportive straps can prevent reinjury. In severe cases, an orthopedic surgical repair is performed.
- Medial Epicondylitis (Golfer's Elbow)
Medial epicondylitis is inflammation at the point where the tendons of the forearm attach to the bony prominence of the inner elbow. As an example, this tendon can become strained in a golf swing, but many other repetitive motions can injure the tendon.
Golfer's elbow is characterized by local pain and tenderness over the inner elbow. The range of motion of the elbow is preserved because the inner joint of the elbow is not affected. Those activities which require twisting or straining the forearm tendon can elicit pain and worsen the condition. X-rays for epicondylitis are usually normal but can indicate calcifications of the tendons if the tendinitis has persisted for extended periods of time.
The usual treatment involves ice packs, resting the elbow, and medications including aspirin and other NSAIDs. Examples of NSAIDs include naproxen (Naprosyn), diclofenac (Voltaren), and ibuprofen (Motrin). With severe inflammation, local corticosteroid (cortisone ) injections are sometimes given. Using a strap can prevent reinjury. After a gradual rehabilitation exercise program, return to usual activity is best accompanied by ice applications after use. This helps to avoid recurrent inflammation.
Olecranon Bursitis
Olecranon bursitis (inflammation of the bursa a the tip of the elbow) can occur from injury or minor trauma, as a result of systemic diseases such as gout or rheumatoid arthritis, or can be due to a local infection. Olecranon bursitis is typically associated with swelling over the tip of the elbow, while range of motion of the inner elbow joint is maintained.
Total Elbow Replacement Surgery
Arthritic Elbow Joint Surfaces
There are many ways to treat the pain caused by arthritis. One way is total elbow replacement surgery. The decision to have total elbow replacement surgery should be made very carefully after consulting your doctor and learning as much as you can about the elbow joint, arthritis, and the surgery.
In total elbow replacement surgery, an artificial hinge made of metal and a very durable plastic material is inserted into the joint so that the elbow can move without allowing the two forearm bones to contact the humerus. We call this artificial hinge an "implant."
Elbow Replacement Surgery Overview
Getting to the Joint
The patient is first taken into the operating room and given anesthesia. After the anesthesia has taken effect, the skin around the elbow is thoroughly scrubbed and sterilized with an antiseptic liquid. A tourniquet is then applied to the upper portion of the arm to help slow the flow of blood.
An incision about six inches long is then made over the elbow joint. The incision is gradually made deeper through muscle and other tissue until the bones of the elbow joint are exposed.
Preparing the Bones
One of the forearm bones, the ulna, has a projection at the end, which extends up and behind the end of the humerus. A special power saw is used to remove part of this projection.
This allows the two forearm bones to be rotated out of the way so parts of the humerus can be removed with the saw. Precision guides are used to help make sure that the cuts are made so the bones will align properly after the implant is inserted.
The middle portion at the end of the humerus is removed first.
The arm bones have relatively soft, porous bone tissue in the center. This part of the bone is called the "canal." Special instruments are used to clear some of this soft bone from the canal of the humerus. These instruments also help shape the canal to fit the shape of the implant.
Then, similar instruments are used to clear some of the soft bone and shape the canal of the ulna.
Attaching the Implants
The elbow implant consists of two metal stems that are connected by a metal locking pin. This pin passes through the ends of both stems, which are lined with a strong plastic material, serving as a bearing that allows the elbow to bend. The stems are inserted into each of the two prepared canals. A special kind of cement for bones is first injected into the canals to help hold the stems in place.
When the cement is hard, the two implant parts are brought together and the pin is inserted to connect them.
Stems Locked Together to Create Hinge
Closing the Wound
If necessary, the surgeon may adjust the ligaments that surround the elbow to achieve the best possible elbow function.
When all of the implants are in place and the ligaments are properly adjusted, the surgeon sews the layers of tissue back into their proper position. A plastic tube may be inserted into the wound to allow liquids to drain from the site during the first few hours after surgery. The edges of the skin are then sewn together, and the elbow is wrapped in a sterile bandage. Finally, the patient is taken to the recovery room.
