Anatomy

Rationale

Preparation

Complications

After Surgery

Our Rehabilitation

Anatomy

Rationale

Preparation

Surgical Procedure

Complications

After Surgery

Our Rehabilitation

Anatomy

Rationale

Preparation

Surgical Procedure

Complications

Our Rehabilitation

Anatomy

Rationale

Preparation

Surgical Procedure

Complications

After Surgery

Our Treatment

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Tennis Elbow (Lateral Epicondylitis).

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tennis can strain the muscles and tendons of the elbow in a way that leads to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow: painting with a brush or roller, running a chain saw, and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

This article will help you understand:

• what parts of the elbow are affected
• the causes of tennis elbow
• ways to make the pain go away

Anatomy

What parts of the elbow are affected?

Tennis elbow causes pain that starts on the outside bump of the elbow, the lateral epicondyle. The forearm muscles that bend the wrist back (the extensors) attach on the lateral epicondyle and are connected by a single tendon. Tendons connect muscles to bone.

Lateral Epicondyle

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Collagen

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

When you bend your wrist back or grip with your hand, the wrist extensor muscles contract. The contracting muscles pull on the extensor tendon. The forces that pull on these tendons can build when you grip things, hit a tennis ball in a backhand swing in tennis, or do other similar actions.

Elbow Anatomy Introduction

Causes

Why did I develop tennis elbow?

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the lateral epicondyle is called lateral epicondylitis.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Scar Tissue

Symptoms

What does tennis elbow feel like?

The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore.

The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Grasping items also makes the pain worse. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won’t straighten out completely.

Diagnosis

How can my health care provider be sure I have tennis elbow?

When you visit First Choice Physical Therapy, our therapist will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing tennis elbow. Our Physical Therapist may position your wrist and arm so you feel a stretch in the forearm muscles and tendons. This is usually painful with tennis elbow. There are also other tests for wrist and forearm strength that we can used to detect tennis elbow.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome, a condition caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, your doctor may suggest tests to rule out problems with the radial nerve.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

The key to nonsurgical treatment is to keep the collagen in your tendon from breaking down further. Our goal is to help the tendon heal.

When you begin your Physical Therapy, our Physical Therapist at First Choice Physical Therapy will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. Our Physical Therapist may advise that you wear an elbow strap that wraps around your upper forearm in a way that relieves the pressure on the tendon attachment.

We may apply ice and electrical stimulation to ease pain and improve healing of the tendon. Our Physical Therapy sessions may also include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine, prescribed by your doctor, into the sore area. This treatment is especially helpful for patients who can’t tolerate injections. Our Physical Therapist will also instruct you in exercises used to gradually stretch and strengthen the forearm muscles.

Because tendonosis is often linked to overuse, we will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, our Physical Therapist will observe your style and motion with the activity. We may provide tips about how to perform the movement so your elbow is protected. We can also check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Although recovery time varies for each patient, in cases where the tendon is inflamed, your First Choice Physical Therapy rehabilitation program is usually only needed for four to six weeks. When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing.

Post-surgical Rehabilitation

Rehabilitation takes much longer after surgery. Immediately after surgery, your elbow is placed in a removable splint that keeps your elbow bent at a 90-degree angle. Your first few Physical Therapy sessions at First Choice Physical Therapy may involve ice and electrical stimulation treatments to help control pain and swelling from the surgery. Our Physical Therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

We will gradually have you work into more active stretching and strengthening exercises. You just need to be careful to avoid doing too much, too quickly. We generally begin active therapy about two weeks after surgery. Our Physical Therapist may begin with light isometric strengthening exercises. These exercises work the muscles of the forearm without straining the healing tissues. You will also use your own muscle power in active range-of-motion exercises.

At about six weeks, we will have you begin more active strengthening. As you progress, our Physical Therapist will teach you exercises to strengthen and stabilize the muscles and joints of the wrist, elbow, and shoulder. You will also do exercises to improve fine motor control and dexterity of the hand. Some of the exercises you’ll do are designed get your hand working in ways that are similar to your work tasks and sport activities. Other exercises will work your elbow in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your elbow.

Although each patient recovers at a different rate, you may need to attend your Physical Therapy sessions for two to three months. It could take four to six months to get back to high-level sports and work activities. Before your therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

When recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

Your doctor may order X-rays of your elbow. The X-rays mostly help your doctor rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the lateral epicondyle at the connection of the extensor tendon.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome. This condition is caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, your doctor may suggest tests to rule out problems with the radial nerve.

When the diagnosis is not clear, your doctor may order other special tests. A magnetic resonance imaging (MRI) scan is a special imaging test that uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.

Ultrasound tests use high-frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show problems with collagen degeneration.

If the problem is caused by acute inflammation, anti-inflammatory medications such as ibuprofen may give you some relief. If inflammation doesn’t go away, your doctor may inject the elbow with cortisone. Cortisone is a powerful anti-inflammatory medication. Its benefits are temporary, but they can last for a period of weeks to several months.

Your doctor may suggest using ultrasound to guide a needle into the sore area. The ultrasound gives a clear picture of areas in the tendon that contain scar tissue. Poking holes in the tendon breaks up scar tissue and gets the tendon to bleed. Bleeding in the tendon helps stimulate the healing response.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for tennis elbow, but recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

Surgery

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.

Tendon Debridement

When problems are caused by tendonosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

Tendon Release

A commonly used surgery for tennis elbow is called a lateral epicondyle release. This surgery takes tension off the extensor tendon. The surgeon begins by making an incision along the arm over the lateral epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the extensor tendon attaches on the lateral epicondyle.

The extensor tendon is then cut where it connects to the lateral epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the lateral epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones.) Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body.) The skin is then stitched together.

This surgery can usually be done on an outpatient basis, which means that you don’t have to stay overnight in the hospital. It can be done using a general anesthetic or a regional anesthetic. A general anesthetic puts you to sleep. A regional anesthetic blocks only certain nerves for several hours. For surgery on the elbow, you would most likely get an axillary block to numb your arm.

Physical Therapy in Lynn Haven and Panama City Beach for Osteoarthritis

Welcome to First Choice Physical Therapy’s patient resource about Osteoarthritis.

The elbow joint is injured less often than many other joints in the body. The most common injuries of the elbow joint are fractures and dislocations. Most elbow injuries tend to heal pretty well.

However, an elbow injury can lead to problems later in life. The injury changes the way the joint works just enough to cause extra wear and tear to the surfaces of the joint. Over time, the joint degenerates, causing pain and difficulty with daily activities. This condition is called osteoarthritis, degenerative arthritis, or posttraumatic arthritis.

This guide will help you understand:

• how elbow osteorarthritis develops
• how elbow osteoarthritis is diagnosed
• what can be done to ease the pain and regain elbow movement

Anatomy

What parts of the elbow are affected?

The elbow joint is made up of three bones: the humerus bone of the upper arm, and the ulna and radius bones of the forearm.

Three Bones in Elbow Joint

The ulna and the humerus meet at the elbow and form a hinge. This hinge allows the arm to straighten and bend. The large triceps muscle in the back of the arm attaches to the point of the ulna (the olecranon). When the triceps muscle contracts, it straightens out the elbow. The biceps muscles in the front of the arm contract to bend the elbow.

View animation of hinge movement:

The connection of the radius to the humerus and the ulna allows the forearm to rotate. The upper end of the radius is round. It turns against the ulna and the humerus as the forearm and hand turn from palm down (pronation) to palm up (supination).

