Serving as the link between the powerful strong movements of the shoulder joint and the fine movements of the hand. The elbow is a common area of overuse and injury. Even minor injuries to the elbow can be severely disabling and impair the ability to use the entire arm correctly.
The most common workplace accidents resulting in lost time from the job are sprains, strains and tears. These are injuries to the muscles, ligaments and tendons that are the result from twisting, stretching, overuse or overexertion.
These injuries certainly can result from trauma but more commonly the result from repetitive stress to the tissues.
One of the most common work- related stress injuries reported is Tennis Elbow. This is a very common repetitive stress injury to the lateral aspect of the elbow. This injury is common result of tasks such as painting, operating tools, cutting, welding, and repeated motion such as picking up objects.
Medial epicondylitis is a traumatic stress injury called Golfers Elbow. In 2019, 34.2 million people played golf either on a formal golf course or off course such as a driving range or indoor simulators. Tennis Elbow is lateral epicondylitis of the elbow. In 2020, 17.84 million people played tennis in the US. (6.7 million of those participated in tennis activities greater than 10 times a year). Of recreational causes of elbow overuse injuries, throwing sports are one of the most common etiologies. In the US, 40 million people participated in baseball or softball in 2019. This includes all age groups from young to old with 18 million playing in softball alone.
The most common elbow injuries seen by medical professionals are lateral and medial epicondylitis.
Structure of the elbow joint
Elbow is composed of 3 bones
- Humerus
- Radius
- Ulna
Articulations of the elbow
- Humeroulnar joint- This is a modified hinge joint and allows flexion and extension
Flexion to 145 degrees/ extension to 0 minus 5 degrees
- Humeroradial joint- This is a modified hinge joint that allows flexion and extension but also pronation and supination, Pronation 90 degrees/Supination 90 degrees
Supination forearm- Movement at the radioulnar joints allowing to palm to turn upward as if holding a bowl of soup
Pronation forearm- movement at the radioulnar joints allowing the palm to be turned downward as if pouring that bowl of soup down the drain
Proper Anatomical Position
To understand the further structures and function of the elbow, understanding the proper anatomical position is critical. The proper anatomical position is standing with arms at the sides with palms forward. The lateral aspect is the outside of the elbow, the thumb is on the outside.
This is the radial bone side.
The medial side is the closest to the body.
The medial side is the side of the 5th finger
The medial side is the ulnar bone side.
Supporting structures
Medial elbow is supported against valgus stress by the ulnar collateral ligament.
The ulnar collateral ligament has three unique sections:
- Anterior bundle- originates from the inferior surface of the median epicondyle of the humerus and passes to insert on the coronoid process of the ulna
- Transverse bundle originates from the median epicondyle of the humerus and also inserts on the coronoid process of the ulna
- Posterior bundle inserts on the olecranon process of the ulna
Lateral elbow is supported against varus stress by the radial collateral ligament
The radial collateral ligament is a thickened area in the lateral joint capsule between the lateral epicondyle of the humerus and the annular ligament at the radial head. This ligament resists varus forces but also assists in maintaining the close relationship between the humerus and radial head articulation
Annular ligament encircles the radial head and it permits the internal and external rotation of the radial head on the humerus.
Interosseous Membrane
This dense band of fibrous connective tissue spans between the length of the radius and ulna and serves as a stabilizer. The fibrous arrangement of this structure transmits force applied to the wrist. The force is then absorbed by the radius and ulna.
Muscles
The muscles inserting on the proximal radius and ulna act to flex and extend the elbow and to pronate and supinate the forearm. Many of the prime muscles that move the wrist and hand originate from the epicondyles of the humerus and the proximal radius and ulna.
Elbow Flexor and Supinator Group
- Biceps brachii
- Brachialis
- Brachioradialis
- Supinator
Elbow Extensor and Pronator Group
- Triceps
- Anconeus
- Pronator teres
- Pronator quadratus
Wrist Flexor Group Tendon
The origin of these tendons is the median epicondyle of the humerus at the common flexor tendon.
Wrist Extensor Group Tendon
The origin on the lateral side epicondyle of the humerus where the common extensor tendon of the wrist is located.
Epicondylitis
Medial Epicondylitis
Activities involving the swift powerful snapping of the wrist and the pronation of the forearm transfer force to the medial epicondyle. Overuse can cause pin point tenderness at the origin of the of the pronator teres, flexor carpi radialis palmaris longus and the flexor carpi ulnaris tendon on the medial epicondyle. In young pitchers in baseball this may result in a avulsion of the tendon from the attachment site and has been named “little leaguer’s elbow”.
The ulnar collateral ligament is also in close proximity to this site and injury or tear can lead to surgery called “Tommy John” surgery. It was named after the famous baseball pitcher first to have this type of surgery.
Lateral Epicondylitis
Inflammation of the common tendon of the extensor group of the wrist is called lateral epicondylitis.
This group of muscles includes; the extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum communis and the supinator. The most common muscle effected is the extensor carpi radialis brevis.
Lateral epicondylitis is common in all racquet sports and more than half of all tennis players are affected by “tennis elbow” during their playing years. In tennis, the pain over the lateral epicondyle is increased during backhand strokes. In all others, gripping an item and lifting it up such as lifting a heavy jar from a box, causes increased pain.