Dressing Care
You will leave the hospital with a dressing covering your knee. You may remove the dressing the day after surgery. You may shower, but should avoid directing water at the incisions. Do not soak in a tub. Keep your incisions clean and dry.
Your orthopaedic surgeon will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.
Elbow Replacement Frequently Asked Questions
This following provides a brief introduction to elbow replacement. It can help you make a list of questions to ask your doctor, but it is not meant to provide complete information. Check with your surgeon's office about more comprehensive resources and patient education materials.
What is elbow replacement?
In elbow replacement surgery, the painful surfaces of the damaged elbow are replaced with artificial elbow parts. One part fits into the humerus (upper arm), and the other part fits into the ulna (forearm). The two parts are then connected and held together by a pin. The resulting hinge allows the elbow to bend.
How do I prepare for elbow replacement surgery?
If you and your surgeon decide that total elbow replacement is right for you, a date will be scheduled for your surgery. Several things may be necessary to prepare for surgery. For example, your surgeon might ask you to have a physical examination by your primary care physician. This will ensure that other health problems you may have, such as diabetes or high blood pressure, will be treated before surgery. Your doctor, or a staff member, will advise you about the things you can do to prepare for your hospital stay, and your rehabilitation after surgery.
What happens during elbow replacement surgery?
On the day of surgery, an intravenous tube will be inserted into your unaffected arm to administer necessary medications and fluids during surgery. You will then be taken to the operating room and given anesthesia. After the anesthesia takes effect, your elbow will be scrubbed and sterilized with special solution.
The procedure is performed through an incision over the elbow that will expose the joint. Special, precision guides and instruments will be used to cut the ends of the humerus (upper arm bone) and ulna (forearm bone), and prepare the bone to accept the implant. The implants are then inserted and fixated in place with a special kind of opoxy cement for bones. The two parts of the hinge are then brought together and secured with a pin. When the surgeon is satisfied with the fit and function, the incision will be closed and covered with dressings. The surgery usually takes one to three hours, although this depends on the severity of the arthritis in your elbow.
A sterile bandage will be placed over the wound, and you will be sent to the recovery room where you will be carefully monitored. As the anesthesia wears off you will slowly regain consciousness. A nurse will be with you, and may encourage you to cough or breathe deeply to help clear your lungs. Your arm will be in a splint, and it may be wrapped in an ice pack to help control pain and swelling. You will also be given pain medication. When you are fully conscious, you will be taken back to your hospital room.
What can I expect after surgery?
When you are back in your hospital room, you will begin a gentle rehabilitation program to help relax the muscles around your new elbow. On the day of surgery you may be encouraged to get out of bed and take a few steps. You will continue to receive pain medication as needed, and your bandage will be removed about two days after surgery.
Depending on your specific situation, you will probably remain in the hospital from one to three days. Your elbow area may be warm and tender for several weeks. Before you are dismissed from the hospital, your physical therapist will show you how to perform the rehabilitation exercises that are important for your recovery.
How soon can I return to normal activities after surgery?
Successful joint replacement surgery may relieve your pain and stiffness, and allow you to resume some of your normal daily activities as instructed by your doctor. While you are recovering, you should not lift more than one pound with the operated arm. Even after you have fully recovered from your surgery, you will still have some restrictions. Normal daily activities for elbow replacement patients do not include contact sports, "jamming" activities such as hammering, heavy or repetitive lifting, or activities that put excessive strain on your elbow. Your doctor may advise you not to lift anything that weights more than five pounds. Although your artificial joint can be replaced, a second implant is seldom as successful as the first.
How long will an elbow replacement last?
Longevity of the prosthetic elbow varies from patient to patient. It depends on many factors, such as a patient's physical condition and activity level, as well as the accuracy of implant placement during surgery. It is useful to keep in mind that prosthetic joints are not as strong or durable as a natural, healthy joint, and there is no guarantee that a prosthetic joint will last the rest of a patient's life.
