– The most complex joint in the human body. It consists of 3 joints, each between the humerus, ulna and radius, and a variety of ligaments and muscles that give it stability. The multitude of important vessels and nerves around the joint, makes a highly specialized approach necessary to treat the subtle pathologies of the elbow.
Popularly known as tennis elbow or epicondylitis humeroradialis, it is a tendon disease of the forearm extensor muscles caused by chronic overuse. On the one hand, it comes from sports such as tennis or golf, but mostly occupationally due to long periods of screwing, sawing, typing or similar monotonous activities, especially between the ages of 30 and 55.
Tennis elbow is initially an inflammation of the tendon insertions of muscles that stretch the fingers and wrist. In the course of the diseases, the inflammation turns into a mostly irreversible degeneration of the tendons. The trigger is mostly that the force that needs to be exerted by the muscles is greater than the muscle strength itself.
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Pain is on the outside of the elbow often radiating to the wrist and fingers. A similar condition can also occur internally, known as ulnar epicondylitis or golfer’s elbow. The diagnosis is made by a thorough examination and an X-ray to rule out bony causes. Magnetic resonance imaging can then be used to visualize the tendon damage.
Treatment is carried out with great success generally and first of all conservatively. The main pillars are rest, ice and stretching of the forearm extensor muscles, at best in the context of physiotherapy with eccentric training. Furthermore, anti-inflammatory painkillers, bandages and, above all, focused shock wave therapy are the means of choice. Cortisone injections should be avoided because, as numerous studies have shown, they have only a short-term effect but damage the tissue in the long term. The best therapeutic options are regenerative measures such as blood plasma injections (PRP or ACP) or stem cell concentrates together with shock wave therapy.
Only in case of non-improvement of symptoms despite intensive therapy for at least 6 months, surgical intervention may be necessary. This procedure can be very effective in relieving the pain and usually restoring the tendon to regeneration. However, most patients are left with minimal loss of strength. Sports and occupational activities may remain restricted for longer due to a rehabilitation period of 3-6 months.
The procedure can be performed arthroscopically or openly, but diagnostic arthroscopy of the elbow should always be performed beforehand to rule out posterolateral rotational instability. In the following surgical procedure, the degeneratively altered tendon tissue is removed and the bone at the tendon insertion is refreshed so that more complete tendon healing can occur. After the operation, the forearm should be rested for 2 weeks and then the forearm muscles should be stretched and built up again as part of remedial gymnastics. If posterolateral rotational instability is present, change to another surgical procedure (see Posterolateral Rotational Instability).
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The biceps is a two-headed muscle that connects the shoulder to the elbow and performs flexion at the elbow. Coming from the shoulder with two tendons, the biceps joins at the elbow to form a tendon that attaches extensively to the radius.
This tendon attachment can become inflamed (tendinitis), which can lead to a painful partial rupture and finally to a complete rupture.
Biceps tendinitis causes pain in the elbow due to inflammation. Partial rupture leads to weakness and dysfunction of the muscle via inflammation. The complete tear is a severe soft tissue trauma with copious bleeding and swelling.
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In addition to the pain in the elbow, especially when weight is applied, the increasing tendon defect is manifested by a loss of strength when bending and turning the elbow, which can be up to 50% when bending and 30% when turning.
The diagnosis of complete biceps retinal rupture is clinically apparent. An ultrasound or MRI confirms the diagnosis and shows how far the tendon has retracted into the upper arm. Tendinitis or partial rupture can only be confirmed by MRI or ultrasonography.
Rupture should be operated on as soon as possible, as the tendon can retract severely, and extensive reconstruction with donor tissue may then be necessary. Tendinitis as well as partial rupture can be treated conservatively in the first instance. Eccentric training, focused shock wave therapy, and ultrasound-targeted infiltrations with PRP are promising measures.
In case of failure of conservative therapy or a complete tear, the tendon stump is refreshed and anchored back into the radius during surgery. In my preferred, but not simple, technique, the stump of the tendon is anchored in the depth of the elbow with a metal plate in a blind hole in the radius, sparing important nerves and vessels. This surgical technique with the most stable fixation means that no immobilization is necessary postoperatively and immediate movement is possible. Isometric strength training is not allowed until after 6 weeks, and a return to manual activity or sports is not allowed until after 12 weeks.
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In elbow stiffness, the soft tissues around the elbow stick together. Scar strands form in the joint, restricting movement. Ossifications can form as well.
The importance of elbow functions are not immediately obvious, but are extremely limiting when lost, as basic needs such as bringing the hand to the head to eat, drink, blow the nose, put on glasses, and more depend on them.
Inability to bend or extend the elbow or to perform a twisting movement is called elbow stiffness or restricted movement.
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The causes of elbow stiffness can be primarily osteoarthritis, jamming joint bodies, bone neoplasms impeding movement, or prolonged immobilization in a cast.
