Call us at 281-633-8600. This article covers several chronic elbow injuries and treatments and it’s based on an interview with Dr. J. Michael Bennett, one of Houston’s top Elbow Specialists. Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon and Fellowship Trained Sports Medicine Physician. Dr. Bennett serves patients from all over the Metro Houston area from offices in Sugar Land, at the intersection of Sweetwater and Lexington and in Houston, near the Houston Galleria. This is the interview transcript:
The chronic elbow injuries are the injuries that occur with repetitive use of the elbow. That could be repetitive throwing or repetitive lifting or repetitive twisting activities and over time those ligaments and tendons can be worn down or attenuated and they can eventually tear. Pitchers are a perfect example of people who can develop chronic conditions of the elbow, because they throw on a daily basis and they put those ligaments under an incredible amount of stress. And the one ligament that endures the most stress across the elbow, particularly in pitchers and throwers is the ulnar collateral ligament, which is the ligament on the inside of the elbow. And if that is torn, it will affect their velocity and their ability to pitch, because it will affect the mechanics of their throw, plus it will be painful for them to throw.
If that’s the case, and these ligaments are torn chronically, then these tissues are stretched out and not very healthy and we need to reconstruct the ligament, which means we need to put a new ligament there as opposed to repairing the other ligament. If we insert a new ligament, we can use their own tendon or we can use a cadaver to recreate the ulnar collateral ligament — this is called a Tommy John procedure because Tommy John was the first pitcher to undergo that procedure. It’s actually very successful and the patients do very well at improving stability, but it has to be symptomatic, meaning that it has to bother them, and it has to affect their ability to do their activities. The MRI which is the diagnostic test, has to confirm that there is indeed a ligament tear there.
You can also have chronic tears in the lateral collateral ligament on the outside of the elbow and that would cause instability as well. And the same situation applies to the lateral. If you have a chronic tear, the ligament is stretched out, it’s not healthy, and just repairing it is not good enough. You have to do a reconstruction, where you recreate that ligament, and that’s called a reconstruction of the lateral collateral ligament and the same thing applies. You can use the patient’s own tendon or you can use a cadaver tendon to reconstruct that ligament, and that gives you more stability across the elbow. Both of those ligaments are very important for stability, particulary in regard to throwing activities.
Those are all elements of stability across the elbow, but you can also have problems within the elbow itself, the joint. You can have arthritis in the elbow, which means the cartilage within the elbow has worn down and you have bone rubbing on bone which leaves the elbow painful and inflamed or you can have specific cartilage flaps or tears within the elbow that can cause clicking or locking of the elbow. Or you can have an inflamation of the lining of the elbow, which is the synovium, creating a large plica, which is a synovial fringe, which gets pinched in the elbow. Kind of like if you’ve ever bit the inside of your mouth and that swelling on the inside of your mouth gets caught between your teeth over and over again, the same thing happens with your elbow. When you extend your elbow, you pinch the lining in the joint and the lining gets inflamed and a small plica gets caught in the joint and creates popping clicking and pain.
Sometimes an injection helps for those types of injuries and those symptoms. Therapy can be very helpful as well. Or if it is popping, clicking or locking of the elbow, sometimes an elbow scope is very beneficial where we put a camera in there and then we can remove the cartilage flap or smooth down the cartilage or actually remove the plicas that are getting caught in the joint and that can make a big difference. One of the nice things we can do with the scope, because it’s minimally invasive, we just have two little holes in the elbow to use the camera to diagnose the injury. We can look at the whole joint with the elbow scope, which is very beneficial in patients who have had significant stiffness of the elbow.
Occasionally I’ll have patients that have poor motion and they’ve gone through extensive therapy but they can’t get their motion back. Sometimes that’s due to arthritis and sometimes it’s due to scar tissue. And with the scope in that case, we can remove the scar tissue adhesions and we do a release in the front and the back of the elbow. And we can smooth down the cartilage arthritic lesions and gain the patient’s motion back, and actually help them get their motion back to full extension. Before they may have had a flexion contracture where they cannot extend their elbow all the way or they cannot bend their elbow all the way. So that’s been a very beneficial technique and it’s a new technique that not a lot of people can do because you have to have the specialty training to do this because there are a lot of nerves and vessels around the elbow which are very close and you have to be very careful in doing this procedure. But once you’ve done a lot of them, then it’s not as hard as it sounds. Then there’s also tendonitis of the elbow and lots of people have that and it’s an inflammation of the tendons around the elbow. It’s not a tear, it’s not a rupture, it’s more like a chronic injury like we talked about before.
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You can have tendonitis on the inside of the elbow which is medial epicondylitis or golfers elbow, or you can have tendonitis on the outside of the elbow, which is lateral epicondylitis, which is called tennis elbow. The reason it’s called tennis elbow is because that’s where it was first described. The majority of tendonitis is just inflamation or degeneration from chronic activities such as golf or tennis or throwing or lifting. The majority of those symptoms can be addressed with non-operative measures such as a physical therapy program as well as bracing and anti inflamatories or injections. This would be a steroid injection of the medial epicondyl or lateral epicondyl of the elbow, which is the inside or the outside of the elbow. Usually that takes care of 95% of the tendonitis that I see. For the other 5% who don’t get better that regimen, we get an MRI, which is a magnetic resonance image of the elbow, to look at the tendons on the inside and the outside to see what the tendon quality looks like. If it’s healthy and intact, then we can continue with conservative measures. If it’s completely torn or very unhealthy then sometimes those patients will benefit from arthroscopic evaluation and debridement of that tendon, particularly on the lateral side, or outside of the tendon. Or we use a small incision to go in there and repair it with a healthy tendon and that will actually take care of the problem. We also now offer the Tenex procedure for tennis elbow.
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