Today, total elbow replacement is becoming a common and predictable procedure. Many patients enjoy relief from pain and improved function, compared to their status before surgery. As a result, some patients may have unrealistic expectations about what the prosthetic elbow can do and how much activity it can withstand. As with any mechanical joint, the components move against each other. Natural fluid in the joint space, called synovial fluid, helps to lubricate the implants just as it lubricates the bones and cartilage in a natural joint. Still, the prosthetic components do wear as they roll and slide against each other during movement. As with car tires or brake pads, the rate of wear depends partly on how the elbow joint is used. Activities that place a lot of stress on the joint implants, as may be the case with more active patients, may reduce the service life of the prosthesis. Implant loosening and wear on the components can lead to the necessity for revision surgery to replace the worn parts, or all of the parts. Your doctor will be in the best position to discuss these issues with you, taking into account your particular clinical circumstances, the type of implants used, and your post-surgical lifestyle.
Points of Successful Elbow Replacement:
- Avoiding repetitive lifting; avoiding lifting anything heavier than one pound during recovery; and avoiding lifting anything heavier than five pounds after recovery.
- Avoiding "jamming" activities such as hammering
- Staying healthy and active.
- Avoiding "impact loading" sports such as boxing
- Consulting your surgeon before beginning any new sport or activity, to find out what type and intensity of sport or activity is appropriate for you.
- Thinking before you move.
- Avoiding any physical activities involving quick stop-start motion, twisting or impact stresses on the operated elbow.
- Not pushing heavy objects.
Tennis Elbow Surgery
"Tennis elbow" is a common term for a condition caused by overuse of arm and forearm muscles that results in elbow pain. You don't have to play tennis to get this, but the term came into use because it can be a significant problem for some tennis players.
Tennis elbow is caused by either abrupt or subtle injury of the muscle and tendon area around the outside of the elbow. Tennis elbow specifically involves the area where the muscles and tendons of the forearm attach to the outside bony area (called the epicondyle) of the elbow. Your doctor may call this condition lateral epicondylitis. Another common term, "golfer's elbow," refers to the same process occurring on the inside of the elbow -- what your doctor may call medial epicondylitis. Overuse injury can also affect the back or posterior part of the elbow as well.
Tennis elbow most commonly affects people in their dominant arm (that is, a right-handed person would experience pain in the right arm), but it can also occur in the nondominant arm or both arms.
What Are the Symptoms of Tennis Elbow?
Symptoms of Tennis Elbow Include:
- Pain slowly increasing around the outside of the elbow. Less often, pain may develop suddenly.
- Pain is worse when shaking hands or squeezing objects.
- Pain is made worse by stabilizing or moving the wrist with force. Examples include lifting, using tools, or even handling simple utensils such as a toothbrush or knife and fork.
Who Gets Tennis Elbow?
Tennis elbow affects 1% to 3% of the population overall and as many as 50% of tennis players during their careers. Less than 5% of all tennis elbow diagnoses are related to actually playing tennis.
Tennis elbow affects men more than women. It most often affects people between the ages of 30 and 50, although people of any age can be affected.
Although tennis elbow commonly affects tennis players, it also affects other athletes and people who participate in leisure or work activities that require repetitive arm, elbow, and wrist movement. Examples include golfers, baseball players, bowlers, gardeners or landscapers, house or office cleaners (because of vacuuming, sweeping and scrubbing), carpenters, mechanics, and assembly-line workers.
How Is Tennis Elbow Diagnosed?
Tennis elbow cannot be diagnosed from blood tests or X-rays. Rather, it is diagnosed by the description of pain you provide to your doctor and certain findings from a physical examination.
Since many other conditions can cause pain around the elbow, it is important that you see your doctor so the proper diagnosis can be made. Then your doctor can prescribe the appropriate treatment.
Tennis elbow usually is successfully treated by medical means and only rarely requires surgery.
The type of treatment prescribed will depend on several factors, including age, type of other medications being taken, overall health, medical history, and severity of pain. The goals of treatment are to reduce pain or inflammation, promote healing, and decrease stress and abuse on the injured elbow.
