Why Does My Elbow Hurt? with Dr. William Seitz Jr.

Podcast Transcript

Deanna Pogorelc:  Welcome to the Health Essentials Podcast brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc, recording here at Cleveland Clinic Lutheran Hospital with Dr. William Seitz. Dr. Seitz is an orthopedic surgeon here at the clinic, who specializes in hand and upper extremity problems. And today we're going to be talking about some common elbow problems and what to do about them. So, listeners, please remember this is for informational purposes only and is not intended to replace your own physician's advice. So, Dr. Seitz, thanks for being here.

Dr. William Seitz:  Thanks for having me.

Deanna Pogorelc:  Can we start by talking a little bit about what's going on in the elbow. What all is in their bones and ligaments and what's going on in there?

Dr. William Seitz:  Well, it's a very unique joint. People like to think of it as, excuse me, the knee of the upper arm, but it's actually not. It works in the opposite direction that the knee does. It's an anti-gravity joint. Almost everything we do with our elbow works against gravity. There are three bones which come together at the elbow. Two forearm bones, the one major forearm bone that allows us to flex and extend called the ulna, which articulates with a portion of the upper arm bone called the humerus called the trochlea. It looks like a spool, if you will, and it actually functions as a hinge.

Dr. William Seitz:  The other bone that articulates also with the humerus is the radius, and the radius gets its name because it rotates around the ulna and forms an arc of radius. And at the elbow, it literally is like a disc that rotates back and forth like this. At the forearm, it rotates around the ulna. So at the far end it forms an excursion of about 180 degrees at the elbow. It just rotates without any change in position other than rotation through a similar arc of somewhere between 160 and 180 degrees.

Dr. William Seitz:  And they're held together by a set of very stout ligaments on the inside and the outside called the collateral ligaments. There are less strong ligaments in the front called the joint capsule. And then there are a set of muscles on the outside we call the extensor and supinator muscles. And on the inside we call the wrist flexor and pronator muscles. And then in the front are very strong brachialis, which is the main flexor of the elbow. And superficial to that is the biceps, which is also a flexor, but it also is a primary supinator of the forearm. Supination is where you turn your palm up. And then in the back we have our very strong triceps muscle. And these all engulf this joint, and when it's healthy and all those structures work well, it works well.

Deanna Pogorelc:  Okay. So are most injuries to the elbow related to sports, or do they happen for other reasons also?

Dr. William Seitz:  They can happen for any reason. Probably it is one of the joints which is frequently injured in sports, such as in throwing sports, such as in contact sports where someone gets thrown to the ground. But most of the injuries occur because of just that, a fall on an outstretched hand, what we call a FOOSH if you will, and the forces that come as the body's weight in motion hits the ground are transmitted through the forearm to the elbow. And therein can be the source of injury to the ligaments, the muscles, the tendons, and the bone, and the joint surface and the nerves that go around it.

Deanna Pogorelc:  Yeah. So can you talk about some of the injuries that can happen that way when someone falls or has some kind of acute event happen to them?

Dr. William Seitz:  Sure. Probably the most common in the adult population is what's called a radial neck or head fracture. Somebody falls down on their forearm like this, and that force gets transmitted and that radial head, which is doing this, can then either get kinked this way or it can come a little off to the side and get split or it can get crushed. There are ligaments between the two forearm bones which prevent too much translation, but if it's a really bad injury, they can get ruptured and now we can have disruption of that same articulation down at the wrist where when we're moving here we may only feel the pain here. So if someone has a radial head fracture, we should always look at the wrist.

Deanna Pogorelc:  Okay. Can you break the elbow? Can you break any of the bones ... well, you talked about a little fracture.

Dr. William Seitz:  The radial, sure. And another common injury is a fracture of the olecranon. That's where someone actually falls directly on the elbow and hits here, and the triceps in the back pulls in one direction and the brachialis and the biceps and the other pull in the other and this little a hinge, and they get split right down the middle and are pulled off by these muscles. You can also have a fracture of the upper arm bone called the humerus, which is usually called either an Intercondylar or a supracondylar fracture. So the fracture may go across the humerus, may go up through the humerus, may do both, or sometimes the elbow just simply dislocate by rupturing the ligaments.

Dr. William Seitz:  In children, a supracondylar fracture is relatively common, especially in the three to eight year old age group, because there are growth plates along there that are kind of weak. And in other children, in the two to three year old age group, when someone is hurry them across the street and go to pick them up by the wrist to get them out of the way of traffic, the radial head can pull out of its little ligament, which is like an annulus or a ring around the head. And all of a sudden the child starts screaming and nobody knows what's the matter, but it's called a nurse maid's elbow. That's usually fixed just simply by restoring some supination. It'll pop right back in. But a supracondylar fracture is a different story, and that needs to be addressed.

