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Non-specific treatments include:
- Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
- Heat or ice
- A counter-force brace or "elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.
Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as the common rest, ice, compression and elevation (R.I.C.E.) will typically be used. This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The patient can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm. The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
Therapy will include a variety of exercises for muscle/tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly begin with isometrics and progresses to eccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the patient to ice the area.
Simple analgesic medication has a place, as does more specific treatment with oral anti-inflammatory medications (NSAIDs). These will help control pain and any inflammation. A more invasive treatment is the injection into and around the inflamed and tender area of a long-acting glucocorticoid (steroid) agent. After causing an initial exacerbation of symptoms lasting 24 to 48 hours, this may produce an improvement of the condition in some five to seven days.
The ulnar nerve runs in the groove between the medial humeral epicondyle and the olecranon process of the ulna. It is most important that this nerve should not be damaged accidentally in the process of injecting a golfer's elbow.
If all else fails, epicondylar debridement (a surgery) may be effective. The ulnar nerve may also be decompressed surgically.
If the appropriate remediation steps are taken - rest, ice, and rehabilitative exercise and stretching - recovery may follow. Few patients will need to progress to steroid injection, and less than 10% will require surgical intervention.
Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit. A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues. Evidence for oral NSAIDs is mixed.
Evidence is poor for long term improvement from injections of any type, whether corticosteroids, botulinum toxin, prolotherapy or other substances. Corticosteroid injection may be effective in the short term however are of little benefit after a year, compared to a wait-and-see approach. A recent randomized control trial comparing the effect of corticosteroid injection, physiotherapy, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (Relative risk 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).
Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site. Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.
Evidence for the treatment of lateral epicondylitis before 2010 was poor. There were clinical trials addressing many proposed treatments, but the trials were of poor quality.
In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.
In the original description by Hume, where the olecranon fractures were not displaced, treatment consisted of closed reduction of the radial head dislocation under general anaesthesia by supination of the forearm. This was followed by immobilisation of the arm in a plaster cast with the elbow flexed at 90° and the forearm in supination for 6 weeks.
Where the olecranon fracture is displaced, open reduction internal fixation is recommended. Once the olecranon has been repaired, closed reduction of the radial head dislocation is usually possible. This is followed by immobilisation with the elbow flexed to 90° and the forearm in the neutral position. The duration of immobilisation depends on clinical assessment of the joint, and mobilisation may be possible after as little as 4 weeks.
UCL injuries may or may not require surgery. Non surgical treatment will primarily focus on strengthening the elbow joint to regain strength and stability. First a course of
RICE (Rest, ice, compression, elevation) is typically coupled with NSAIDS (Non-steroidal anti-inflammatory drugs) to help alleviate pain and swelling. When the swelling has subsided, individual exercises or physical therapy may be prescribed to strengthen muscles around the elbow joint to compensate for tearing in the UCL. These may include biceps curls (non resistance and resistance), pronating and supinating the forearm, and grip strengthening exercises, performed with low resistance and moderate repetitions no more than three times a week.
Surgical treatment may help restore the ability to perform the overhand throwing motions most commonly associated with UCL injuries. The reconstructive surgery, generally known as Tommy John surgery, was first performed by Dr. Frank Jobe in 1974 and has modified several times over the past 30 years. The surgery involves an autograft of the palmaris longus tendon (mostly seen as an accessory tendon) or an allograft of tissue from a cadaver or donor. The new tendon is attached by drilling holes in the medial epicondyle of the humerus and the sublime tubercle of the ulna and lacing the tendon through them in a figure eight. The patient may begin physical therapy shortly after. It usually takes about 15 months after the surgery for standard rehabilitation. In study conducted by Dr. Frederick Azar, 78 Tommy John surgeries were performed and analyzed after the surgeries. Of the 78 patients, 8 of them (8.8%) reported complications. Two patients had superficial infections that resolved with oral antibiotics, two patients reported tightness of tenderness at the surgery site, and one had a superficial wound infection at the elbow incision that resolved with oral antibiotics. One patient developed postoperative ulnar nerve damage. Two patients had damages to the posteromedial part of the olecranon and required to have reoperation.
Recent studies have shown that MLB pitchers who undergo Tommy John surgery return to pitch in the MLB 83% of the time and only 3% fail to return to pitch in the MLB or the minor league.
Recently, there has been a recorded increase of Tommy John surgery. The increase is related to the false perception that the surgery improves the stability of the UCL joint. Many athletes believe in this false perception and cause them to lie about their symptoms in hopes to undergo the surgery. In order to combat these rumors, physicians are motivated to educate the public that Tommy John surgeries are only for those who have severe UCL injuries. The surgery will have an insignificant effect if the patient does not have a severe UCL injury.
The tendon chosen is then woven in a figure eight pattern through the humerus and ulna, which holes were first drilled in the bones. After surgery occurs, rehabilitation comes into place and usually takes about a year because a tendon needs time to convert into a ligament.
Most olecranon fractures are displaced and are best treated surgically:
Medication is not the primary treatment for hypermobility, but can be used as an adjuct treatment for related joint pain. NSAIDS are the primary medications of choice. Narcotics are not recommended for primary or long term treatment and are reserved for short term use after acute injury.