View animation of elbow pronation/supination:

In the elbow joint, the ends of the bones are covered with articular cartilage. Articular cartilage is a slick, smooth material. It protects the bone ends from friction when they rub together as the elbow moves. Articular cartilage is soft enough to act as a shock absorber. It is also tough enough to last a lifetime, if it is not injured.

Related Document: First Choice Physical Therapy’s Guide to Elbow Anatomy

Elbow Anatomy Introduction

Causes

What causes osteoarthritis?

Osteoarthritis is caused by degeneration of the articular cartilage of a joint. Degeneration is wear that happens over time. Doctors use the term degenerative arthritis to describe the wear and tear of a joint over many years. Degenerative arthritis is another term for osteoarthritis.

Degeneration

View animation of degeneration:

Some doctors use the term degenerative arthrosis. (Arthrosis just means that the joint is wearing out.) Arthritis is technically a condition of joint inflammation. Often, joints with osteoarthritis aren’t inflamed. The term arthritis should really only be used to describe true inflammatory conditions, such as gout, infection, and rheumatoid arthritis.

A bad sprain or fracture can actually damage the articular cartilage. The cartilage can also be bruised when too much pressure is put on the cartilage surface. Osteoarthritis (OA) may be idiopathic, meaning there isn’t a known reason for the condition. But most of the time, elbow osteoarthritis is linked with excess use of the arm.

The cartilage surface may not look any different. The injury often doesn’t show up until months later. Sometimes the damage to the cartilage is severe. Pieces of the cartilage can actually be ripped away from the bone. These pieces do not grow back. Usually they must be surgically removed. If the pieces aren’t removed, they may float around in the joint, causing it to catch. These pieces are referred to as loose bodies. They can also cause a lot of pain and do more damage to the joint surfaces.

Your body does not do a good job of repairing these holes in the cartilage surface. The holes fill up with scar tissue. Scar tissue is not as slick or rubbery as the articular cartilage.

An injury doesn’t have to damage the cartilage to start the process of osteoarthritis. Any injury to the elbow joint can change the way the joint works. For example, after an elbow fracture the bone fragments may not line up exactly. They heal slightly differently from their condition before the injury. Even this slight difference can cause the joint to begin the cycle of wear and tear.

A dislocation can also cause lasting damage. After the ligaments have been injured in a dislocation, the elbow joint may move differently. This change in movement alters the forces on the articular cartilage. It’s just like a machine, if the mechanism is out of balance, it wears out faster.

Over many years, this imbalance in joint mechanics can damage the articular cartilage. Since articular cartilage cannot heal itself very well, the damage adds up. Finally, the joint can no longer compensate for the damage, and the elbow begins to hurt.

Osteoarthritis of the elbow isn’t like OA of the hip or knee. Most of the time, the articular cartilage isn’t damaged. The joint space remains close to normal. The biggest changes are hypertrophic osteophyte (bone spur) formation and capsular contracture.

Capsular contracture refers to the process by which the capsule dries out and tightens up. The capsule has two layers: a fibrous covering that surrounds the joint and an inner lining. The inner layer is called the synovium. The synovial layer holds the lubricating fluid inside the joint.

Symptons

What symptoms does osteoarthritis cause?

Pain and stiffness are the main symptoms of osteoarthritis of any joint. At first, the pain comes only with activity. Most of the time the pain lessens while doing the activity, but after resting for several minutes pain and stiffness increase. As the condition worsens, you may feel pain even when resting. The pain may interfere with sleep.

You may have swelling around your elbow. Your elbow joint may fill with fluid and feel tight, especially after using it. When all the articular cartilage is worn off the joint surface, you may begin hearing a squeak and feel a creak in the joint when you move your elbow. This creaking sensation is called crepitus.

Osteoarthritis eventually affects the elbow’s motion. The elbow joint is one of the most sensitive to injury. It quickly becomes stiff and loses motion. The first thing most people notice is that it becomes hard to completely straighten the arm. Later they find it hard to bend.

Loss of motion leads to weakness and decreased function. Carrying heavy objects at the side of the body with the elbow straight is especially difficult.

Diagnosis

How will my health care provider know if I have osteoarthritis?

The diagnosis of osteoarthritis of the elbow begins with a medical history of the problem. When you first visit First Choice Physical Therapy, our Physical Therapist will ask questions about your pain, how it affects your daily activities, and any past injuries to your elbow. Because osteoarthritis develops over a long time, you may be asked questions about things you did long ago.

For example, throwing athletes (such as baseball pitchers) have a higher risk of developing osteoarthritis of the elbow later in life. Men with a history of heavy use of the arm are also at risk. This includes manual laborers and weight lifters.

Our Physical Therapist will also do a physical examination of the elbow and possibly other joints in the body. The moving and prodding may hurt, but it is important that we see exactly where and when you feel pain. Our Physical Therapist will feel for catching sensations as the joint moves. Catching may be caused by loose fragments of cartilage and bone. (These fragments are sometimes called joint mice.)

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

In almost all cases, it is preferable to try nonsurgical treatments first. Surgery is usually not considered until it has become impossible to control your symptoms.

At First Choice Physical Therapy, the goal of nonsurgical treatment of osteoarthritis is to help you manage your pain and use your elbow without causing more harm. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control swelling and pain. We may use other treatments, such as heat, to help control your pain.

The Physical Therapy and occupational therapy programs at First Choice Physical Therapy have a critical role in your treatment plan for elbow osteoarthritis. Our services can help you learn how to control symptoms and maximize the health of your elbow. Our Physical Therapist can show you ways to calm your pain and symptoms. We may instruct you to use rest, heat, or topical rubs.

You may be issued a special elbow splint to immobilize and protect the elbow. Resting the joint can help ease pain and inflammation. Our Physical Therapist may then begin range-of-motion and stretching exercises to improve your elbow flexibility. Strengthening exercises for the arm help steady the elbow and protect the joint from shock and stress. Our therapist will give you tips on how to get your tasks done with less strain on the joint.

To get rid of your pain, you may also need to modify or limit your activities. You may even need to change jobs, if your work requires heavy, repetitive motions with the hand and wrist.

Although the amount of time required for recovery is different for each patient, as a guideline, you will probably progress to a home program within four to six weeks. When recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Post-surgical Rehabilitation

After surgery, your elbow will be bandaged with a well-padded dressing and an elbow splint for support. At First Choice Physical Therapy, you can expect to participate in physical or occupational post-surgical Physical Therapy sessions for up to three months. Our first few treatment sessions will focus on controlling the pain and swelling from surgery. We will then instruct you in exercises that help strengthen and stabilize the muscles around the elbow joint. Our Physical Therapist will also give you tips on ways to do your activities without straining your elbow.

First Choice Physical Therapy provides Physical Therapy services in *client_area*.

Physician Review

Your doctor will probably order standard X-rays. X-rays are usually the best way to see what is happening with your bones. X-rays can help your doctor assess the damage and track how your joint changes over time. X-rays can also help your doctor see how many bone spurs are present and if there are any loose bodies in the joint. X-rays also show the size of the joint space and how much articular cartilage is left.

CT scans give a 3-D view to show the size and location of any bone spurs present. CT scans can reveal osteophytes that don’t appear on plain X-rays. CT scans also show the surgeon how close the bone spurs are to the ulnar nerve. This information is very useful when planning surgery to remove the spurs.

Your doctor may order blood tests if there is any question about the cause of your osteoarthritis. Blood tests can show certain systemic diseases, such as rheumatoid arthritis.

