Elbow

Cubital Tunnel Syndrome

Cubital Tunnel Syndrome is a condition characterized by compression of the ulnar nerve in an area of the elbow called the cubital tunnel.

The ulnar nerve travels down the back of the elbow behind the bony bump called the medial epicondyle, and through a passageway called the cubital tunnel. The cubital tunnel is a narrow passageway on the inside of the elbow formed by bone, muscle, and ligaments with the ulnar nerve passing through its center. The roof of the cubital tunnel is covered with a soft tissue called fascia.

When the elbow is bent, the ulnar nerve can stretch and catch on the bony bump. When the ulnar nerve is compressed or entrapped, the nerve can tear and become inflamed leading to a variety of symptoms, called cubital tunnel syndrome.

Signs and Symptoms

In general, signs and symptoms of Cubital Tunnel Syndrome arise gradually, progressing to the point where the patient seeks medical attention. Left untreated, Cubital Tunnel Syndrome can lead to permanent nerve damage in the hand. Commonly reported symptoms associated with Cubital Tunnel Syndrome include:

• Intermittent numbness, tingling, and pain to the little finger, ring finger, and the inside of the hand. These symptoms occur more frequently at night, and with elbow bending or prolonged resting on the elbow.
• Aching pain to the inside of the elbow
• Weakness in hand with diminished grip strength
• Diminished sensation and fine motor control in the hand causing the person to drop objects or have difficulty in handling small objects.
• Muscle wasting in the hand and permanent nerve damage, if left untreated.

Causes

The common causes responsible for cubital tunnel syndrome, include:

• Trauma
• Repetitive motion
• Frequent pressure on the elbow for extended periods due to sitting posture
• Medical Conditions such as bone spurs, ganglion cysts, or tumors in the cubital tunnel leading to pressure and irritation of the ulnar nerve.

Diagnosis

Your physician will perform the following:

• Medical History
• Physical Examination

Your physician may order X-ray and electro diagnostic tests such as electromyography and nerve conduction studies. These tests can assist your doctor in determining how well the nerve is functioning and locate areas of muscle wasting and nerve compression.

Treatment

Your physician will recommend conservative treatment options initially to treat the symptoms unless muscle wasting or nerve damage is present.
Conservative treatment options may include:

• Avoid frequent bending of the elbow.
• Avoid pressure to the elbow by not leaning on it. Elbow pads may be worn to decrease pressure when working at a desk.
• Wear a brace or splint at night while sleeping to keep the elbow in a straight position. You can also wrap the arm loosely with a towel and apply tape to hold in place.
• Avoid activities that tend to bring on the symptoms.
• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) such as ibuprofen or aspirin, may be ordered to reduce swelling.
• Referral to OT (Occupational Therapy) for instruction in strengthening and stretching exercises may be recommended.

If conservative treatment options fail to resolve the condition or if muscle wasting or severe nerve compression is present, your surgeon may recommend a surgical procedure to treat your condition.

The goal of Cubital Tunnel surgery is to reduce the pressure on the ulnar nerve by providing more space for the nerve to move freely and to increase blood flow to promote healing of the ulnar nerve. There are different surgeries that can be performed to treat your condition, such as:

Medial Epicondylectomy:  This surgery involves removing the medial epicondyle, the bony bump on the inside of the elbow, enabling the ulnar nerve to glide smoothly when the elbow is flexed and straightened.

Ulnar Nerve Transposition:  This surgery involves creating a new tunnel in front of the medial epicondyle and transposing (moving) the ulnar nerve to the new tunnel.

Your surgeon will decide which options are best for you depending on your specific circumstances.

