The patient was given various treatment options, including the option of living with his current pain and range of motion but with significant activity modification. Also, surgery was discussed with the patient as an option to improve range of motion and pain, with the understanding that he may have more joint laxity postoperatively. This, in turn, if he continued weightlifting, would lead to a possible increase in pain. The patient's main goal was to regain range of motion so he could perform more functional activities again, i.e., be able to button the top of his shirt.
The patient elected to proceed with surgery and underwent left elbow arthroscopy with debridement of the posterior olecranon and coronoid spurs with chondroplasty of the articular surface. Physical therapy was begun at 1 wk after surgery. By 3 months he lacked only 10 degrees of extension with flexion to 100 degrees and was able to button his top shirt button. His left elbow was placed in a Dynasplint to help him achieve the last few degrees of its extension. Overall, he was pleased with both the improved range of motion and decreased pain.
The elbow joint is composed of three articulations: ulnotrochlear, radiocapitellar, and proximal radioulnar joints. The articulation between the ulna and the humerus provides most of the joint's stability, with flexion-extension occurring at the ulnotrochlear joint and pronation-supination occurring through the radiocapitellar joints and proximal/distal radioulnar joints (7).
The etiology of elbow arthritis can be traced to sequelae of joint infection, crystalline arthropathy, hemophilia, primary osteoarthritis (OA), rheumatoid arthritis, and trauma to the elbow, which is the most common (4).
Primary OA of the elbow is uncommon in the general population, affecting less than 2% of individuals. When it occurs, it is seen more commonly on the dominant side of middle-aged men with a history of heavy use in sport or on those who engage in strenuous manual activities (1,3,10). In weightlifters, elbow arthritis is more prevalent because of the increased stress and use of the joint. OA of the elbow differs from that of other joints in that the joint space usually is preserved. Early on, it is characterized by osteophyte formation, capsular contracture, and, frequently, loose bodies (3). Although it is considered to be a non-weight-bearing joint, it does bear load. In fact, dynamic loading, seen with throwing or heavy pounding, produces forces more than six times the body weight (2). When elbow OA does develop, it usually begins laterally, with early degeneration of the radiocapitellar joint, followed by the ulnohumeral joint (5).
Overall, the presentation of a patient with elbow OA varies depending on the etiology of the arthritis and the stage of disease. Generally, in primary OA, a patient's primary presenting symptom is pain, especially at the end of range of motion accompanied with stiffness or restriction of motion. There is loss of terminal elbow extension and flexion with impingement-type pain. Joint space still is maintained, with osteophyte formation at the olecranon fossa and proximal portion of the olecranon causing discomfort in maximal extension. Osteophytes also form in the trochlea or in the coronoid process, causing impingement pain in extreme flexion (7). Then, the elbow progresses to a greater degree of restriction and pain throughout the arc of motion in the later stages (1).
Initial radiographic evaluation is done with standard anteroposterior and lateral radiographs, which usually reveal anterior and medial osteophytes involving the coronoid process and a posteromedial osteophyte on the olecranon process (3). Extensive narrowing of the joint space, without osteophytes, is more indicative of an inflammatory process (3). Although additional imaging studies usually are not necessary for preoperative planning, magnetic resonance imaging or computed tomography can help delineate substantial bony deformities or intra-articular loose bodies (4). This is especially important, because up to 30% of loose bodies are not detected on plain radiographs (6,9).
A conservative nonsurgical treatment of primary OA includes rest, nonsteroidal anti-inflammatory medications, and long-term activity modification (3). Intra-articular corticosteroid injections can provide some relief of symptoms. Physical therapy with range-of-motion exercises to maintain mobility and strength has been recommended, with or without dynamic hinged and static progressive splinting (1,4). However, one must remember that primary elbow OA is a disease affecting the bone, and that physical therapy is aimed at muscle and soft tissue. Moreover, viscosupplementation has been studied, and it was found to provide minimal pain relief at 3 months, with no lasting benefit at 6 months (8).
When conservative measures do fail, the patient's primary complaint should be the main consideration in surgical planning. Patients with restriction of motion or with pain at extremes of motion as their primary complaint likely would benefit from open or arthroscopic debridement and possible capsular release. This is in contrast to patients with evidence of late-stage disease who have pain throughout the arc of motion and diffuse narrowing of the joint space. They are likely to benefit from distraction interposition arthroplasty, total elbow arthroplasty, or elbow arthrodesis (10). Among these three more aggressive approaches, distraction interposition arthroplasty, which is reserved for those younger than 65 years, has the least postoperative activity restrictions, although it is done rarely, while arthroplasty or arthrodesis is for those aged 65 years and older who are willing to live with low levels of activity (1).
The authors have no funding disclosures.
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© 2011 American College of Sports Medicine
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