An injection of cortisone into the elbow joint can give temporary relief. Cortisone is a powerful anti-inflammatory medication. It can very effectively relieve pain and swelling. Its effects are temporary, usually lasting several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Surgery

Eventually, it may be necessary to consider some type of surgical treatment. There are several operations to treat advanced osteoarthritis of the elbow. Your surgeon will consider many factors when deciding which procedure is best for you, including the severity of joint degeneration, your age, your activity level, and how you use your elbow.

Arthroscopic Debridement

If you are in an early stage of osteoarthritis, your doctor may recommend arthroscopic debridement. Other names for this procedure include arthroscopic ulnohumeral arthroplasty or osteocapsular arthroplasty.

Arthroscopic procedures use an arthroscope, a tiny TV camera that is inserted into the joint through a very small incision. The arthroscope allows the surgeon to see inside the elbow joint.

In arthroscopic debridement, the surgeon makes other small incisions for inserting special tools to get rid of bone spurs, remove loose bodies, or smooth the cartilage. Sometimes a capsular release is needed. The capsule is a fibrous covering around the joint. An incision is made in the tissue and the anterior (front) of the capsule is removed.

Your surgeon may also do lavage in the joint. Lavage involves rinsing the joint with a sterile saltwater solution. Lavage helps remove tiny debris that may be irritating the joint. The arthroscope allows the surgeon to watch what he or she is doing on a TV screen during the procedure.

The majority of patients treated with arthroscopic debridement for elbow osteoarthritis have less pain and more motion after surgery. Symptoms may come back in some patients, but they are usually less severe.

Interposition Arthroplasty

Before the invention of high-quality artificial joints, surgeons used many techniques to keep the bone surfaces of arthritic joints from rubbing against each other. One of these techniques is distraction interposition arthroplasty. This procedure involves placing a piece of tendon or fascia between the bony surface of the elbow joint. (Fascia is a connective tissue, similar to tendon, that lies in a flat sheet. It covers the muscles and acts as a divider between different compartments of the body.)

As the joint heals, the tendon or fascia forms a cushion of thick, tough tissue between the bones. The tissue pads the ends of the bones and reduces pain while still allowing the elbow to move.

Interposition arthroplasty is rarely indicated but may be used in rare cases. It works fairly well in the elbow. It doesn’t work very well in the weight-bearing joints of the hip, knee, and ankle.

Elbow Fusion

A fusion surgery (also called arthrodesis) eliminates pain by making the bones of the joint grow together, or fuse, into one solid bone. Fusions were very common before the invention of artificial joints. Even today, joint fusions are commonly used in many different joints to get rid of the pain of arthritis.

An elbow fusion will greatly decrease the motion in your arm. However, it does leave you with a strong and pain-free elbow. People who need a good range of motion in their elbow should consider another type of operation, such as an elbow joint replacement.

Elbow Joint Replacement

Elbow joint replacement or total elbow arthroplasty (TEA) is not nearly as common as hip, knee, or shoulder replacement. This is true for a couple of reasons. Osteoarthritis in the elbow is not as common as osteoarthritis in weight-bearing joints.

Elbow Joint Replacement

Elbow joint replacement also has a higher complication rate than the more common replacement surgeries. Infection and slowed healing in the surgical incision are two complications of this type of procedure. Fracture, dislocation, and loosening are other problems reported with total elbow arthroplasty (TEA).

The elbow joint replacement is a good choice for patients who need improved motion rather than strength. Older patients who don’t need as much strength will probably prefer the results of elbow replacement surgery. They must be willing to accept low levels of activity involving the elbow. Patients with advanced rheumatoid arthritis are also good candidates for total elbow arthroplasty (TEA).

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Olecranon Bursitis.

Olecranon bursitis is inflammation of a small sac of fluid located on the tip of the elbow. This inflammation can cause many problems in the elbow.

This article will help you understand:

• how olecranon bursitis develops
• why the condition causes problems
• what can be done for olecranon bursitis

Anatomy

Where is the olecranon bursa, and what does it do?

A bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.

The olecranon bursa is located between the tip, or point, of the elbow (called the olecranon) and the overlying skin. This bursa allows the elbow to bend and straighten freely underneath the skin.

Olecranon Bursa

Related Document: First Choice Physical Therapy’s Guide to Elbow Anatomy

Elbow Anatomy Introduction

Causes

How does olecranon bursitis develop?

Bursitis is the inflammation of a bursa. The olecranon bursa can become irritated and inflamed in a number of ways.

In some cases, a direct blow or a fall onto the elbow can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as olecranon bursitis.

Olecranon bursitis can also occur over a longer period of time. People who constantly put their elbows on a hard surface as part of their activities or job can repeatedly injure the bursa. This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to the same condition in the end: olecranon bursitis.

The olecranon bursa can also become infected. This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, it becomes filled with pus. The area around the bursa becomes hot, red, and very tender.

Symptoms

What does olecranon bursitis feel like?

Olecranon bursitis causes pain and swelling in the area at the tip of the elbow. It may be very difficult to put the elbow down on a surface due to the tenderness. If the condition has been present for some time, small lumps may be felt underneath the skin over the olecranon. Sometimes these lumps feel as though something is floating around in the olecranon bursa, and they can be very tender. These lumps are usually the thickened folds of bursa tissue that have formed in response to chronic inflammation.

The bursa sac may swell and fill with fluid at times. This is usually related to your activity level, and more activity usually causes more swelling. Over time the bursa can grow very thick, almost like an elbow pad on the olecranon.

Finally, if the bursa becomes infected, the elbow becomes swollen and very tender and warm to the touch around the bursa. You may run a fever and feel chills. An abscess, or area of pus, may form on the elbow. If the infection is not treated quickly, the abscess may even begin to drain, meaning the pus begins to seep out.

Abscess Draining

Diagnosis

How do health care providers identify the condition?

The diagnosis of olecranon bursitis is usually obvious from the physical and visual examination. In cases where the elbow swells immediately after a fall or other injury to the elbow, X-rays may be necessary to make sure that the elbow isn’t fractured. Usually chronic olecranon bursitis is also easy to diagnose without any special tests.

If your doctor is uncertain whether or not the bursa is infected, a needle may be inserted into the bursa and the fluid removed. This fluid will be sent to a lab for tests. The results are used to determine whether infection is present. If so, the type of bacteria that is causing the infection is identified. Your doctor will use this information to know what antibiotic will work best to cure the infection.

Our Treatment

Non-surgical Rehabilitation

Chronic olecranon bursitis is sometimes a real nuisance. The swelling and tenderness get in the way and causes pain. This can create a hardship both at work and during recreational activities.

At First Choice Physical Therapy treatment for this condition, usually starts by trying to control the inflammation. This may include a short period of rest. Medications such as ibuprofen and aspirin may be suggested by your doctor to control the inflammation and swelling. An elbow pad might be useful in making it easier to put the elbow on hard surfaces.

When you begin your Physical Therapy program at First Choice Physical Therapy program, our Physical Therapists or occupational therapists may suggest the use of ice and ultrasound to help calm pain and swelling. We may give you tips and strategies to avoid repetitive elbow motion and to do your activities without putting extra pressure on your elbows.

Chronic olecranon bursitis will usually improve over a period of time from weeks to months. The fluid-filled sac is not necessarily a problem. If it does not cause pain, it is not always a cause for alarm or treatment. The sac of fluid may come and go with variation in activity. This is normal.