Post-Operative Care

After surgery, your surgeon will give you guidelines to follow depending on the type of repair performed and the surgeon’s preference. Common post-operative guidelines include:

• A bulky dressing with a plaster splint is usually applied following surgery for 10-14 days.
• Elevating the arm above heart level and moving the fingers are important to prevent swelling.
• The arm dressing is removed after 10-14 days for removal of the sutures.
• Elbow immobilization for 3 weeks after surgery is usually indicated, longer depending on the repair performed.
• Ice packs are applied to the surgical area to reduce swelling. Ice should be applied over a towel to the affected area for 20 minutes every hour. Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
• Occupational Therapy will be ordered a few weeks after surgery for strengthening and stretching exercises to maximize use of the hand and forearm

Risks and Complications

Most patients suffer no complications following Cubital Tunnel surgery, however, complications can occur following elbow surgery and include:

• Infection
• Nerve damage causing permanent numbness around the elbow or forearm.
• Elbow instability
• Elbow flexion contracture
• Pain at site of scar
• Symptoms unresolved even after the surgery

Tennis Elbow

Tennis elbow is the common name used for the elbow condition called lateral epicondylitis. It is an overuse injury that causes inflammation of the tendons that attach to the bony prominence on the outside of the elbow (lateral epicondyle). It is a painful condition occurring from repeated muscle contractions at the forearm that leads to inflammation and micro tears in the tendons that attach to the lateral epicondyle. The condition is more common in sports activities such as tennis, painting, hammering, typing, gardening and playing musical instruments. Patients with tennis elbow experience elbow pain or burning that gradually worsens and results in a weakened grip.
Your doctor will evaluate tennis elbow by reviewing your medical history, performing a thorough physical examination and ordering X-rays, MRI or electromyogram (EMG) to detect any nerve compression.

Your doctor will first recommend conservative treatment options to treat the tennis elbow symptoms. These may include:

• Limit use and rest the arm from activities that worsen symptoms.
• Splints or braces may be ordered to decrease stress on the injured tissues.
• Apply ice packs on the elbow to reduce swelling.
• Avoid activities that bring on the symptoms and increase stress on the tendons.
• Anti-inflammatory medications and/or steroid injections may be ordered to treat pain and swelling.
• Physical therapy may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased.
• Pulsed ultrasound may be utilized to increase blood flow and promote healing to the injured tendons.

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend a surgical procedure to treat tennis elbow called lateral epicondyle release surgery. Your surgeon will decide whether to perform your surgery in the traditional open manner (single large incision) or endoscopically (2 to 3 tiny incisions and the use of an endoscope - narrow lighted tube with a camera). Your surgeon will decide which options are best for you depending on your specific circumstances.

Your surgeon moves aside soft tissue to view the extensor tendon and its attachment on the lateral epicondyle. The surgeon then trims the tendon or releases the tendon and then reattaches it to the bone.  Any scar tissue present will be removed as well as any bone spurs. After the surgery is completed, the incision(s) are closed by suturing or by tape.

Following surgery, you are referred to physical therapy to improve the range of motion and strength of your joint.

Rupture of the Biceps Tendon

The biceps muscle is in the front of your upper arm. It helps in bending your elbow, rotational movements of your forearm and maintaining stability in the shoulder joint. It has two tendons, one of which attaches it to the shoulder bone (proximal biceps tendon) and the other attaches it at the elbow (distal biceps tendon). The biceps tendon can tear at the shoulder or elbow with overuse, or injury when you lift heavy objects or fall on your hand.

Biceps tendons can tear partially or completely. The most common symptoms are sudden, severe pain in the upper arm, “pop” sound, swelling, visible bruising, weakness in the elbow, trouble turning your arm from a palm up to a palm down position, and a gap in the front of the elbow caused by the absence of the tendon. A characteristic bulge called a “Popeye muscle” may appear in your arm caused by the recoiled, shortened biceps muscle.

Biceps tendon rupture is usually diagnosed based on your symptoms, medical history and physical examination. During the physical examination, your doctor will look for a gap in the tendon by palpating the front part of your elbow, and diagnose a partial tear by the presence of pain when you bend your arm and tighten the biceps muscle. X-rays may be taken to rule out other conditions causing elbow pain and an MRI scan, to determine if the tear is partial or complete.

Mild biceps tendon tears can be treated with conservative methods such as rest, ice application, non-steroidal anti-inflammatory medications (NSAIDs) and physical therapy. When nonsurgical methods fail to relieve symptoms, surgery is performed to reattach the torn tendon to the bone. This can be done by drilling holes in the bone and anchoring the tendon with stitches or by using small metal implants.