When is Tennis Elbow Surgery Advised?
For most sufferers of tennis elbow, medically termed lateral epicondylitis, their bodies will heal themselves. The best way to enable this body healing is to rest the elbows by eliminating the most aggravating activities.
If the pain persists for several months, surgery may be advised.
Tennis Elbow Treatment Options:
- trim abnormal tendons 3-4 cm
- release tendon from bone
- ossatripsy
Options Before Lateral Epicondylitis Surgery
Before lateral epicondylitis surgery is considered, most doctors will want to make sure that the patient has undergone at least 6 months of conservative treatment.
If tennis elbow surgery is to be considered, due to the inherent risks with any invasive surgery, most doctors will want to make sure that the patient has a pain level that prevents normal activity. Ideally, the patient has been given several cortisone shots with no improvement in the lateral epicondylitis pain.
Elbow Surgery Options
Surgery may be done arthroscopically, by traditional open surgery, or by a combination of the two techniques depending on the type of problem and the method the doctor prefers to use. Arthroscopy is not widely used.
Surgery can be done with general or regional anesthetic and can require an overnight stay in the hospital.
If the patient meets the criteria for tennis elbow surgery the current most common type of surgery is one of two types of invasive lateral epicondylitis surgery.
The first invasive tennis elbow surgery creates a 3 - 4 cm incision ( cut ) in the arm. The tendon sheaths are trimmed and the incision closed. The second type of invasive tennis elbow surgery also involves cutting open the arm and releasing the tendon from the bone with a scalpel.
Both of these invasive surgeries are performed on an outpatient basis with the patient going home the same day as the surgery. The treated arm is usually placed in a sling, although the arm may be place in a plaster cast based on how extensive the surgery was and based on the doctors assessment. The arm should be kept elevated to minimize swelling. It is also important to keep the arm dry to keep the arm healthy. Moisture may weaken the body's scar tissue in these initial stages. It is very important to follow your doctor's guidelines exactly to ensure you have the best surgical results.
Tennis Elbow Surgery Risks:
- infection
- bleeding
- nerve damage
- slight loss of the ability to extend ( straighten ) the arm
- a scar on the skin surface that may be painful and/or unsightly
- persistent weakness in the arm and/or wrist
Finally there is the risk that the treatment may not improve the tennis elbow condition at all. There is even the possibility that the pain may be worse. Most patients will have to wait 3-4 weeks after treatment to see if there is any improvement in their pain.
Tennis Elbow Surgery Recovery
Recovery varies based on the doctor's assessment of the patients recovery from the surgery. Most patients are advised not to drive for a week. Stitches are usually removed 10 - 14 days after treatment. Rehabilitation of the arm begins after the doctor gives the go ahead.
Recovery varies from person to person, usually taking at least 3 to 6 months for a complete recovery.
Recovery Factors:
- Cigarette smoking slows tendon and wound healing.
- Recovery depends on the amount of time and effort you put into a rehabilitation program.
- You may not be able to keep doing the activity that caused your tennis elbow. Or you may have to make some changes to the way you do that activity in the future.
Most patients do not like the idea of being cut open, so fortunately there is a non-invasive option called OssaTripsy. A company called HealthTronics SSI was granted FDA approval in March 2003 for high energy orthopedic lithotripsy treatment of Lateral Epicondylitis.
This treatment has been found to be very effective method of treating chronic lateral epicondylitis.
How To Reduce Pain and Inflammation of Tennis Elbow:
- Rest and avoid any activity that causes pain.
- Apply ice to the affected area.
- Take nonsteroidal anti-inflammatory drugs (NSAIDs).
- Cortisone-type medication may be injected into the sore area
Promoting healing begins a couple of weeks after pain has been reduced or eliminated. It involves specific physical-therapy exercises to stretch and strengthen muscles and tendons around the injured elbow. Any activity that aggravates the pain must be avoided.
Decrease Stress and Abuse on the Injury:
- Use the proper equipment and technique in sports and on the job.
