Forearm & Elbow Conditions

The biceps muscle is found in the front of the upper arm and is attached to the shoulder and lower arm bone by tendons. It helps control lower arm movement and is particularly instrumental in the follow through of forceful throwing movements such as those in football or baseball. When the tendons are overused or overstressed, they become irritated and inflamed. This condition is called Biceps Tendonitis. It is often secondary to rotator cuff instability.

Biceps tendonitis may cause pain along the front of the shoulder during arm and shoulder movement - particularly forward and upward movements. Pain may intensify at night and become increasingly prevalent during daily activity such as lifting or carrying groceries or garbage bags.

Those at Risk
While athletes in throwing sports are often diagnosed with this condition, it can affect any active male or female who repetitively overuses the biceps muscle. A direct trauma or calcification in the tendon may also prompt the condition.

Diagnosis
Following patient history, physical examination and pain analysis, radiographic testing will confirm diagnosis.

Treatment
Biceps tendonitis is generally treated with a conservative nonsurgical program involving anti-inflammatory medication and cold compression. A rehabilitative exercise program designed to strengthen and promote flexibility of the shoulder stabilizers is developed. Depending on the severity of the pain, corticosteroid injections may be indicated in order to reduce the inflammation and pain. And an ongoing rehabilitation program is developed specifically to the patient in order to ensure a safe return to sport with no recurrence.

Cubital Tunnel Syndrome results when the ulnar nerve, which runs through the cubital tunnel on the inside of the elbow, is irritated by an injury or unusual pressure. The condition may occur when the elbow is frequently bent as in pulling and lifting, or from constant leaning. It can also occur from a direct injury.

In establishing a cause for the condition, it is thought that the ulnar nerve - which stretches several millimeters when the elbow is bent - occasionally shifts or snaps over the bony medial epicondyle on the inside edge of the elbow and, over time, becomes irritated. The nerve may also become irritated when pressed for long periods against a hard service, or if it becomes damaged from a blow to the cubital tunnel.

The pain resulting from the condition is similar to that experienced when the "funny bone" is hit. What many refer to as the "funny bone" is actually the ulnar nerve, which originates at the side of the neck, crosses at the elbow and ends in the fingers. The most common symptoms related to cubital tunnel syndrome include: numbness in the hand and/or ring and little fingers; general pain in the hand; and muscle weakness in the hand and thumb affecting grip strength and ability to perform certain activities.

These symptoms are similar to other elbow conditions such as medial epicondylitis (golfer's elbow) and should be accurately diagnosed by a physician.

Those at Risk
Cubital tunnel syndrome is most often seen in adults and can affect the athlete, laborer and office worker alike. An ambitious weekend project subjecting the elbow to unusual stress and pressure can result in the condition as well.

Diagnosis
Following a complete medical history and physical examination, patients may require a nerve conduction test, which helps determine the speed of signals traveling down a nerve - in order to determine if there is a compression or constriction. An electromyogram (EMG) targeted at the forearm muscle may be used in order to evaluate nerve and muscle function, which is controlled by the ulnar nerve. Poor muscle function may indicate a problem with the ulnar nerve and confirm diagnosis.

Treatment
A number of conservative nonsurgical treatment options are available for cubital tunnel syndrome - including the cessation of irritating activity, a removable splint to limit movement and reduce irritation, an elbow pad to protect against hard surfaces and anti-inflammatory medication. And a patient-specific physical or occupational therapy program can also show significant improvement.

In chronic cases nonresponsive to conservative treatment, surgery is indicated in order to release the pressure on the ulnar nerve, where it passes through the cubital tunnel. A number of different surgical procedures can accomplish this and are done as an outpatient procedure.

Also known as Golfer's Elbow, medial epicondylitis is similar in nature to lateral epicondylitis or Tennis Elbow - though one affects the outer (lateral) portion of the elbow and the other affects the inner (medial) portion.

Medial epicondylitis affects the inner portion of the elbow and is caused by the excessive and repeated force used to bend the wrist toward the palm. This occurs in such activity as pitching a baseball, swinging a golf club or serving a tennis ball. The force causes damage to the tendons responsible for this bending action and causes a pain that generates from the elbow to the wrist, on the palmar side of the forearm.

While the condition may also result from a number of other activities such as carrying a heavy suitcase, chopping wood with an ax, throwing a javelin and frequently using other hand tools, it has become popularized by golfers and is most often referred to as Golfer's Elbow.

Those at Risk
Those adults subjecting repeated force on the wrist are likely to experience medial epicondylitis. It is often diagnosed in those actively involved in a sporting activity or manual labor - generally between the ages of 20 and 40.

Diagnosis
Diagnosis of medial epicondylitis usually consists of patient history and a physical examination of the arm and wrist in various positions of resistance.

Treatment
Unless chronic and severe, most cases are treated with conservative nonsurgical treatment plans that may include: cold compression, anti-inflammatory medications, and strengthening exercises.

When the condition is nonresponsive to conservative treatment, surgery is indicated to repair the ligament.

