Lateral Epicondylitis, Medial epicondylitis, Distal biceps tendon rupture
Normal Elbow and Forearm Anatomy
The elbow and forearm form a functional unit whose primary role is to accurately position the hand in space. The elbow has a long lever arm and moves the forearm and hand 130 degrees covering much of the functional space used in our activities of daily living and in this sense the elbow is considered the most important single joint of the upper limb, second only to the thumb carpometacarpal joint. The functional space is defined as the space directly in front of a person’s body that lies below eye level and above the belly button. Because the elbow joint covers the entire functional space by virtue of its arc of motion, there has never been a satisfactory position to fuse an elbow joint if it were ever destroyed by injury or disease.
The elbow anatomy is best understood by thinking of it in three layers. The first layer is the bony layer, the second layer is the ligament layer and the third layer is the muscular layer within which the arteries and nerves travel.
Elbow & Forearm Elbow Joint Front View & Side View
The first layer is comprised of three bones that unite to form the elbow joint. The elbow joint is located at the lower end of the arm bone (humerus), and the proximal end (towards the shoulder) of the radius and ulna which are the two forearm bones. These three bones allow the elbow to bend (Flex) and straighten (Extend) in a hinged type motion and the forearm to rotate the hand in a palm up (supination) and palm down position (pronation). The joint surfaces of the elbow are covered by hyaline cartilage which forms a cushioned layer that allows for smooth gliding and painless elbow motion.
Elbow & Forearm Ligament LayerElbow Joint Ligament Layer
Lateral Elbow Ligament View Medial Elbow Ligament View
The second layer in the elbow and forearm is the capsular ligament layer made up of collagen tissue. The ligament layer in the forearm is called the interosseous membrane. The collagen tissue forming the elbow joint capsule is normally very thin except on the inside (medial) and outside (Lateral) sides of the elbow where thickenings in the collagen substance form the ligaments of the elbow. These ligaments provide passive stability to the elbow joint keeping the humerus, radius and ulna together, allowing them to function as a unit.
Foerarm Flexor CompartmentForearm Flexor & Mobile Wad Compartments
Elbow Flexor Muscles Elbow Extensor Muscles
The third layer of the elbow and forearm is the muscle layer and is formed by the various muscle groups that pass through the elbow and forearm either originating (beginning) or ending in the elbow and forearm. The muscles of the arm that pass through the elbow include the triceps muscle in the back of the arm and the brachialis and biceps muscles in the front of the arm. The forearm muscles that cross the elbow joint are divided into three compartments with each compartment containing several muscles that work to move the elbow, forearm, wrist and hand in specific directions.
The three compartments are:
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1. the extensor compartment
2. the flexor compartment and
3. the mobile wad of Henry compartment. The median, ulnar, and radial nerves pass through the elbow and forearm within the muscle layers and innervate the muscles within these compartments as well as, the muscles of the hand.
Pathology: Lateral Epicondylitis and medial Epicondylitis
Tennis Elbow Golfers Elbow
Lateral epicondyltis also called tennis elbow and medial epicondylitis called golfers elbow is a condition affecting the forearm muscles’ on the humeral bone at the elbow called the lateral and medial epicondylitis respectively. This condition, as well as, biceps tendon ruptures occurs in patients between the ages of 30-50 years. Although lateral and medial epicondylitis is often associated with a minor traumatic event andrupture of the distal biceps tendon with a major traumatic event, all three conditions are considered the result of a degenerative process in the muscle tendon structure and not the result of an inflammatory process, as the names lateral and medial epicondylitis would imply.
Lateral epicondylitis and biceps tendon ruptures occur in about 1-2% of the population while medial epicondyltitis occurs1/10th as often. The use of the hands in mostactivities occurs in the palm down position (pronation) which may help explain whytennis elbow is ten times more common than golfers elbow. Rupture of the biceps tendon occurs when aheavy eccentric load is placed over the elbow as occurs when lifting a heavy object. On the other hand, tennis and golfers elbow occurs with repetitiveuse of the hands and forearms when manual laborers perform their routine job requirements requiring repetitiveand forceful forearm rotation and wrist extension and flexion movements.
Thetendons affected with the degenerative process in tennis elbow are the extensor carpi radialis brevis in all cases, and the extensor digitorum communis origin in some of the cases. In golfers elbow, the pronator teres and the flexor carpi radialis tendon origins are the involved tendons. Cubital tunnel syndrome or compression of the ulnar nerve at the elbow can occur in association with golfers elbow in as much as 30% of the cases. Partial or complete rupture of the biceps tendon at its insertion occurs secondary to an eccentric load on the biceps tendon as a result of forceful contraction of the biceps while the elbow is simultaneously extending. The use of oral steroids has been associated with an increase incidence of distal biceps tendon ruptures. Lateral epicondylitis and medial epicondylitis both present with pain as the initial complaint. The severity of the pain typically correlates with the severity of the condition and will dictate which treatment options are initially taken. Associated weakness of grip, radiation of the pain down the dorsal forearm or towards the shoulder is not uncommon.
Treatment
The treatment of tennis elbow, golfers elbow and a partial biceps tendon ruptures is often successfully treated with activity modification, splinting, anti-inflammatory medication, and therapy. Therapy includes stretching exercises followed by isometric strengthening, then concentric muscle strengthening and finally eccentric muscle strengthening. These strengthening exercises are done sequentially and not advanced until the previous exercises can beaccomplished without pain. A conservative approach can take six to nine months to be successful. If pain persists beyond this time, surgery is required which has an excellent success rate. There are two types of surgical techniques performed, the direct and indirect approach. Each category has several different techniques described and which technique is used will depend on the surgeon’s experience and how quick the wants to return to heavy lifting.
Complete distal biceps tendon rupture, is an urgent conditions that is treated surgically, preferably within one week of injury but for an optimum result, no later than two weeks. If repair is attempted after two weeks, the use of tendon graft may be necessary since the biceps muscle shortens quickly and cannot be put back on the radial tuberosity bone where it attatches. The complication rate of surgery increases with surgical delay of more than two weeks. The incisions used for repair are small and cosmetic. The postoperative rehabilitation must be performed carefully over a six month period before return to full normal function is obtained.