Deanna Pogorelc:  Sure. What about a sprain and/or a strain? And what's the difference between those two, and do they happen kind of immediately like that?

Dr. William Seitz:  They can or it can be repetitive. So a sprain is a partial tearing or a stretch of a ligament. Ligaments are very stout, structures which are not very compliant, and they hold the joint together securely. A strain usually is a partial injury to a muscle, if you will, and that can happen in the muscle belly. It can happen where the muscle and the tendon come together. And so that can be the source of soreness. The sprain can heal if it's on its own, but if there's a throwing athlete that keeps throwing, it can become a chronic problem and then suddenly things get out of control and that's when we have to do surgeries like the Tommy John's surgery.

Deanna Pogorelc:  Right. So if someone has elbow pain and maybe isn't sure exactly what caused it, or maybe they did have some kind of fall or accident, what are some signs that it's kind of an emergency and they need to seek medical help right away?

Dr. William Seitz:  Sure. Well, certainly, if it feels unstable, if it feels that it's going to come out of place, if it feels so painful that you can't bend it. You should be able to touch your shoulder with your hand and you should be able to straighten your arm out at least within 10 degrees of being straight. Obviously, if there's been a disruption and there's something unstable, it can look deformed, it can look out of place, and that should be certainly a red flag. In addition, if you know you have a known injury and it hasn't gotten better and it's swollen, that's something that should raise a red flag.

Dr. William Seitz:  Finally there are things that can cause an infection in the elbow, if you have a lowered immune system, if you've had a scrape or a cut, abrasion, and suddenly your elbow swells up and gets very, very painful. There's a bursa on the back of your elbow called the olecranon bursa. That's what the tip of the elbow is called, the olecranon. And that can fill with fluid or infectious fluid, and that can become an infected bursa.

Dr. William Seitz:  And finally, any sign where suddenly there's severe pain emanating down into the hand, if you start to feel numbness or tingling, again, depending on which fingers. The median nerve here in the front usually radiates down towards the palm. The radial nerve on the outside radiates down towards to the wrist on the outside. And the ulna nerve, the so-called funny bone, if you will, is back here on the inner side of the elbow. And that gives you feeling in the last two fingers. So again, anything that has persistent, not just transient, but persistent neurologic symptoms, much as we might see in a carpal tunnel in the wrist, should also be considered something that should be investigated.

Deanna Pogorelc:  Sure. And you mentioned the funny bone, which I think is interesting. So when you kind of get that sensation of hitting your funny bone, is there anything damaging happening there or it's totally fine?

Dr. William Seitz:  Maybe, but more often than not it's not. It depends. Lean people have the potential for having their nerve here ... the ulna nerve comes down the posterior inner side of your upper arm, goes right behind a little prominent bone here called the medial epicondyle and then it comes down and it goes in between the wrist flexor here, the muscle, and it innovates some of the finger flexor muscles down below and then finally down into the small muscles of the hand.

Dr. William Seitz:  The restraining ligaments to that nerve, which are not very stout, can be stretched out either because you have big strong triceps that's pushing it out or because the person is very lean and long and just, when you're lifting, that nerve can start to slip over. So it can just simply be irritated by snapping back and forth over this inner portion. And sometimes there are little muscles in there that don't belong that can cause pressure on the nerve. There can be bands of tight fibrous tissue, which can cause pressure on the nerve. And any of those can give you the sensation of numbness and tingling in the last two fingers.

Deanna Pogorelc:  So what about just some occasional soreness? Maybe I'm a tennis player, whenever I have some elbow soreness, how would you go about ... is that something I also need to see a physician about or can I do some ice?

Dr. William Seitz:  Yeah. I think if there's no neurologic symptoms and you just start getting some soreness, that may be that you've either done too much too quickly or you've accumulated a fair amount of wear. It might be a good idea to just lay off for a while. There are a little braces that you can wear on your form that provide compression, which help prevent a little bit of pull through. More often than not, it's what's called a lateral epicondylitis, which is a fancy name for tennis elbow, but there are tendons which attach onto the elbow. And in fact, what happens to them is that they get a little bit of wear and tear. It's not really a true tendonitis. It's what we call a tendinosis, a little bit of degeneration. Treatment for that is to let it heal and just avoid the provocative activities. But again, you can wear a little splint at night to take the pressure off when you're sleeping because you don't realize what position your arms in when you sleep. You can take some anti-inflammatory medicine that's prescribed by your physician, and you can just avoid provocative activities.