Post-surgical Rehabilitation

If surgery is required, the Physical Therapists at First Choice Physical Therapy can develop a personalized plan for your rehabilitation. You will initially need a period of rest. Then our Physical Therapist will start you on a careful and gradual exercise program.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Physician Review

Olecranon bursitis that is caused by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks, and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a needle may be inserted to drain the blood and speed up the process. There is a slight risk of infection in putting a needle into the bursa.

Needle Inserted to Drain Blood

Animation of draining the bursa:

During the drainage procedure, if there is no evidence of infection, a small amount of cortisone can be injected into the bursa to control the inflammation. Again, there is a small risk of infection if the bursa is drained with a needle.

If an infection is found to be causing the olecranon bursitis, the bursa will need to be drained with a needle, perhaps several times over the first few days. You will be placed on antibiotics for several days.

Surgery

Bursa Drainage

If the infection is slow to heal, the bursa may have to be drained surgically. This method is different than the nonsurgical drainage mentioned earlier. Surgery to drain the bursa begins with an incision to open the bursa. The skin and bursa are kept open by inserting a drain tube into the bursa for several days. This allows the pus to drain and helps the antibiotics clear up the infection.

Surgical Draining

Bursa Removal

Surgery is sometimes necessary to remove a thickened bursa that has not improved with any other treatment. Surgical removal is usually done because the swollen bursa is restricting your activity.

To remove the olecranon bursa, an incision is made over the tip of the elbow. Since the bursa is outside of the elbow joint, the joint is never entered. The thickened bursa sac is removed, and the skin is repaired with stitches. Your elbow may be placed in a splint to rest the elbow and prevent it from moving for a few days. This allows the wound to begin to heal and prevents bleeding into the area where the bursa was removed.

Incision

Removal of Thickened Bursa

Skin is Repaired

Some types of bursae will grow back after surgery, because the skin needs to slide over the olecranon smoothly. The body forms another bursa as a response to the movement of the olecranon against the skin during the healing phase. If all goes well, the bursa that returns after surgery will not be thick and painful, but more like a normal bursa.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Golfers Elbow (Medial Epicondylitis).

Medial epicondylitis is commonly known as golfer’s elbow. This does not mean that only golfers have this condition. But the golf swing is a common cause of medial epicondylitis. Many other repetitive activities can also lead to golfer’s elbow: throwing, chopping wood with an ax, running a chain saw, and using many types of hand tools. Any activities that stress the same forearm muscles can cause symptoms of golfer’s elbow.

This guide will help you understand:

• what parts of the elbow are affected
• what causes golfer’s elbow
• how to make the pain go away

Anatomy

What parts of the elbow are affected?

Golfer’s elbow causes pain that starts on the inside bump of the elbow, the medial epicondyle. Wrist flexors are the muscles of the forearm that pull the hand forward. The wrist flexors are on the palm side of the forearm. Most of the wrist flexors attach to one main tendon on the medial epicondyle. This tendon is called the common flexor tendon.

Medial Epicondyle

Tendons connect muscle to bone. Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Collagen

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull against both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

The wrist flexor muscles contract when you flex your wrist, twist your forearm down, or grip with your hand. The contracting muscles pull on the flexor tendon. The forces that pull on the tendon can build when you grip a golf club during a golf swing or do other similar actions.

Elbow Anatomy Introduction

Causes

Why did I develop golfer’s elbow?

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop golfer’s elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Shoveling, gardening, and hammering nails can all cause the pain of golfer’s elbow. Swimmers who try to pick up speed by powering their arm through the water can also strain the flexor tendon at the elbow.

In some cases, the symptoms of golfer’s elbow are due to inflammation. In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis.

However, golfer’s elbow often is not caused by inflammation. Rather, it is a problem within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Scar Tissue

Symptoms

What does golfer’s elbow feel like?

The main symptom of golfer’s elbow is tenderness and pain at the medial epicondyle of the elbow. Pain usually starts at the medial epicondyle and may spread down the forearm. Bending your wrist, twisting your forearm down, or grasping objects can make the pain worse. You may feel less strength when grasping items or squeezing your hand into a fist.

Diagnosis

How can I be sure I have golfer’s elbow?

When you first visit First Choice Physical Therapy, our Physical Therapist will take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing golfer’s elbow. Our Physical Therapist may position your wrist and arm so you feel a stretch on the forearm muscles and tendons. This is usually painful with golfer’s elbow. We may also use other tests of wrist and forearm strength to help diagnose golfer’s elbow.

Golfer’s elbow symptoms are very similar to a condition called cubital tunnel syndrome. This condition is caused by a pinched ulnar nerve as it crosses the elbow on its way to the hand. If your pain does not respond to treatments for golfer’s elbow, our therapist may suggest tests to rule out problems with the ulnar nerve.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

The key to nonsurgical treatment is to keep the collagen in your tendon from breaking down further. Our goal is to help the tendon heal.

When you begin your Physical Therapy program at First Choice Physical Therapy, our Physical Therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. Our Physical Therapist may advise the use of an elbow strap that wraps around the upper forearm in a way that relieves the pressure on the tendon attachment.

Your Physical Therapist in Lynn Haven and Panama City Beach may apply ice and electrical stimulation to ease pain and improve healing of the collagen. Our Physical Therapy sessions may also include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine, prescribed by your doctor,  into the sore area. This treatment is especially helpful for patients who can’t tolerate injections. Exercises are used to gradually stretch and strengthen the forearm muscles.

Because tendonosis is often linked to overuse, our therapist will work with you to reduce repeated strains during activity. When symptoms are from a particular sport or work activity, we will observe your style and motion with the activity. Our Physical Therapist may suggest ways to protect the elbow during your activities. We can also check your sports equipment and work tools and recommend ways to alter them to keep your elbow safe.

Although the time required for rehabilitation is different for each patient, in cases where the tendon is inflamed, nonsurgical treatment is usually only needed for four to six weeks. When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If the tendonosis is chronic and severe, complete healing can take up to six months.

Post-surgical Rehabilitation

Recovery from surgery takes longer. Immediately after surgery, your elbow is placed in a removable splint that keeps your elbow bent at a 90-degree angle.

When you begin your Physical Therapy program, ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Our Physical Therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

We will gradually have you work into more active stretching and strengthening exercises. You just need to be careful to avoid doing too much, too quickly. We typically begin patients on active therapy about two weeks after surgery. Our Physical Therapist may begin with light isometric strengthening exercises. These exercises work the muscles of the forearm without straining the healing tissues. You will also begin to use your own muscle power in active range-of-motion exercises.

At about six weeks, our Physical Therapist may have you start doing more active strengthening. As you progress, we will give you exercises to help strengthen and stabilize the muscles and joints of the wrist, elbow, and shoulder. You’ll also do exercises to improve fine motor control and dexterity of the hand. Some of the exercises you’ll do are designed to work your hand and elbow in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your elbow.

Although the amount of time required for recovery varies among patients, you may need Physical Therapy for two to three months. It may take four to six months to get back to high-level sports and work activities. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

To diagnose golfer’s elbow, your doctor may order X-rays of your elbow. The X-rays mostly help your doctor rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the medial epicondyle at the connection to the flexor tendon.

Golfer’s elbow symptoms are very similar to a condition called cubital tunnel syndrome. This condition is caused by a pinched ulnar nerve as it crosses the elbow on its way to the hand. If your pain does not respond to treatments for golfer’s elbow, your doctor may suggest tests to rule out problems with the ulnar nerve.

