What is tennis elbow and golfer's elbow?

Tennis elbow (lateral epicondylitis) involves inflammation or tearing of tendons on the outside of the elbow, often due to repetitive wrist extension. Golfer's elbow (medial epicondylitis) affects the tendons on the inside of the elbow, typically from repetitive wrist flexion and forearm pronation.

What is the first line of treatment for tennis and golfer's elbow?

The initial treatment typically involves rest, good stretching exercises, and oral NSAIDs. If pain is severe and limits function, a low-dose cortisone injection may be administered to reduce inflammation.

When is surgery considered for elbow injuries?

Surgery is generally considered when conservative treatments fail, or for acute injuries like a distal biceps tendon rupture or triceps tendon rupture. These ruptures are often disabling and require surgical repair to restore function.

What is the significance of the 'funny bone' nerve?

The 'funny bone' nerve is the ulnar nerve, which runs close to the medial epicondyle. While bumping it causes a distinct sensation, it can also become irritated or injured, contributing to pain or discomfort in the inner elbow.

What is the Tommy John ligament and who needs surgery for it?

The Tommy John ligament is the ulnar collateral ligament (UCL) on the inside of the elbow. Surgery is primarily indicated for elite throwing athletes whose UCL has ruptured due to extreme, superphysiologic forces, leading to a significant loss in throwing velocity.

How is the elbow examined for injuries?

An elbow examination involves assessing range of motion (flexion, extension, pronation, supination), strength testing under specific stresses, palpating for tenderness and swelling at key points like the epicondyles and olecranon, and checking for nerve involvement.

What are common causes of triceps tendon ruptures?

Triceps tendon ruptures typically occur due to eccentric loading, often seen when individuals fall while skiing and try to brace themselves. This sudden, powerful eccentric force can cause the triceps tendon to tear off the olecranon.

Key Moments

Elbow: discussion + exam with orthopedic surgeon, Alton Barron, M.D.

Peter Attia MD

Science & Technology4 min read27 min video

Nov 28, 2022|2,341 views|65|3

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Key Moments

TL;DR

Orthopedic surgeon discusses elbow anatomy, common injuries (tennis/golfer's elbow, biceps/triceps tears), and their treatments, including a physical exam.

Key Insights

The elbow joint's stability comes from the interlocking shapes of the humerus, ulna, and radius, but this also limits wiggle room and can lead to arthritis with imprecise healing.

Common elbow tendon injuries include lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow), often caused by overuse and specific movement patterns.

Biceps tendon ruptures primarily affect forearm supination strength, while triceps tendon ruptures, often from eccentric loading during falls, are highly disabling and require surgical repair.

Conservative treatments for epicondylitis involve rest, NSAIDs, and stretching/strengthening, with corticosteroid injections used to reduce inflammation in persistent cases.

Surgical interventions are reserved for cases that fail conservative treatment, such as chronic tendon tears or significant ruptures like distal biceps or triceps tendons.

The 'Tommy John' ligament (ulnar collateral ligament) is crucial for throwing athletes, and tears are typically due to super-physiologic loads, with reconstruction primarily benefiting elite throwers.

ELBOW ANATOMY AND JOINT STABILITY

The elbow joint is formed by the humerus, ulna, and radius. Its complex, undulating surfaces provide intrinsic stability, akin to puzzle pieces fitting together. Tendons for the forearm and hand muscles generally originate above the joint from the humerus, while those from the shoulder attach below. The radial head allows forearm rotation, and the ulna provides a fixed axis. This intricate structure, while stable, offers minimal room for error during healing, meaning even subtle fractures can lead to rapid arthritis if not perfectly aligned during treatment.

COMMON TENDON INJURIES: TENNIS AND GOLFER'S ELBOW

The most frequent tendon injuries involve the lateral epicondyle (tennis elbow/lateral epicondylitis) and the medial epicondyle (golfer's elbow/medial epicondylitis). These conditions often stem from degenerative changes and partial tears in the attached tendons, commonly the extensor carpi radialis brevis for tennis elbow and the flexor pronator muscles for golfer's elbow. While named after sports, these injuries affect individuals of all activity levels due to overuse or repetitive strain.

MECHANISMS AND TREATMENT OF EPICONDYLITIS

Historically, tennis elbow was linked to the one-handed backhand due to its greater stress on external rotators. Golfer's elbow often resulted from impacting the ground (duffing shots) with the trailing arm, causing eccentric load on medial tendons. Modern trends, like topspin in tennis and powerful drives in golf, overwork pronator muscles, increasing medial epicondylitis cases. Conservative treatment includes rest, NSAIDs, stretching, and strengthening; corticosteroid injections can provide temporary relief for severe inflammation and pain.

DISTAL BICEPS AND TRICEPS TENDON RUPTURES

Rupture of the distal biceps tendon, often seen in active individuals after antecedent pain or overexertion, significantly impacts forearm supination strength more than elbow flexion. Diagnosis involves assessing supination strength and pain during resisted pronated curls. Triceps tendon ruptures, commonly occurring during falls with eccentric loading (e.g., skiing), detach the tendon from the olecranon. This is a highly disabling injury requiring prompt surgical repair due to the triceps' critical role in extending the elbow and pushing up from a seated position.

