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 Plate 2-38).
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.
 |
| EPICONDYLITIS AND OLECRANON BURSITIS |
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.
Olecranon Bursitis
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 BICEPS AND TRICEPS TENDON |
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 Plate 2-39).
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.
 |
| MEDIAL ELBOW AND POSTEROLATERAL ROTATORY INSTABILITY TESTS |
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 Plate 2-40).
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.