When the diagnosis is not clear, the doctor may order other special tests, such as a magnetic resonance imaging (MRI) scan or ultrasound. An MRI scan uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.

Ultrasound tests use high-frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show collagen degeneration.

If the problem is caused by inflammation, anti-inflammatory medications such as ibuprofen may give you some relief. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. If inflammation doesn’t go away, your doctor may inject the elbow with cortisone. Cortisone is a powerful anti-inflammatory medication. Its benefits are temporary, but they can last for a period of weeks to several months.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for golfer’s elbow, but recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

Surgery

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.

Tendon Debridement

When problems are caused by tendonosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

Tendon Release

A commonly used surgery for golfer’s elbow is called a medial epicondyle release. This surgery takes tension off the flexor tendon. The surgeon begins by making an incision along the arm over the medial epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the flexor tendon attaches to the medial epicondyle.

The flexor tendon is then cut where it connects to the medial epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the medial epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones.) Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body.)

The following images show each step:

Tendons Released

Damaged Tissue Removed

Bone Spurs Removed

Tendons Reattached

Your surgeon will look at the ulnar nerve, to make sure that it is not being pinched. If the nerve looks fine, the skin is then stitched together.

This surgery can usually be done on an outpatient basis, which means that you don’t have to stay overnight in the hospital. It can be done using a general anesthetic or a regional anesthetic. A general anesthetic puts you to sleep. A regional anesthetic blocks only certain nerves for several hours. For surgery on the elbow, you would most likely get an axillary block to numb your arm.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Distal Biceps Rupture.

A distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. This injury occurs mainly in middle-aged men during heavy work or lifting. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. Distal biceps ruptures make up only three percent of all biceps tendon ruptures.

This article will help you understand:

• what parts of the elbow are affected
• the causes of distal biceps rupture
• ways to treat this problem

Anatomy

What parts of the elbow are affected?

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. Tendons attach muscles to bone. Two separate tendons connect the upper part of the biceps muscle to the shoulder. One tendon connects the lower end of the biceps to the elbow.

The lower biceps tendon is called the distal biceps tendon. The word distal means that the tendon is further down the arm. The upper two tendons of the biceps are called the proximal biceps tendons, because they are closer to the top of the arm.

The distal biceps tendon attaches to a small bump on the radius bone of the forearm. This small bony bump is called the radial tuberosity. The radius is the smaller of the two bones between the elbow and the wrist that make up the forearm. The radius goes from the outside edge of the elbow to the thumb side of the wrist. It parallels the larger bone of the forearm, the ulna. The ulna goes from the inside edge of the elbow to the wrist.

Distal Biceps Tendon

The upper (proximal) end of the biceps has two attachments to the shoulder. The main attachment is the long head of the biceps. It connects the biceps muscle to the top of the shoulder socket, called the glenoid. The short head of the biceps angles up and in to its attachment on the corocoid process of the shoulder blade. The corocoid process is a small bony knob in the front of the shoulder.

Two Attachments of Upper Biceps

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Collagen

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles contract, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

Contracting the biceps muslce can bend the elbow upward. The biceps can also help flex the shoulder, raising the arm up. And the biceps can rotate, or twist, the forearm in a way that points the palm of the hand up. This movement is called supination. Supination positions the hand as if you were carrying a tray.

Biceps Muscle Contracting

Supination

Elbow Anatomy Introduction

Causes

Why did I develop a rupture of the distal biceps?

The most common cause of a distal biceps rupture happens when a middle-aged man lifts a box or other heavy item with his elbows bent. Often the load is heavier than expected, or the load may shift unexpectedly during the lift. This forces the elbow to straighten, even though the biceps muscle is working hard to keep the elbow bent. The biceps muscle contracts extra hard to help handle the load. As tension on the muscle and tendon increases, the distal biceps tendon snaps or tears where it connects to the radius.

Symptoms

What does a ruptured distal biceps feel like?

When the distal biceps tendon ruptures, it usually sounds and feels like a pop directly in front of the elbow. At first the pain is intense. The pain often subsides quickly after a complete rupture because tension is immediately taken off the pain sensors in the tendon. Swelling and bruising in front of the elbow usually develop shortly after the pop. The biceps may appear to have balled up near the elbow. The arm often feels weak with attempts to bend the elbow, lift the shoulder, or twist the forearm into supination (palm up).

The distal biceps tendon sometimes tears only part of the way. When this happens, a pop may not be felt or heard. Instead, the area in front of the elbow may simply be painful, and the arm may feel weak with the same arm movements that are affected in a complete rupture.

Diagnosis

How can I be sure that I’ve ruptured my distal biceps?

An early diagnosis is best. If surgery is needed, people who’ve ruptured their distal biceps tendon usually have better results when surgery is done soon after the injury.

When you first visit First Choice Physical Therapy, our Physical Therapist will take a detailed medical history. You will need to answer questions about the mechanism of injury, your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing a rupture of the distal biceps tendon. Our Physical Therapist may position your elbow and forearm to see which movements are painful and weak. By feeling the muscle and tendon, we can often tell if the tendon has ruptured off the bone.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

At First Choice Physical Therapy, when we treat a ruptured biceps tendon nonsurgically, we generally advise that you avoid heavy arm activity for three to four weeks. As the pain and swelling resolve, it will become safe to begin doing more normal activities.

Our nonsurgical measures may include recommending a sling to rest the elbow. Anti-inflammatory medicine may be suggested to you by your doctor to help ease pain and swelling and to help you get back to activities sooner.

When you begin your Physical Therapy program at First Choice Physical Therapy, our Physical Therapist will give you tips how to rest your elbow and how to do your activities without putting extra strain on the joint. Our Physical Therapist may apply ice and electrical stimulation to ease pain. We will teach you exercises that are used to gradually strengthen other muscles that can help do the work of a normal biceps muscle.

If the tendon is only partially torn, recovery takes longer. Our patients usually need to rest the elbow using a protective splint or sling. As symptoms ease, you will usually begin a carefully progressed rehabilitation program under the supervision of our Physical Therapists or occupational therapists. The program often involves one to two months of therapy.

When recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Post-surgical Rehabilitation

Rehabilitation takes longer after surgery. Immediately after surgery, your surgeon may cast your elbow for up to six weeks. Some surgeons prefer to use a special range-of-motion brace with careful elbow motion starting within one to two weeks. When you begin your post-surgical Physical Therapy at First Choice Physical Therapy, our first few sessions may involve ice and electrical stimulation treatments to help control pain and swelling from the surgery. Our Physical Therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

We will then gradually have you start exercises to improvement movement in the forearm, elbow, and shoulder. You need to be careful to avoid doing too much, too quickly.

Exercises for the biceps muscle are usually avoided until at least four to six weeks after surgery. Our Physical Therapist may begin by having you do light isometric strengthening exercises. These exercises work the biceps muscle without straining the healing tendon.

At about six weeks, you may be able to start doing more active strengthening. As you progress, our Physical Therapist will teach you exercises to strengthen and stabilize the muscles and joints of the wrist and hand, elbow, and shoulder. We may recommend other exercises to work your elbow in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your elbow.

Although the time required for recovery is different for every patient, as a guideline you may require therapy for two to three months. It generally takes four to six months to safely begin doing forceful biceps activity. Before your Physical Therapy sessions end, we will teach you a number of ways to avoid future problems.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

When evaluating your condition, your doctor may order X-rays. X-rays are mainly used to find out if there are other injuries in the elbow. Plain X-rays do not show soft tissues like tendons. They will not show a distal biceps rupture unless a small piece of bone got pulled off the radius as the tendon ruptured. This type of injury is called an avulsion fracture.