Deanna Pogorelc:  Yeah. Can the elbow joint be replaced, and what's a case when that would need to happen?

Dr. William Seitz:  Yeah. Elbow joint can be replaced. It's much less commonly done than other joints, such as the hip and knee or even the shoulder, these days. But in the United States, there's somewhere between a half a million total hips and three-quarters of million total hips, the same number of total knees, that are done across the country. In the upper limb, we have about 20,000 total shoulders done a year, probably in the ballpark of five or 6,000 total elbows. So it's a much smaller number. So there's a lower need, and therefore, there's fewer of us that do a lot of them. And the same thing is true, it's even more so with the wrist. That, again, the need for replacements are not that great.

Dr. William Seitz:  But the things that cause the need for this are really bad arthritis that is not respondent to all of the conservative things we would do for other joints, to badly traumatized joints which have not responded to or can't be put back together with surgery. And those are indications for doing joint replacements. And sometimes we could do partial joint replacements, like just the radial head. Sometimes we can do clean outs if there's portions of the joint that's still healthy. And so we try to do all of the most conservative things first when it comes to surgery if there's some degree of salvage that we can provide, and sometimes we can buy five to 10 years. But arthritic joints are just that. They keep wearing over time, but just a lot of education helps.

Deanna Pogorelc:  Yeah. And you mentioned arthritis, which we didn't really talk about, but is that a common cause for ... does it commonly affect the elbow? Because Like said, you normally think about knees and hips and ...

Dr. William Seitz:  We see arthritis fairly commonly in the elbow, but not necessarily end-stage arthritis. I would say, 30 plus years ago when I started in practice, it was very rare to do an elbow replacement. Now I do them all the time. But as I started to get more involved in elbow reconstruction, I would tell you honestly it would be about eight to two rheumatoid patients to non-rheumatoid patients. Today, because of the success of doing elbow replacements and because of the fact that our rheumatology colleagues have come up with such good medications to try to keep people from reaching that end stage point, it's probably just the opposite. I probably see eight to two osteoarthritic or post-traumatic arthritic patients than rheumatoid patients. But we still do the replacements for all of those things. And then also there are conditions where there have been congenital deformities, where they've been tumors that had needed to be resected and so forth. So we do very highly specialized surgeries for joint replacement in the elbow and the shoulder and the wrist, but they're only when absolutely needed.

Deanna Pogorelc:  You mentioned if they can't be fixed by surgery, so there's something else that you would do before that?

Dr. William Seitz:  There could be, yeah. I mean, again, it depends on where the patient is on the spectrum. If it's end stage, it's end stage and then we have only one thing to do. Because doing what had been tried for years was to do a fusion, to fix the elbow in one position, fuse the forearm to the upper arm, but once you don't have movement of the elbow, you can't get your hand to your mouth. If you fix it so you can't get your hand to your mouth, you can't take care of your own hygiene. So the fusion is not a great resort. In fact, if it were me and I couldn't have a total elbow replacement, I would opt to just simply have my elbow taken away and have a flail elbow but give me a brace that I could position.

Deanna Pogorelc:  Okay. So as we kind of wrap up, is there anything we can do to prevent some of these common elbow problems? I don't know. It's like for an athlete or somebody who's very active, doing some kind of activity where they're frequently using their elbow. Is there anything we can do to kind of protect it?

Dr. William Seitz:  I think it's really being both vigilant and introspective. You need to look at yourself, especially if you're an athlete, and say, "Is it a specific pitch that hurts all the time? Is it something that I'm doing with my workouts that seem to be irritating this?" And see if you can adjust your routine to some degree. If that doesn't work, then you should seek consultation. And sometimes more sophisticated imaging studies can be helpful in identifying the degree of injury to a ligament or degree of irritation of a nerve or the degree of instability or stiffness or arthritis of a joint. But the sooner we can identify that this is a problem that isn't going away, the sooner we can make some degree of intervention where we can say, "Maybe we can do this now, and we're not going to get to a total elbow."

Deanna Pogorelc:  Right. Okay. Great. Well, thank you so much for being here today. And for more information on this topic, please visit ccf.org/elbowpain. and to listen to more interviews with our Cleveland Clinic experts, visit clevelandclinic.org/hepodcast or subscribe wherever you get your podcasts. And for more health tips, news, and information, follow us at clevelandclinic, one word, on Facebook, Twitter, and Instagram. Thanks for joining us.