Diagnosis of Medial and Lateral Epicondylitis
- Diagnosis is made clinically but history and physical exam. Palpation over these areas can reproduce the pain and flexion and extension of the wrist against resistance will increase the pain confirming the etiology
- X rays can reveal calcifications in the surrounding tissues or insertion sites and are beneficial to rule out other bony pathologies
- MRI is useful in evaluating the extent or severity of the disease and the presence of other pathologies
- Ultrasound can evaluate changes in the region and structural changes and echo texture of the common tendon
- EMG are only used if there is suspicion of nerve pathology from the cervical spine or brachial plexus pathology causing the pain
Treatment of Medial and Lateral Epicondylitis
- Conservative treatment is the primary treatment. Stop the offending motion such as pitchers stop throwing the baseball. Rest is mandatory, Ice, Heat, Ultrasound can all be used in the acute period
- Brace or splinting may also be used acutely but long term can have negative consequences such as forearm weakness
- Physical Therapy is used to increase pain free range of motion and strengthen muscles
- Non-Steroidal Anti-Inflammatory Agents used for pain and to reduce inflammation but again can have complications long term
- Extra-corporal shock wave therapy has been proven effective in pain relief and elbow function
- Injectables corticosteroids, botulinum toxin, lidocaine, platelet- rich-plasma, hyaluronic acid
- Surgery
Surgery
Although the greater majority of epicondylitis cases can be treated conservatively or non -operatively 4-11% of patients with pain greater than 6 months duration and functional disability non-responsive to other therapies require some type of surgical intervention.
Surgical interventions can include tendon resection via arthroscopic approaches or open surgery.
Injections
Non-invasive interventional therapies with injections are widely used with excellent short and long term outcomes.
- Corticosteroids are commonly used and has been the mainstay treatment modality for years. However, in many studies, the anti-inflammatory properties are reported to have only a short- term efficacy for pain relief and improved outcomes measure by clinical scores. The repeated use of corticosteroids is discouraged due to its adverse effects such as weakening of the tendon.
- Botulinum toxin blocks neural impulses by inhibiting acetylcholine and consequent paralysis of target muscle. Although widely studied as an inducer of the repair of the affected tendon during a temporary rest period, it is not widely used. Several favorable studies have demonstrated long term clinical outcomes in pain and clinical scores when compared to other therapies and therefore could be considered in refractory cases as an alternative to surgery.
- Hyaluronic acid is one of the components of synovial fluid and tendon extracellular matrix and has been proven to yield beneficial effects both in pain relief but functional improvements after injection. A study in sports athletes has shown superior pain relief and an earlier return to normal activities vs control.
- Platelet- Rich-Plasma defined as an autologous blood product with concentrations of platelets greater than baseline. PRP releases substances that promote tissue repair and influence the reactivity of vascular and other blood cells in angiogenesis and inflammation. Many reports on the use of PRP for epicondylitis describe superior results compared to other treatments.
Local corticosteroid injections were considered to be the gold standard for the treatment of epicondylitis. However, many studies have proven corticosteroids provided only a short -term benefit. Many studies have now proven PRP to be superior to corticosteroids in intermediate and long- term benefit.
WHY?
Initially epicondylitis was believed to be only an inflammatory process. In 1979, it was described as the disorganization of normal collagen architecture by invading immature fibroblasts in association with an immature vascular reparative response. Tendon injuries in epicondylitis share common histologic findings characterized by angio-fibroblastic hyperplasia showing a disorganized mix of immature collagen fibers with fibroblastic and vascular components. Microscopic studies of these tissues has proven the tissues of epicondylitis are a failure of reparative responses rather than an inflammatory process.
Based on the above evidence, corticosteroids may aid in acute pain but NOT in the long-term treatment of epicondylitis.
Therefore, Corticosteroids have limited long term effects and results in tendon degeneration with chronic use, platelet-rich-plasma is the best long- term choice for pain and functional outcomes in epicondylitis.
Studies
- Platelet-Rich-Plasma vs corticosteroids for elbow epicondylitis Medicine 2019 Dec;98(51): e18358 PMID 31860992
Purpose- The aim of this meta-analysis was to compare the effectiveness of PRP vs corticosteroids for the treatment of lateral elbow epicondylitis
Results- Corticosteroids demonstrated favorable outcomes vs PRP during the short term 4-8 weeks post injection. However, PRP had improved outcomes over corticosteroids at the long term follow up at 24 weeks. PRP provided improved pain and function as proven by the VAS and DASH scores
- To Improve Pain and Function, Platelet-Rich-Plasma Injections May Be an Alternative to Surgery for Treating Lateral Epicondylitis: A Systemic Review
Purpose: To determine whether PRP injection for lateral epicondylitis offers patients comparable outcomes to lateral epicondylar surgery
Results: In Comparison with surgery, PRP offers similar improvements in pain and function for patients suffering from lateral epicondylitis. PRP injections are an appropriate alternative for the treatment of lateral epicondylitis
- Platelet-Rich-Plasma Is an Equal Alternative to Surgery in the Treatment of Type 1 Medial Epicondylitis Orthop J Sports Med 2020 Mar25;8(3): 2325967120908952 PMID 32232070
Purpose: To compare the outcomes of recalcitrant type medial epicondylitis after treatment with either PRP or surgery
Conclusion: The use of PRP showed clinically similar outcomes to those of surgery. PRP can be considered as an alternative to surgery in the treatment of medial epicondylitis with an earlier time to full ROM and time to pain free status.
- Platelet-Rich-Plasma verses TENEX in the Treatment of Medial and Lateral Epicondylitis J Shoulder Elbow Surg 2019 Jan;28(1): 112-119. PMID 30551782
Purpose: To compare the effectiveness of PRP vs tenotomy for the treatment of medial and lateral epicondylitis
Results: The PRP and Tenex procedures were both successful in producing clinically and statistically significant improvements in pain, function and quality of life
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