- Use of a counter-force brace, an elastic band that wraps around the forearm just below the injured elbow (tendon) may help to relieve pain in some people.
Overall, 90% to 95% of people with tennis elbow will improve and recover with the treatment plan described. However, about 5% of people will not get better with conservative treatment and will need surgery to repair the injured muscle-tendon unit around the elbow. For 80% to 90% of people who have surgery, it results in pain relief and return of strength.
Golfer's Elbow Surgery
Golfer’s elbow (medial epicondylitis) causes pain and inflammation in the tendons that connect the forearm to the elbow. The pain centers on the bony bump on the inside of your elbow and may radiate into the forearm. It can usually be treated effectively with rest.
Golfer’s elbow is usually caused by overusing the muscles in the forearm that allow you to rotate your arm and flex your wrist. Repetitive flexing, gripping, or swinging can cause pulls or tiny tears in the tendons.
Despite the name, this condition doesn't’t just affect golfers. Any repetitive hand, wrist, or forearm motions can lead to can lead to golfer’s elbow. Risky sports include tennis, bowling, and baseball -- in fact, it’s sometimes called pitcher’s elbow. People may also get it from using tools like screwdrivers and hammers, raking, or painting.
Golfer’s elbow is not as well known as its cousin, tennis elbow. Both are forms of elbow tendinitis. The difference is that tennis elbow stems from damage to tendons on the outside of the elbow, while golfer’s elbow is caused by tendons on the inside. Golfer’s elbow is also less common.
Golfer's Elbow Overview
Golfer's elbow causes pain that starts on the inside bump of the elbow, the medial epicondyle. Wrist flexors are the muscles of the forearm that pull the hand forward. The wrist flexors are on the palm side of the forearm. Most of the wrist flexors attach to one main tendon on the medial epicondyle. This tendon is called the common flexor tendon.
Tendons connect muscle to bone. Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.
Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull against both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.
The wrist flexor muscles contract when you flex your wrist, twist your forearm down, or grip with your hand. The contracting muscles pull on the flexor tendon. The forces that pull on the tendon can build when you grip a golf club during a golf swing or do other similar actions.
Causes of Golfer's Elbow
Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop golfer's elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Shoveling, gardening, and hammering nails can all cause the pain of golfer's elbow. Swimmers who try to pick up speed by powering their arm through the water can also strain the flexor tendon at the elbow.
In some cases, the symptoms of golfer's elbow are due to inflammation. In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis.
However, golfer's elbow often is not caused by inflammation. Rather, it is a problem within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.
Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.
No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.
Symptoms of Medial Epicondylitis
The main symptom of golfer's elbow is tenderness and pain at the medial epicondyle of the elbow. Pain usually starts at the medial epicondyle and may spread down the forearm. Bending your wrist, twisting your forearm down, or grasping objects can make the pain worse. You may feel less strength when grasping items or squeezing your hand into a fist.
Diagnosing Golfer's Elbow
Your doctor will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.
The physical exam is often most helpful in diagnosing golfer's elbow. Your doctor may position your wrist and arm so you feel a stretch on the forearm muscles and tendons. This is usually painful with golfer's elbow. Other tests for wrist and forearm strength are used to help your doctor diagnose golfer's elbow.
You may need to get X-rays of your elbow. The X-rays mostly help your doctor rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the medial epicondyle at the connection to the flexor tendon.
Golfer's elbow symptoms are very similar to a condition called cubital tunnel syndrome. This condition is caused by a pinched ulnar nerve as it crosses the elbow on its way to the hand. If your pain does not respond to treatments for golfer's elbow, your doctor may suggest tests to rule out problems with the ulnar nerve.
When the diagnosis is not clear, the doctor may order other special tests, such as a magnetic resonance imaging (MRI) scan or ultrasound. An MRI scan uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.
Ultrasound tests use high-frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show collagen degeneration.
Treatment Options for Golfer's Elbow
Nonsurgical Treatment
The key to nonsurgical treatment is to keep the collagen from breaking down further. The goal is to help the tendon heal.