THE ULNAR COLLATERAL LIGAMENT AND THROWING INJURIES

The medial collateral ligament, known as the ulnar collateral ligament (UCL) or 'Tommy John ligament,' is vital for throwing athletes, withstanding super-physiologic torques. Maintaining fitness, particularly in the flexor pronator muscles, shoulder, biceps, and triceps, helps protect this ligament from repetitive stress. Rupture leads to a significant loss of throwing velocity, making it primarily relevant for elite throwers. While reconstruction surgery has advanced, it’s crucial to distinguish between true injury and parental desires for enhanced athletic performance in non-injured young athletes.

DIAGNOSTIC EXAM AND FUNCTIONAL ASSESSMENT

An orthopedic examination of the elbow involves assessing the carrying angle, looking for swelling, and checking for asymmetry. Specific tests isolate pain and weakness in the distal biceps (resisted supination, pronated curls), lateral epicondyle (resisted wrist extension), and medial epicondyle (resisted wrist flexion). Range of motion, including extension, flexion, pronation, and supination, is meticulously evaluated to detect contractures or limitations significant for daily function. Testing the triceps involves resisted extension from a flexed position.

NERVE ASSESSMENT AND IDEAL EXERCISE POSITIONS

Assessment includes evaluating the ulnar nerve, often palpable rolling over the medial epicondyle, which can be a normal variant. While not always causing issues, nerve mobility is noted. Regarding exercise, optimal triceps workouts, particularly for tendon health, are performed with the humerus in a flexed position (overhead) to place the triceps under stretch, rather than fully extended or neutral positions, assuming shoulder tolerance.

Mentioned in This Episode

●Tools

●Concepts

●People Referenced

Elbow Injury Prevention and Management

Practical takeaways from this episode

Do This

Prioritize rest and good stretching for elbow pain.

Strengthen grip strength and forearm muscles.

Ensure proper conditioning before returning to strenuous activities.

For triceps workouts, consider exercises with the humerus in an extended position (e.g., overhead) to stretch the muscle.

If experiencing chronic pain, consider a booster dose of cortisone to reduce inflammation.

In cases of distal biceps rupture, surgical repair is often necessary to restore supination strength.

Avoid This

Avoid overdoing repetitive motions without adequate conditioning.

Do not ignore persistent elbow or forearm pain; seek professional evaluation.

Be cautious of 'shady' operations or parents pushing unnecessary procedures like Tommy John surgery on non-elite athletes or children with no current issues.

Avoid pushing through significant pain during specific movements that exacerbate elbow conditions like tennis or golfer's elbow.

Do not neglect the importance of proper mechanics in sports like tennis and golf, as these can significantly impact elbow health.

Common Questions

The elbow joint is primarily formed by the humerus (upper arm bone), the ulna (the larger forearm bone), and the radius (the smaller forearm bone). These bones have undulating surfaces that fit together, providing stability.

Topics

Health & Longevity Sports Injuries Orthopedic Examination Fitness & Exercise Medicine & Clinical Tendon Injuries Elbow Anatomy Joint Mechanics

Mentioned in this video

Products

Humerus

The arm bone that forms the upper part of the elbow joint.

Concepts

Radius

One of the two bones of the forearm, located on the thumb side, connected to the radial head.

Ulna

The larger of the two bones in the forearm, located on the pinky finger side, forming the main structure of the elbow joint.

Biceps Tendon

The tendon that attaches the biceps muscle to the radius, involved in elbow flexion and forearm supination.

Ulnar Nerve

The nerve responsible for the 'funny bone' sensation, running along the inside of the elbow.

tennis elbow

Also known as lateral epicondylitis, an inflammation or microtearing of the tendons that attach to the lateral epicondyle of the humerus, often caused by repetitive wrist extension.

golfer's elbow

Also known as medial epicondylitis, an inflammation or microtearing of the tendons that attach to the medial epicondyle of the humerus, often caused by repetitive wrist flexion and pronation.

triceps

The large muscle on the back of the upper limb of many vertebrates, responsible for extending the elbow.

Olecranon Bursa

A small sac of fluid located over the tip of the elbow that can become inflamed and swell.

Medial Collateral Ligament

A thick ligament on the inside of the elbow that provides stability. Also known as the ulnar collateral ligament.

Ulnar Collateral Ligament

A thick ligament on the inside of the elbow that provides stability. Also known as the medial collateral ligament, commonly injured in throwing athletes.

Supraspinatus Tendon

One of the tendons of the rotator cuff in the shoulder, subject to similar degenerative processes as elbow tendons.

Distal Biceps Rupture

A tear of the biceps tendon near its attachment to the radius, often resulting in a 'Popeye' muscle deformity and loss of supination strength.

Popeye muscle

The visual bulge or deformity seen when the biceps tendon ruptures and the muscle retracts proximally.

Brachialis

A muscle in the upper arm that lies underneath the biceps, primarily responsible for elbow flexion and contributing to basic curling strength.

Tommy John Surgery

A reconstructive surgery for the ulnar collateral ligament, commonly performed on elite throwing athletes.

Olecranon

The bony projection of the ulna that forms the tip of the elbow, serving as the attachment point for the triceps tendon.

ECRB tendon

Extensor Carpi Radialis Brevis tendon, a common source of pain in tennis elbow.

Supplements

NSAIDS

Nonsteroidal anti-inflammatory drugs, commonly used as a first-line treatment for elbow pain.

Drugs & Medications

Cortisone

A corticosteroid injection used to reduce inflammation and pain, often in treating epicondylitis.

People

Nolan Ryan

A famous baseball pitcher known for his longevity and powerful fastball, used as an example of elite throwing ability.

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