Also known as Resistant Tennis Elbow, Radial Tunnel Syndrome is considered an overstress or repetitive stress condition caused when the nerve instrumental in the function of several muscles around the wrist and hand (a branch of the radial nerve) is compressed, or pinched at the forearm or the elbow. This results in weakness of the affected muscles and pain over the compressed area.

Compression can take the form of an injury, ganglia, lipomas, bone tumors and inflammation of the surrounding bursa or muscles. Patients suffering from the condition report a piercing pain at the top of the forearm and back of the hand when straightening the wrist and fingers.

Since the radial nerve primarily connects to muscle, there is no loss of sensation. The radial nerve begins at the side of the neck, where individual nerve roots leave the spine. The nerve roots exit through small openings (called foramen) between the vertebrae. The nerve roots join to form the three main nerves responsible for arm and hand function (radial, ulnar and median) - and travel down the arm to the hand. The radial nerve passes down the back of the upper arm, around the outside of the lateral portion of the elbow and down the forearm and hand.

Through the radial tunnel, the radial nerve passes below the supinator muscle, which allows clockwise twisting of the hand. It then fans out and attaches to the muscles on the back of the forearm.

Though the symptoms of radial tunnel syndrome are similar to those of tennis elbow, the cause is not. It is most similar to the nerve compression experienced in carpal tunnel syndrome - though a different nerve is compressed.

Those at Risk
It is believed that radial tunnel syndrome is caused by repetitive stress. Those involved in repetitive, forceful pushing and pulling, gripping, bending, or twisting of the arm, are at risk of stretching and irritating the nerve. Though, sometimes a direct blow to the outside of the elbow can also injure the radial nerve.

Diagnosis
Diagnosis of radial tunnel syndrome can be difficult, as few tests have been effective in identifying it. Following a complete patient history and physical examination that may involve an assessment of pain in various arm positions, an electromyogram (EMG) may be indicated. An EMG will test to verify that muscles of the forearm are working properly or not. Improper functioning of the muscle is generally caused by the improper function of the supervising nerve.

A nerve conduction velocity (NCV) test may also be used, in order to measure the speed of an electrical impulse as it travels along the radial nerve. A slow speed indicates a compressed, or pinched nerve.

Treatment
The first phase of treatment for radial tunnel syndrome is conservative and includes refraining from the activity responsible for the condition, as well as those irritating the condition. A lightweight plastic removable arm splint may be indicated at night if pain worsens during sleep. A patient-specific physical or occupational therapy is established in order to increase the success of the other conservative treatment plans.

When the condition is nonresponsive to conservative treatment and symptoms persist, an outpatient procedure that helps to decompress the nerve may be indicated.

And following all treatment options is a rehabilitation program that demonstrates correct alignment and positions during activity. It also includes active forearm range of motion and stretching exercises - possibly combined with a soft-tissue massage. Isometric exercises following a surgical procedure helps to improve forearm hand strength while placing minimal stress on the tissues near the radial tunnel.

Known by physicians as lateral epicondylitis, Tennis Elbow affects the lateral, or outer, portion of the elbow and results when the elbow is overstressed or repetitively overused.

The forearm muscles that bend the wrist back (the extensors) attach at the lateral epicondyle (bony bump at the outer portion of the elbow) and are connected by a single tendon. Lateral epicondylitis is the irritation and subsequent inflammation of the tendon around the lateral epicondyle, or bony elbow bump, thought to be the result of tissue degeneration within the tendon.

Initially moderate pain is felt at the outer portion of the elbow. Over time pain increases and may spread down the forearm and to the back of the middle and ring fingers - eventually causing debilitating pain and weakness in arm function. Reaching and grasping activities may become painful, and a nagging discomfort may be present while resting after activities.

Those at Risk
While it got its name because five in 10 recreational and professional tennis players suffers from the condition, the average man and woman between the ages of 40 and 60 is far more likely to suffer from the condition doing everyday activities - painting with a brush or roller, using a chain saw or hand tools, pruning shrubs, lifting children up and down. The overuse of the muscles and tendons of the forearm and elbow is likely to prompt the condition.

Diagnosis
In diagnosing tennis elbow, patient history and a pain analysis are generally followed by a physical exam that places the arm and wrist in various positions that require the forearm muscles and tendons to stretch. An X-ray may be indicated in order to eliminate other causes of elbow pain. A magnetic resonance image (MRI) or ultrasound test may also be used in establishing and confirming diagnosis.

Treatment
Beginning always with conservative nonsurgical treatment for such conditions, a plan to prevent further degeneration and promote an environment conducive to tendon healing is established. This may entail a course of anti-inflammatory medications if acute inflammation is determined. A physical or occupational therapy program helps instruct patients on ways to perform activities without placing strain on the elbow.

And recently available to patients suffering from chronic tennis elbow nonresponsive to traditional conservative treatment options is a new noninvasive high-energy shockwave therapy. This nonsurgical procedure is called the OssaTron Treatment and is performed as an outpatient procedure that takes less than 20 minutes.

When the condition is nonresponsive to conservative treatment and not conducive to shockwave therapy, surgery may be indicated, in order to relieve the tension from the extensor tendon. This procedure is called lateral epicondyle release and can also be done as outpatient.