Your doctor may also order a magnetic resonance imaging (MRI) scan to see if the biceps tendon is only partially torn or if the tendon fully ruptured. An MRI is a special imaging test that uses magnetic waves to create pictures of the elbow in slices. The MRI can also show if there are other problems in the elbow.

Many doctors prefer to treat distal biceps tendon ruptures with surgery. Nonsurgical treatments are usually only used for people who do minimal activities and require minimal arm strength. Nonsurgical treatments are only used if arm weakness, fatigue, and mild deformity aren’t an issue. If you are an older individual who can tolerate loss of strength, or if the injury occurs in your nondominanat arm, you and your doctor may decide that surgery is not necessary.

Not having surgery often results in significant loss of strength. Flexion of the elbow is somewhat affected, but supination (which is the motion of twisting the forearm, such as when you use a screwdriver) can be very affected. A distal biceps rupture that is not repaired reduces supination strength by about 50 percent.

Surgery

People who need normal arm strength get best results with surgery to reconnect the tendon right away. Surgery is needed to avoid tendon retraction. When the tendon has been completely ruptured, contraction of the biceps muscle pulls the tendon further up the arm. When the tendon recoils from its original attachment and remains there for a very long time, the surgery becomes harder, and the results of surgery are not as good.

Direct Repair

Direct repair surgery is commonly done soon after the rupture. Doing a direct repair soon after the injury lessens the risk of tendon retraction.

In a direct repair, the surgeon begins by making a small incision across the arm, just above the elbow. Forceps are inserted up into this incision to grasp the free end of the ruptured biceps tendon. The surgeon pulls on the forceps to slide the tendon through the incision.

Attention is given to the free end of the tendon. A scalpel is used to slice off the damaged and degenerated end. Sutures are then crisscrossed through the bottom inch of the distal biceps tendon.

Free End of Tendon

A curved instrument is passed through the incision and directly between the radius and ulna bones. The surgeon pushes the instrument through this space, puncturing the muscles and soft tissues. The surgeon feels the back side of the forearm for the spot where the instrument is protruding. A second incision is made at this spot.

Second Incision

The original attachment on the radius, the radial tuberosity, is prepared. An instrument called a burr shaves off the surface of the tuberosity. The burr is then used to create a small cavity in the bone for the tendon to fit inside. Three small holes are drilled into the top of the rim of bone to secure the sutures.

Radius Prepared

The tendon is passed between the radius and ulna, exiting through the second incision that was made on the back of the forearm. The sutures are threaded into the three holes that were drilled into the rim of the radial tuberosity. The surgeon ties the sutures, securing the newly reattached biceps tendon. When the surgeon is satisfied with the repair, the skin incisions are closed, and the elbow is placed either in a cast or a range-of-motion brace.

Newly Reattached Biceps Tendon

Suture Anchor Method

A new method of anchoring the torn tendon to the radius is gaining popularity. This method uses special anchors, called suture anchors, to fix the tendon in place. The procedure requires only one incision and appears to lessen the risk of myositis ossificans. Myositis ossificans is an abnormal healing response that causes bone to form in the muscles and soft tissues.

The surgeon begins by making a single incision across the arm, just above the elbow. Along the outside edge of the arm, the incision curves and goes upward for a short distance. The skin and underlying tissues are pulled back using retractors. This reveals the front of the lower biceps muscle and allows the surgeon to avoid injuring nearby nerves and arteries. The fascia (connective covering over the muscle) is cut away so the surgeon can see the radial tuberosity.

The original attachment on the radius, the radial tuberosity, is prepared by shaving off the surface with a burr. The burr is then used to create a small cavity in the bone for the tendon to fit inside. Two small suture anchors are embedded into the cavity in the radial tuberosity. These anchors can either be screwed into the bone or implanted like a staple. Each anchor has a long thread (suture) connected to it. The suture is woven into the lower end of the tendon and crisscrossed upward. The surgeon slides the sutures back and forth, which coaxes the end of the tendon into the cavity. When the end of the tendon is positioned in the cavity, the surgeon tightens the sutures, fixing the tendon in place.

Preparation of Radial Tuberosity

When the surgeon is satisfied with the repair, the skin incisions are closed, and the elbow is placed either in a cast or a range-of-motion brace.

Graft Repair

If more than three or four weeks have passed since the rupture, the surgeon will usually need to make a larger incision in the front of the elbow. Also, because the tendon will have retracted further up the arm, graft tissue will be needed in order to reconnect the biceps to its original point of attachment on the radial tuberosity.

The surgeon begins by making a curved incision across the arm, just above the elbow joint. The incision curves along the front surface of the upper arm to expose the lower part of the biceps muscle.

Cuved Incision

The surface of the radial tuberosity is removed. A burr is used to create a small cavity within the tuberosity. Several suture holes are drilled around the rim of the tuberosity.

Radial Tuberosity

A curved instrument is passed through the incision and directly between the radius and ulna bones. The surgeon pushes the instrument through this space, puncturing the muscles and soft tissues. The surgeon feels the back of the forearm to find the point where the instrument is protruding. A second incision is made at this spot.

Second Incision

The surgeon then prepares a graft of tissue to lengthen the retracted biceps tendon. Some surgeons use a piece of hamstring tendon for the graft. Others use a section of the Achilles tendon where it attaches to the heel. This type of graft is usually an allograft, meaning that the tissue is taken from a cadaver (human tissue preserved for medical purposes).

When the Achilles tendon allograft is used, the surgeon leaves a small piece of the heel bone attached to the piece of tendon. Small holes are drilled into the piece of bone. Sutures are woven through these holes and will later be used to secure the end of the graft to the radial tuberosity. In this way, the graft will have a bone-to-bone connection that heals together. The healed bone solidly fixes the the graft to the radial tuberosity. After the graft is in place, its top end is then stitched over the front of the biceps muscle.

Achilles Tendon Allograft

Next, the lower end of the graft is passed between the radius and ulna, exiting through the second incision that was made on the back of the forearm. The sutures from the bony end of the graft are threaded into holes that were drilled into the rim of the radial tuberosity earlier. The surgeon ties the sutures, securing the graft to the radius.

Securing the Graft

When the surgeon is satisfied with the repair, the skin incisions are closed, and the elbow is placed in a protective brace.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Cubital Tunnel Syndrome.

Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow. The symptoms are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

This guide will help you understand:

• what causes this condition
• ways to make the pain go away
• what you can do to prevent future problems

Anatomy

What is the cubital tunnel?

The ulnar nerve actually starts at the side of the neck, where the individual nerve roots leave the spine. The nerve roots exit through small openings between the vertebrae. These openings are called neural foramina.

The nerve roots join together to form three main nerves that travel down the arm to the hand. One of these nerves is the ulnar nerve.

The ulnar nerve passes through the cubital tunnel just behind the inside edge of the elbow. The tunnel is formed by muscle, ligament, and bone. You may be able to feel it if you straighten your arm out and rub the groove on the inside edge of your elbow.

The ulnar nerve passes through the cubital tunnel and winds its way down the forearm and into the hand. It supplies feeling to the little finger and half the ring finger. It works the muscle that pulls the thumb into the palm of the hand, and it controls the small muscles (intrinsics) of the hand.

Elbow Anatomy Introduction

Causes

What causes cubital tunnel syndrome?

