TENDON AND LIGAMENT DISORDERS AT THE ELBOW
Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, or “tennis elbow,” is due to degenerative changes or tendinosis at the origin of the common extensor tendons. The most commonly affected tendon is the extensor carpi radialis brevis (ECRB), but the other common extensor tendons may also be involved. The condition does not typically occur directly at the lateral epicondyle but just distal to this point at the tendon origin. The disease process is a degenerative rather than an inflammatory condition; therefore, tendinosis is a better descriptive term than epicondylitis. The condition most commonly affects patients age 30 to 60 years, and symptoms include chronic lateral elbow pain that is aggravated by wrist extension and/or forearm supination, particularly repetitive activities that involve these motions. Examination of the elbow demonstrates tenderness to palpa- tion just distal and posterior to the lateral epicondyle, at the origin of the ECRB and other common extensor tendons (see ). This pain is worsened by resisted wrist extension and/or resisted long finger extension (isolates the ECRB).
Nonoperative management consists of activity modification, nonsteroidal anti-inflammatory drugs, cortisone injections, physical therapy, and splinting for symptom relief. Therapy is focused on both strengthening and stretching of the affected muscles. Splinting can include a wrist splint to place the extensor tendons in a resting position or a counterforce strap to unload the area of tendinosis during lifting activities. Cortisone injections can be beneficial but if too frequent can cause tissue atrophy or even rupture of the common extensor or lateral collateral ligament origin. Surgery is indicated when nonoperative measures fail and involves debridement of the area of tendinosis to remove the degenerated tissue. Arthroscopic techniques are now being used in some instances for this procedure.
Medial Epicondylitis (Golfer’s Elbow)
Medial epicondylitis, or “golfer’s elbow,” is due to degenerative changes or tendinosis at the origin of the flexor-pronator mass. The pronator teres and flexor carpi radialis are the most commonly involved tendons. As with lateral epicondylitis, the disease process involves the tendon origin rather than the epicondyle directly and is a degenerative rather than an inflammatory condition. Therefore, tendinosis is a better description for the condition than epicondylitis. Symptoms include chronic medial elbow pain that is aggravated by wrist flexion and/or forearm pronation. Examination of the elbow demonstrates tenderness to palpation just distal and anterior to the medial epicondyle, at the origin of the flexorpronator mass. Resisted wrist flexion and/or forearm pronation exacerbate the pain. Care must be taken to distinguish symptoms of medial epicondylitis from those that may be coming from the cubital tunnel, because both conditions may occur together. Treatment tis utilizes similar strategies as treatment for lateral epicondylitis. Surgical intervention may require addressing the ulnar nerve if symptoms of cubital tunnel syndrome are also present.
The olecranon bursa is a common site to develop bursitis because of its superficial location and the tendency to put pressure on this area from leaning on the elbow.
It may develop from a direct blow, repetitive activities that aggravate the site, inflammatory conditions such as gout and rheumatoid arthritis, or infectious situations. A septic olecranon bursitis can occur from a direct inoculation or may develop secondarily as a complication of treatment for an aseptic olecranon bursitis. Pain and swelling over the olecranon process are common findings, with palpable fluctuance when a significant fluid collection is present. Worrisome signs for infection include warmth, erythema, and more severe pain or purulent drainage from a wound site.
Mild, aseptic cases can be managed with activity modification aimed at avoiding direct pressure on the site, with or without the use of a compressive dressing or short-term splint for further protection. Cases with a significant fluid collection should be aspirated, with the fluid sent for Gram stain, culture, and cell count if infection is a concern. Aseptic cases can be injected with cortisone after aspiration and protected with a compressive dressing or short-term extension splint to help prevent fluid reaccumulation. Septic olecranon bursitis should be treated with antibiotics in combination with serial aspirations or surgical drainage. Occasionally, surgical excision of a chronically inflamed olecranon bursa is performed, such as in inflammatory conditions like gout and rheumatoid arthritis. However, wound healing can be a concern after this procedure, with the risk of developing a nonhealing wound.
