Common Problems
of the Elbow

Below is a list of common problems of the elbow. The brief treatment descriptions are meant only as introduction. Our highly-qualified physicians will be able to discuss in further detail your condition and treatment options.

Cubital Tunnel Syndrome

Introduction

Cubital tunnel syndrome is a condition where a nerve gets compressed as it passes by the inner side of the elbow. When the nerve gets compressed, people experience a variety of symptoms including numbness and weakness of the hand and pain around the elbow. Often the symptoms are brought on by keeping the elbow in a flexed position or by direct pressure on the inner side of the elbow. For example, many people notice symptoms while sleeping with the elbow bent or while talking on the telephone.


The particular nerve involved is called the ulnar nerve. The ulnar nerve provides the feeling to the ring and small fingers. When you accidentally hit the “funny bone” on inside of the elbow and feel pins and needles in this area, you are really hitting the ulnar nerve and not a bone at all. The ulnar nerve also carries the signals that control the many of the small muscles between the metacarpal bones of the hand and many of those that control the pinky. For example, crossing your fingers for good luck is an ulnar nerve function. The ulnar nerve passes by the inner side of the elbow through a channel called the cubital tunnel. The floor of the tunnel is a groove in the end of the arm bone known as the humerus. The roof is a dense, fibrous sheet of soft tissue.

 

The exact cause of cubital tunnel syndrome is not known. Occasionally it can occur in reaction to an injury or repetitive pressure around the inner elbow, but most cases develop slowly without a specific event.

Treatment

For mild cases, simply avoiding specific arm positions that bring out the symptoms may be all that is needed. Examples would include avoiding resting on the elbow while seated and keeping the elbow straight while sleeping. If simple measures are not keeping the symptoms under control, surgery may be a consideration. Although a variety of surgical techniques are commonly used, they all share the goal of opening the roof of the tunnel to create more room. This is sometimes combined with a repositioning of the nerve to keep it from stretching with elbow movement. Cubital tunnel surgery can be safely performed in an outpatient setting.

 

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Commonly, symptoms arise while sleeping or talking on the telephone.

Carpal Tunnel Syndrome

Figure: Ulnar Nerve at elbow joint (inner side of elbow)

Photos used with permission from www.assh.org

Steroid injections

Introduction

Steroid, or “cortisone”, injections are a very common treatment for a wide range of painful or inflammatory conditions around the hand, wrist and elbow. Unlike pills, injected steroids deliver a high concentration of the medicine directly to the area of concern and minimize the side effects to the body as a whole.


The steroids that are used for injection are just one member of a large family of compounds known are hormones. The hormones produced naturally in the body regulate many biological functions such as growth, metabolism, inflammation and reaction to stress or injury. The synthetically produced steroids used for injections (e.g. betamethasone, triamcinolone) are in a group called glucocorticoids. Like their naturally occurring counterparts, this group has a number of functions including regulation of inflammation and the immune system. These the steroids should not be confused with anabolic steroids that have been misused for performance enhancement in sports. Anabolic steroids mimic the action of testosterone and are not generally used for musculoskeletal problems.


Two of the most common conditions treated by steroid injection are tendonitis and arthritis. In the wrist and hand, most of the tendons pass through tunnels (tendon sheathes) that keep them tracking properly as they move. When a tendon is injured or overused, it often becomes swollen, making it more difficult to glide through its narrow tunnel. This results in pain and limitation of motion. A steroid injection can quickly reduce the swelling and associated pain, sometimes on a permanent basis.

 

In arthritic conditions, the protective tissue at the ends of the bones (articular cartilage) is reduced or lost, allowing bone to bone contact within the joint. This triggers inflammation, with resulting pain, stiffness and swelling. A steroid injection in the joint can quickly reduce the inflammation, allowing resumption of activity with comfort. Although the effect is temporary, since the underlying cartilage loss remains, the benefits can often last for months at a time.

 

Like most medications, steroid injections do have potential side effects. The most common is a temporary flare of pain directly in the site of injection. Though uncomfortable, it predictably resolves over a period of a few days. Less common side effects include lightening of the skin color or thinning of the fat at the site of injection. These effects are not dangerous, and will often reverse over time. Extremely rare complications include infection and tendon ruptures.

 

Some common misunderstandings exist regarding steroid injections. One popular myth is that a person can only receive three injections in one location in their lifetime. Although the frequency of injections is often kept to three or less a year, there is no specific lifetime limit. Injections are often stopped after three attempts because they are no longer effective, not due to safety concerns. Another common myth is that steroid injections cause arthritis. Although increased activity due to pain relief may play some role, the worsening of arthritis is largely due to the natural progression of the disease rather than to steroid exposure.

 

Steroid injections are a safe and effective treatment alternative for a variety of painful conditions. You can have a detailed discussion with your hand surgeon or other health care professional to determine whether or not it is right for you.

 

More info at www.assh.org

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Injected steroids minimize the side effects to the body as a whole.

Carpal Tunnel Syndrome

Figure: Steroid injection sites

Photos used with permission from www.assh.org

Tennis and Golfer Elbow

Introduction

Tennis elbow and its cousin, golfer’s elbow are common conditions that effect the elbows of active, middle-aged individuals. The technical names are lateral and medial epicondylitis. In lateral epicondylitis, there is activity related pain in the outer part of the elbow. In medial epicondylitis the pain is on the inner side of the elbow. Both conditions are brought on or flared up by repetitive gripping. In spite of the popular name, most cases occur in people who do not play either tennis or golf.

 

The main muscles that we use to flex and extend the fingers and wrist are divided into two groups. The flexors make the fingers and wrist bend while the extensors straighten them. Using short stretches of tendon, both groups of muscle are anchored to specific points on the end of the arm bone (humerus). The flexors attach to a bump on the inner side called the medial epicondyle and the extensors attach to a bump on the outer side called the lateral epicondyle. With epicondylitis, the tiny fibers (collagen) that make up the substance of the anchoring tendons start to break down or degenerate. When this occurs, it becomes painful to use the affected muscles because it pulls on the damaged tendon.

Treatment

The most import thing to remember about epicondylitis is that the vast majority of cases go away on their own regardless of treatment. Although it can take an average of one to two years, gradual return to normal, painless function is the rule. Treatment is mostly directed at keeping individuals comfortable while waiting for the condition to run its course.


For mild cases of epicondylitis, simply cutting back on activities that require firm grip or heavy lifting may keep things under control. Therapy is often considered when activity modification is not working. It usually involves gentle stretching and strengthening exercises to encourage tendon healing. An elbow brace (sometimes called a counterforce brace) may make activity more comfortable by altering the direct pull on the affected tendon.


If the condition is not responding to the usual conservative measures, steroid (cortisone) injections are occasionally used to address the pain. Although studies have shown that steroids do not promote healing, they can temporarily reduce pain to make daily activity more manageable.

 

In a small minority of cases, when all the conservative measures have failed, surgery may be considered. Several techniques have been used, but most are directed at removal of the degenerated tissue to stimulate a healing response from the surrounding tissue.

 

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In spite of the popular name, most cases occur in people who do not play either tennis or golf.

Broken Bones - Scaphoid

Figure: The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist

Photos used with permission from www.assh.org