Cubital tunnel syndrome has several possible causes. Part of the problem may lie in the way the elbow works. The ulnar nerve actually stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle. (The medial epicondyle is the bony point on the inside edge of the elbow.) Over time, this can cause irritation.

One common cause of problems is frequent bending of the elbow, such as pulling levers, reaching, or lifting. Constant direct pressure on the elbow over time may also lead to cubital tunnel syndrome. The nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive or while running machinery. The ulnar nerve can also be damaged from a blow to the cubital tunnel.

Symptoms

What does cubital tunnel syndrome feel like?

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel will cause an electric shock sensation down to the little finger. This is called Tinel’s sign.

Diagnosis

When you first visit First Choice Physical Therapy, we will take a detailed medical history. Our Physical Therapist will ask questions about how your hand is affected and whether or not you are experiencing any weakness. We will also ask you about your work and home activities and any past injuries to your elbow.

Our Physical Therapist will then do a physical exam. The cubital tunnel is only one of several spots where the ulnar nerve can get pinched. We will try to find the exact spot that is causing your symptoms. The prodding may hurt, but it is very important to pinpoint the area causing you trouble.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Non-surgical Rehabilitation

The early symptoms of cubital tunnel syndrome usually lessen if you just stop doing whatever activity is causing the symptoms. Anti-inflammatory medications suggested to you by your doctor may help control the symptoms, however it is much more important to stop doing whatever is causing the pain in the first place. If necessary, work with your supervisor to modify your job activities.

If your symptoms are worse at night, your First Choice Physical Therapy Physical Therapist may advise that you wear a lightweight plastic arm splint or athletic elbow pad while you sleep to limit movement and ease irritation. You can also wear the elbow pad during the day to protect the nerve from the direct pressure of leaning.

Your Physical Therapy or occupational Physical Therapist will work with you to ease symptoms and improve elbow function. During your initial Physical Therapy session, our Physical Therapist will give you tips how to rest your elbow and how to do your activities without putting extra strain on your elbow. Our Physical Therapist may apply heat or other treatments to ease pain. Exercises are used to gradually stretch and strengthen the forearm muscles.

We may show you how to do special exercises to help the ulnar nerve glide within the cubital tunnel. Treatment then progresses to include strengthening exercises that mimic your daily and work activities.

You may need to continue wearing your elbow pad or splint at night to control symptoms. You will also be encouraged to do your activities using healthy body and wrist alignment, limit repeated motions of the arm and hand, and avoid positions and activities where the elbow is held in a bent position.

If nonsurgical treatments are successful, you may see improvement in four to six weeks, although the time required for recovery is different for each patient.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Post-surgical Rehabilitation

Recovery after elbow surgery depends on the procedure used by your surgeon. If you only had the medial epicondyle removed, you’ll have a soft bandage wrapped over your elbow after surgery. Your Physical Therapy program can progress quickly after this type of surgery. Our treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful to avoid doing too much, too quickly.

Physical Therapy goes slower after ulnar nerve transposition surgery. Although the time required for recovery varies among patients, you could require therapy for three months. This is because the flexor muscles had to be sewn together to form the new tunnel. Your elbow will be placed in a splint and wrapped in bulky dressing, and your elbow will be immobilized for about three weeks.

When the splint is removed, your Physical Therapy program will begin with passive movements. In passive exercises, your elbow is moved, but your muscles stay relaxed. Our Physical Therapist gently moves your arm and gradually stretches your wrist and elbow. We may also teach you how to do passive exercises at home.

Active Physical Therapy usually starts six weeks after surgery. We will show you how to use your own muscle power in active range-of-motion exercises. Light isometric strengthening exercises are started. You may begin careful strengthening of your hand and forearm by squeezing and stretching special putty. These exercises work the muscles without straining the healing tissues.

At about eight weeks, you’ll start doing more active strengthening. Our Physical Therapist will give you exercises to help strengthen and stabilize the muscles and joints in the wrist, elbow, and shoulder. We may recommend additional exercises to improve fine motor control and dexterity of the hand.

Some of the exercises you’ll do are designed get your elbow working in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways that you can do your tasks that don’t put too much stress on your elbow. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

You may need to see a physician for special tests used to get more information about the nerve. One common test is the nerve conduction velocity (NCV) test. The NCV test measures the speed of the impulses traveling along the nerve. Impulses are slowed when the nerve is compressed or constricted.

The NCV test is sometimes combined with an electromyogram (EMG). The EMG tests the muscles of the forearm that are controlled by the ulnar nerve to see whether the muscles are working properly. If they aren’t, it may be because the nerve is not working well.

Surgery

Your symptoms may not go away, even with changes in your activities and nonsurgical treatments. In that case, your doctor may recommend surgery to stop damage to the ulnar nerve.

The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. There are two different kinds of surgery for cubital tunnel syndrome. It is not clear whether one operation is better than the other.

Ulnar Nerve Transposition

One method is called ulnar nerve transposition. In this procedure, the surgeon forms a completely new tunnel from the flexor muscles of the forearm. The ulnar nerve is then moved (transposed) out of the cubital tunnel and placed in the new tunnel.

Ulnar Nerve Transposition

The following images show each step:

Cubital Tunnel Opened

Muscles Detached from Epicondyle

Ulnar Never Transposed

Muscles Reattached

Medial Epicondylectomy

The other method simply removes the medial epicondyle on the inside edge of the elbow, a procedure called medial epicondylectomy. By getting the medial epicondyle out of the way, the ulnar nerve can then slide through the cubital tunnel without pressure from the bony bump.

Removal of Medial Epicondyle

The following images show each step:

Cubital Tunnel Opened

Muscles Detached from Epicondyle

Medial Epicondyle Removed

Muscles Reattached

Cubital tunnel surgery is often done as an outpatient procedure. This means you won’t have to stay in the hospital overnight. Surgery can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks the nerves in only one part of your body. In this case, you would have an axillary block, which would affect only the nerves of the arm.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s patient resource about Radial tunnel syndrome.

Radial tunnel syndrome happens when the radial nerve is squeezed where it passes through a tunnel near the elbow. The symptoms of radial tunnel syndrome are very similar to the symptoms of tennis elbow (lateral epicondylitis). There are very few helpful tests for radial tunnel syndrome, which can make it hard to diagnose.

This document will help you understand:

• what parts of the elbow are affected
• the causes of radial tunnel syndrome
• ways to make the pain go away

Anatomy

What is the radial tunnel?

The radial nerve starts at the side of the neck, where the individual nerve roots leave the spine. The nerve roots exit through small openings between the vertebrae. These openings are called neural foramina.

Nerve Roots Leaving Spine

The nerve roots join together to form three main nerves that travel down the arm to the hand. One of these nerves is the radial nerve. The nerve passes down the back of the upper arm. It then spirals outward and crosses the outside (the lateral part) of the elbow before it winds its way down the forearm and hand.

Radial Nerve

On the lateral part of the elbow, the radial nerve enters a tunnel formed by muscles and bone. This is called the radial tunnel.

Radial Tunnel

Passing through the radial tunnel, the radial nerve runs below the supinator muscle. The supinator muscle lets you twist your right hand clockwise. This is the motion of using a screwdriver to tighten a screw.

Supinator Muscle

After the radial nerve passes under the supinator muscle, it branches out and attaches to the muscles on the back of the forearm.

Elbow Anatomy Introduction

Causes

What causes the pain of radial tunnel syndrome?