Rupture Of The Distal Biceps Tendon
This uncommon injury, which is associated with degenerative changes in the distal biceps tendon, is usually caused by a sudden, forceful flexion of the elbow against resistance. Rupture usually occurs at the tendon insertion on the radial tuberosity and is seen primarily in males 40 to 60 years old. Patients often report the sensation of an acute “pop” in their elbow at the time of injury, followed by the development of swelling, ecchymosis, and cosmetic deformity. If the tendon retracts proximally after rupture, an obvious defect is seen in the antecubital fossa (see ). Occasionally, tendon retraction will not occur after injury because the bicipital aponeurosis remains intact and a clinical deformity may not be obvious. Strength testing after complete rupture typically shows a loss of elbow flexion strength of 15% to 30%, and a loss of forearm supination strength of 40% to 50%. Surgical repair of the ruptured tendon is best done within the first several weeks after injury, before the tendon becomes significantly retracted, and can be performed through a single-incision or two-incision technique. Chronic injuries can be difficult to repair because the tendon may be too scarred and retracted to be brought back to bone. In such instances, a graft tissue (i.e., semitendinosus autograft or allograft, Achilles tendon allograft) may be used to span the defect, but results are much less successful than those after a primary, acute repair. Chronic injuries may do well with nonoperative management focused on physical therapy to regain as much strength and function as possible, but supination weak-ness is typically still noticeable.
Rupture Of The Distal Triceps Tendon
Rupture of the distal triceps tendon is an even rarer injury than rupture of the distal biceps but may occur more equally in both males and females. The mechanism of injury is usually caused by a sudden, forceful extension of the elbow against resistance, and rupture usually occurs at the tendon insertion on the olecranon. As with distal biceps rupture, clinical findings include swelling, ecchymosis, and cosmetic deformity. Strength testing after rupture shows a loss of elbow extension strength. This injury may be more subtle than distal biceps rupture and may require advanced imaging, such as MRI, to confirm the diagnosis. Surgical repair of the ruptured tendon is also best done within the first several weeks after injury, before the tendon becomes significantly retracted. Chronic injuries also may require reconstructive techniques with graft tissue, such as Achilles tendon allograft, to span a defect.
The anterior band of the medial or ulnar collateral ligament originates at the midportion of the medial epicondyle and inserts onto the coronoid or sublime tubercle of the ulna and is the primary restraint to valgus stress of the elbow (see Plate 2-6). Disruption or attenuation of this ligament will lead to medial or valgus elbow instability. Typically this is a chronic overuse injury, such as with repetitive overhead use or throwing. Rarely, isolated, acute rupture of this ligament can occur from a valgus load, such as a fall on an out-stretched hand. The ligament may also be acutely injured in the setting of an elbow dislocation. In chronic throwing injuries, pain is usually gradual in onset along the medial side of the elbow and associated with the acceleration phase of pitching, when valgus stress across the elbow is greatest. Tearing typically occurs in the midsubstance of the ligament or at the distal insertion with these injuries. Associated pathologic processes may be present in throwers, including ulnar neuritis, posteromedial olecranon osteophytes, loose bodies, or osteochondritis dissecans of the capitellum. Valgus instability may be difficult to elicit in an awake patient on examination because of muscle guarding, but patients will typically complain of pain and/or appre-hension with valgus stress testing.
Treatment is initially nonoperative and includes rest and activity modification, followed by a graduated rehabilitation and/or throwing program. Surgery is indicated for failure of nonoperative management and consists of ulnar collateral ligament reconstruction with autograft (i.e., palmaris longus) or allograft (i.e., semi-tendinosus) tendon and treatment of any associated pathologic processes, such as ulnar nerve decompression. In the rare cases of acute, isolated rupture of the ulnar collateral ligament, surgical repair of the torn ligament can be performed.
Posterolateral Rotatory Elbow Instability
The ulnar component of the lateral collateral ligament complex, or the lateral ulnar collateral ligament (LUCL), originates from the anteroinferior portion of the lateral epicondyle and inserts onto the supinator crest of the ulna (see Plate 2-6). This ligament is the primary restraint to varus stress of the elbow, and ligament disruption leads to posterolateral rotatory instability. Injuries to the LUCL typically occur from a varus stress to the elbow when it is in an extended and pronated position, such as in a fall on an outstretched hand. The ligament may also be acutely injured in the setting of an elbow dislocation. Rarely, iatrogenic injury can occur during elbow surgery for another reason (i.e., lateral epicondylitis debridement) or from excessive cortisone injections on the lateral side of the elbow. Traumatic tearing typically occurs at the proximal origin of the ligament. Symptoms include lateral elbow pain and instability complaints, such as catching or giving way of the elbow. As with the medial side of the elbow, instability may be difficult to elicit in an awake patient on examination due to muscle guarding, but patients may complain of pain and/or apprehension with varus or posterolateral stress testing (see ).
Treatment is initially nonoperative and includes rest, activity modification, and a rehabilitation program. A hinged elbow brace may be useful in the acute setting to provide stability while the injury is healing. Surgery is indicated for failure of nonoperative management and consists of LUCL reconstruction with a tendon graft. In cases of acute, isolated rupture of the LUCL, surgical repair of the torn ligament can be performed.