If the problem is caused by inflammation, anti-inflammatory medications such as ibuprofen may give you some relief. If inflammation doesn't go away, your doctor may inject the elbow with cortisone. Cortisone is a powerful anti-inflammatory medication. Its benefits are temporary, but they can last for a period of weeks to several months.
Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for golfer's elbow, but recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.
Doctors commonly have their patients with golfer's elbow work with a physical or occupational therapist. At first, your therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. Your therapist may apply tape to take some of the load off the elbow muscles and tendons. You may use an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.
Your therapist may apply ice and electrical stimulation to ease pain and improve healing of the collagen. Therapy sessions may also include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can't tolerate injections. Exercises are used to gradually stretch and strengthen the forearm muscles.
Because tendonosis is often linked to overuse, your therapist will work with you to reduce repeated strains during activity. When symptoms are from a particular sport or work activity, your therapist will observe your style and motion with the activity. Your therapist may suggest ways to protect the elbow during your activities. Your therapist can also check your sports equipment and work tools and recommend ways to alter them to keep your elbow safe.
Surgical Treatment Options
Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.
Tendon Debridement:
When problems are caused by tendonosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.
Tendon Release:
A commonly used surgery for golfer's elbow is called a medial epicondyle release. This surgery takes tension off the flexor tendon. The surgeon begins by making an incision along the arm over the medial epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the flexor tendon attaches to the medial epicondyle.
The flexor tendon is then cut where it connects to the medial epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the medial epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones.) Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body.)
Your surgeon will look at the ulnar nerve, to make sure that it is not being pinched. If the nerve looks fine, the skin is then stitched together.
This surgery can usually be done on an outpatient basis, which means that you don't have to stay overnight in the hospital. It can be done using a general anesthetic or a regional anesthetic. A general anesthetic puts you to sleep. A regional anesthetic blocks only certain nerves for several hours. For surgery on the elbow, you would most likely get an axillary block to numb your arm.
Rehabilitation and Recovery After Surgery
Nonsurgical Rehabilitation
In cases where the tendon is inflamed, nonsurgical treatment is usually only needed for four to six weeks. When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If the tendonosis is chronic and severe, complete healing can take up to six months.
Recovery After Surgery
Recovery from surgery takes longer. Immediately after surgery, your elbow is placed in a removable splint that keeps your elbow bent at a 90-degree angle. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.
You will gradually work into more active stretching and strengthening exercises. You just need to be careful to avoid doing too much, too quickly. Active therapy starts about two weeks after surgery. Your therapist may begin with light isometric strengthening exercises. These exercises work the muscles of the forearm without straining the healing tissues. You will use your own muscle power in active range-of-motion exercises.
At about six weeks, you start doing more active strengthening. As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints of the wrist, elbow, and shoulder. You'll also do exercises to improve fine motor control and dexterity of the hand. Some of the exercises you'll do are designed to work your hand and elbow in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your elbow.
You may need therapy for two to three months. It may take four to six months to get back to high-level sports and work activities. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
Elbow Anatomy
The Elbow
The elbow joint is formed by three bones, the humerus, radius, and ulna. Articulations between the trochlea of the humerus with the ulna and the capitulum of the humerus with the head of the radius comprise the joint. The elbow is an example of a hinge joint, or a joint that moves in only one direction.
The Ligaments
Two ligaments are present in the elbow joint, the ulnar collateral ligament and the radial collateral ligament. These ligaments provide strength and support to the joint as do the surrounding muscles.
The ulnar collateral ligament is a strong fan shaped condensation of the fibrous joint capsule. It is located on the medial side of the joint, extending from the medial epicondyle of the humerus to the proximal portion of the ulna. This ligament prevents excessive abduction of the elbow joint.
The radial collateral ligament is also a strong fan shaped condensation of the fibrous joint capsule. It is located on the lateral side of the joint, extending from the lateral epicondyle of the humerus to the head of the radius. This ligament prevents excessive adduction of the elbow joint.
|