Pain is caused by pressure on the radial nerve. There are several spots along the radial tunnel that can pinch the nerve. If the tunnel is too small, it can squeeze the nerve and cause pain. Repetitive, forceful pushing and pulling, bending of the wrist, gripping, and pinching can also stretch and irritate the nerve.

Sometimes a direct blow to the outside of the elbow can injure the radial nerve. Constant twisting movements of the arm, common in assembly work, can also pinch the radial nerve and lead to radial tunnel syndrome.

Symptoms

What does radial tunnel syndrome feel like?

The symptoms of radial tunnel syndrome are tenderness and pain on the outside of the elbow. The symptoms of radial tunnel syndrome are very similar to the symptoms of tennis elbow. As in tennis elbow, pain from radial tunnel syndrome often starts near the lateral epicondyle. (The lateral epicondyle is a bony point on the outside of your elbow joint.) The pain gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow.

One difference between radial tunnel syndrome and tennis elbow is the exact location of the pain. In tennis elbow, the pain starts where the tendon attaches to the lateral epicondyle. In radial tunnel syndrome, the pain is centered about two inches further down the arm, over the spot where the radial nerve goes under the supinator muscle. Radial tunnel syndrome may also cause a more achy type of pain or fatigue in the muscles of the forearm. Nerve pressure inside the radial tunnel leads to weakness in the muscles on the back of the forearm and wrist, making it difficult to steady the wrist when grasping and lifting. It can even lead to wrist drop, meaning the back of the hand can’t be cocked up. Skin sensation is not changed because the sensory portion of the radial nerve branches off above the elbow and does not enter the radial tunnel.

Diagnosis

The diagnosis of radial tunnel syndrome can be difficult. Many cases are initially diagnosed as tennis elbow. Tests don’t always help tell the two conditions apart.

When your first visit First Choice Physical Therapy, our Physical Therapist will take a detailed medical history. You will be asked questions about your pain, your activities, and any past injuries to your elbow.

Our Physical Therapist will then do a physical examination to look for the most painful spot. The prodding and movement may hurt. But it is important that we know exactly where and when you have pain. We will examine your neck as well as your arm, since radial tunnel symptoms may result from nerve pressure in either or both locations. Pinpointing the source of the pain will be most helpful in determining whether you have radial tunnel syndrome or tennis elbow.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, First Choice Physical Therapy has treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

How can I make my pain go away?

Treating radial tunnel syndrome can be frustrating, for you and your health care providers. Getting your symptoms under control and helping you regain the use of your elbow can be a challenge.

Non-surgical Rehabilitation  

The most important part of your treatment is to avoid the activity that caused the problem in the first place. You need to avoid repetitive activities that require your wrist to be repeatedly bent backwards. Repeated use of the wrist in twisting motions (such as using a screwdriver) also make the problem worse. If your work tasks caused your condition, you should modify your work site or your duties. This is crucial for treatment to be successful. You need to take frequent breaks as you work and play. You also need to limit heavy pushing, pulling, and grasping.

Our Physical Therapist will work with you to ease your symptoms and improve elbow function. At first, we will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. Ice and electrical stimulation may be applied to ease pain.

If symptoms are worse at night, our Physical Therapist may recommend that you wear a lightweight plastic arm splint while you sleep. This limits your elbow movements at night and eases further irritation. The splint can help your elbow rest, giving the nerve time to recover from irritation and pressure.

Exercises are used to gradually stretch and strengthen the forearm muscles. Your Physical Therapist at First Choice Physical Therapy may instruct you in special exercises to help the radial nerve glide within the radial tunnel. Treatment eventually progresses to include strengthening exercises that mimic daily and work activities.

Although the time required for recovery varies, if non-surgical treatments are successful, you may see improvement in four to six weeks. You may need to continue wearing your wrist strap during the day and the elbow pad or splint at night to control symptoms. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated hand and forearm motions, heavy grasping, and twisting motions of the arm and hand.

Post-surgical Rehabilitation

If you have surgery for radial tunnel syndrome, your elbow will be placed in a removable splint and wrapped in a bulky dressing following surgery. Although recovery time varies, you may be required to attend occupational or Physical Therapy sessions for six to eight weeks, and you should expect full recovery to take approximately three to four months.

You’ll most likely begin your Physical Therapy program about a week after surgery, with active forearm range-of-motion exercises. Our Physical Therapists also use ice packs, soft-tissue massage, and hands-on stretching to improve range of motion.

When the stitches are removed, you may start carefully strengthening your hand and forearm by squeezing and stretching special putty. We may also recommend the use of isometric exercises to improve forearm and hand strength without straining the tissues near the radial tunnel.

As you progress, our Physical Therapist will give you exercises to help strengthen and stabilize the muscles and joints in the wrist, elbow, and shoulder. Other exercises are used to improve fine motor control and dexterity of the hand.

Some of the exercises you’ll do are designed get your elbow working in ways that are similar to your work tasks and sport activities. We will help you find ways to do your tasks that don’t put too much stress on your elbow. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

Physician Review

Your doctor may do some tests of the radial nerve. An electromyogram (EMG) tests to see if the muscles of the forearm are working properly. If the test shows a problem with the muscles, it may be caused by a problem with the radial nerve. The nerve conduction velocity (NCV) test measures the speed of an electrical impulse as it travels along the radial nerve. If the speed is too slow, then the nerve is probably pinched.

These tests are not very accurate in diagnosing radial tunnel syndrome. Many people who have radial tunnel syndrome will have normal EMG and NCV test results. Your doctor will consider all parts of the examination in diagnosing whether or not you have a problem with radial tunnel syndrome.

Doctors commonly have their patients with radial tunnel syndrome work with a Physical Therapist or occupational therapist.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

Your doctor may do some tests of the radial nerve. An electromyogram (EMG) tests to see if the muscles of the forearm are working properly. If the test shows a problem with the muscles, it may be caused by a problem with the radial nerve. The nerve conduction velocity (NCV) test measures the speed of an electrical impulse as it travels along the radial nerve. If the speed is too slow, then the nerve is probably pinched.

These tests are not very accurate in diagnosing radial tunnel syndrome. Many people who have radial tunnel syndrome will have normal EMG and NCV test results. Your doctor will consider all parts of the examination in diagnosing whether or not you have a problem with radial tunnel syndrome.

Doctors commonly have their patients with radial tunnel syndrome work with a Physical Therapist or occupational therapist.

Surgery

Sometimes symptoms of radial tunnel syndrome aren’t relieved, even after many months of nonsurgical treatment. In these cases, surgery may be the best treatment option. It is generally considered a last resort.

The goal of surgery for radial tunnel syndrome is to relieve any abnormal pressure on the nerve where it passes through the radial tunnel. The surgeon begins by making an incision along the outside of the elbow and down the forearm, near the spot where the radial nerve goes under the supinator muscle.

Soft tissues are gently moved aside so the surgeon can check the places where the radial nerve may be getting squeezed within the radial tunnel. The nerve can be pinched in many spots, so it is important to check all the areas that may be causing problems. Any parts of the tunnel that are pinching the nerve are cut. This expands the tunnel and relieves pressure on the nerve. At the end of the procedure, the skin is stitched together.

The following images show each step:

Incision Site

Retracting the Overlying Muscles

Releasing Pressure on the Nerve

Radial tunnel surgery can usually be done as an outpatient procedure. This means you won’t have to stay in the hospital overnight. Surgery can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks nerves in only one part of your body. In this case, you would have an axillary block, which would affect only the nerves of the arm.