Diagnosis is made after clinical examination and by X-ray. The extent of bony neoplasms is best assessed on computed tomography; MRI shows mainly soft tissue thickening.
It is important to first determine why the elbow stiffness occurred, since sometimes a ligament instability can be behind it, which then also needs to be treated.
In principle, the treatment is conservative. Especially a pure soft tissue stiffness with thickening of joint capsule, tendons and ligaments can be treated very well with physiotherapy and ultrasound-targeted hydrodilation. This is done analogously to the shoulder, inflating the joint with a mixture of local anesthetic, cortisone, and lots of sodium chloride solution.
Stubborn soft tissue stiffness or elbow stiffness caused by bony causes then require surgical intervention by means of arthroscopy, capsular mobilization, removal of bony obstructions, and possibly nerve mobilization.
It is important to mobilize the elbow immediately and consistently after surgery, ideally under a pain blockade in which the arm nerve plexus is switched off.
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Osteoarthritis of the elbow is less common than in other joints due to the less severe stress and also causes less pain. Predominant is the restriction of movement, which is the main problem.
Causes of elbow osteoarthritis are fractures caused by direct trauma, but also by slight changes in the mechanics of the elbow, causing post-traumatic osteoarthritis, although only tele of the joint may be affected. Normal elbow joint wear is rare, but can occur with certain manual activities, such as work with a sledgehammer.
Repeated microtrauma, such as boxing or even after fractures, can cause free joint bodies to form, leading to entrapment symptoms.
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This and the wear and tear of the cartilage lead to painful synovitis with swelling. Patients with a swollen elbow can then only bend and extend it to a very limited extent.
An X-ray shows the wear and also already free joint bodies in the elbow. MRI can be used to precisely localize the cartilage lesions, and CT can then be used to localize the free joint bodies
Osteoarthritis, especially in the elbow joint, can be successfully treated conservatively for a very long time. Exercise therapy, manual joint distraction, and especially then regenerative measures such as ultrasound-targeted injections with PRP, stem cell concentrates if necessary, and hyaluronic acid can regenerate the joint environment and reduce friction so that the inflammatory response is suppressed.
If conservative therapy fails or if there are signs of entrapment due to free joint bodies, surgical intervention by arthroscopy is recommended to remove the painful joint skin, free joint bodies and sharp-edged osteophytes. After such a procedure, the elbow should be moved again immediately and pain ideally pushed back 5-7 years.
Only in rare cases of pronounced osteoarthritis is surface or joint replacement necessary.
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Chronic overuse, repeated microtrauma or even major trauma can lead to injuries of the lateral ligamentous apparatus at the elbow and thus to instability. Often this pain can be misinterpreted as medial or lateral epicondylitis (tennis elbow or golfer’s elbow) and accordingly treated conservatively for a long time without success.
First and foremost, throwing and impact sports, as well as recurrent overuse and microtrauma to the elbow, pose the risk of permanent instability in addition to major injuries such as elbow dislocation. In particular, the primary suspected diagnosis of epicondylitis and its treatment with cortisone infiltrations can contribute to further injury to the collateral ligament apparatus.
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The diagnosis of elbow insufficiency or collateral ligament injury is often difficult. The patient typically does not come to the physician with a complaint of instability, but reports the nonspecific symptom of “pain.” Clinical examination of lateral ligament instability is performed by stress testing of the lateral ligamentous apparatus. Internally, instability can usually be diagnosed very well. However, the more common posterolateral roation instability on the outer side can often be insufficiently detected. The problem is that due to the muscular bias, it is hardly meaningful in the awake patient. Only during anesthesia or under arthroscopic control does a provocation test reveal the true instability. Because in posterolateral rotational instability the anatomical unit of the radius and ulna rotates out of the joint to the humerus due to instability of the radial (external) collateral ligament complex, this rotational motion is often known as the mechanism of trauma.
An MRI scan is also a very sensitive exam to detect a collateral ligament injury. Unfortunately, the findings are often misinterpreted as inflammation, and the severity of the instability cannot be determined either, since MRI is a static examination. However, concomitant pathologies such as free joint bodies, cartilage damage, subluxation positions of the joint, etc. can be visualized very well.
Ultimately, diagnostic elbow arthroscopy is the last resort to reliably detect posterolateral rotational instability and perform reconstruction of the insufficient ligaments with autologous tendons to restore joint stability.
Treatment is exclusively surgical by reconstructing the torn ligament. This is done with a combined procedure of arthroscopic and open approach. After the instability is identified during elbow arthroscopy, a piece of the triceps tendon is openly harvested and then woven between the humerus and ulna as a ligament replacement. Postoperatively, a splint must be worn for 6 weeks, with movements already allowed during the last 2 weeks. After that, a gradual muscle build-up is carried out. Full loading is possible again after 3 months. The surgery has a success rate of over 90%, but only if performed by a specialist, as it is an extremely complex procedure.
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