The goal of treatment in Panner disease is to relieve pain. Treatment for Panner Disease is very minimal because in most children the bones repair their blood supply and rebuild themselves and this leads to the rebuilding of the growth plate and the capitellum returns to its normal shape. The period of rebuilding and regrowth varies from child to child and can last anywhere between weeks to several months. To relieve the pain, the child is restricted from participating in sports and activities until the elbow is healed and to also rest the affected elbow. Rest will allow for the pain to be relieved and return of full elbow movement. It may also be recommended for children to apply an icepack or heat to the elbow to alleviate pain and swelling. If the child has great difficulty bending and straightening the arm then physical therapy may also be recommend. Occasionally, it is recommended for children to use nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen to also reduce pain and swelling. For treatment, Panner Disease heals well in children with rest and restriction of physical activity and sports using the affected arm. The prognosis is also good with treatment and the affected capitellum is remodeled. Irregularities of the capitellum and surrounding elbow area can both be seen by radiograph and MRI. When treatment is effective the flattened and fragmented capitellum is completely remodeled and returns to its normal circular shape, and also the high intensity signal on a MRI T2 series disappears. These results indicate that the capitellum is completely remodeled and the child is able to return to normal physical and sports activities.
Conservative management of minor cases involves icing, a firm compression bandage, and avoidance of the aggravating activity. This can also be augmented with oral or topical anti-inflammatory medications such as NSAIDs. Elbow padding can also be used for symptomatic relief. Treatment for more severe cases may include the excess bursa fluid with a syringe (draining of the bursa), or injecting into the bursa a hydrocortisone type medication which is aimed at relieving the inflammation and preventing further accumulation of fluid.
In case of infection, the bursitis should be treated with an antibiotic.
Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.
Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly. There is insufficient evidence on the routine use of injection therapies (Autologous blood, Platelet-rich plasma, Deproteinised haemodialysate, Aprotinin, Polysulphated glycosaminoglycan, Corticosteroid, Skin derived fibroblasts etc.) for treating Achilles tendinopathy. As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies.
This method is indicated for cases when open reduction and internal fixation is unlikely to be successful. For example: extensive comminutions, elderly patients with osteoporotic bone, and small or non-union fractures.
If the fluid continues to return after multiple drainings or the bursa is constantly causing pain to the patient, surgery to remove the bursa is an option. The minor operation removes the bursa from the elbow and is left to regrow but at a normal size over a period of ten to fourteen days. It is usually done under general anesthetic and has minimal risks. The surgery does not disturb any muscle, ligament, or joint structures. To recover from surgical removal, a splint will be applied to the arm to protect the skin. Exercises will be prescribed to improve range of motion.
The most-often prescribed treatments for early-stage RSIs include analgesics, myofeedback, biofeedback, physical therapy, relaxation, and ultrasound therapy. Low-grade RSIs can sometimes resolve themselves if treatments begin shortly after the onset of symptoms. However, some RSIs may require more aggressive intervention including surgery and can persist for years.
General exercise has been shown to decrease the risk of developing RSI. Doctors sometimes recommend that RSI sufferers engage in specific strengthening exercises, for example to improve sitting posture, reduce excessive kyphosis, and potentially thoracic outlet syndrome. Modifications of posture and arm use (human factors and ergonomics) are often recommended.
Conservative therapies include NSAIDs, pain medication, weight management and exercise restriction. The problems with these therapies is that they do not work well, especially long-term.
This method should be used within the first 48–72 hours after the injury in order to speed up the recovery process.
Heat: Applying heat to the injured area can cause blood flow and swelling to increase.
Alcohol: Alcohol can inhibit your ability to feel if your injury is becoming more aggravated, as well as increase blood flow and swelling.
Re-injury: Avoid any activities that could aggravate the injury and cause further damage.
Massage: Massaging an injured area can promote blood flow and swelling, and ultimately do more damage if done too early.
Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach. Other treatments for which research is on-going includes vitamin E, vitamin B6, nitric oxide, Platelet Rich Plasma (PRP), and stem cell injections.
One study found increased achilles tendon healing in rats supplemented with high doses of vitamin C, which is needed for collagen synthesis.
The aim of treatment is to minimize pain and to restore as much normal function as possible. Most humerus fractures do not require surgical intervention. One-part and two-part proximal fractures can be treated with a collar and cuff sling, adequate pain medicine, and follow up therapy. Two-part proximal fractures may require open or closed reduction depending on neurovascular injury, rotator cuff injury, dislocation, likelihood of union, and function. For three- and four-part proximal fractures, standard practice is to have open reduction and internal fixation to realign the separate parts of the proximal humerus. A humeral hemiarthroplasty may be required in proximal cases in which the blood supply to the region is compromised. Fractures of the humerus shaft and distal part of the humerus are most often uncomplicated, closed fractures that require nothing more than pain medicine and wearing a cast or sling for a few weeks. In shaft and distal cases in which complications such as damage to the neurovascular bundle exist, then surgical repair is required.
There is moderate quality evidence that manual therapy and therapeutic exercise improves pain in patients with thumb CMC
OA at both short- and intermediate-term follow-up, and low to moderate quality evidence that magneto therapy improves pain
and function at short-term follow-up. There is moderate evidence that orthoses (splints) can improve hand function at long-term follow-up. There is very low to low-quality evidence that other conservative interventions provide no significant improvement in pain and in function at short- and long-term follow-up. Some of the commonly performed conservative interventions performed in therapy have evidence to support their use to improve hand function and decrease hand pain in patients with CMC OA.
Prevention of the condition requires restoration of blood flow after injury and reduction of compartmental pressure on the muscles. Any splints, bandages, or other devices that might be obstructing circulation must be removed. A fasciotomy may be required to reduce pressure in the muscle compartment. If the contracture occurs, surgery to release the fixed tissues may help with the deformity and function of the hand.
Surgical rehabilitation is vital, progressive and supervised. The first phase focusses on early motion and usually occupies post-surgical weeks one through three. Passive range of motion is restored in the shoulder, elbow, forearm, and wrist joints. However, while manual resistance exercises for scapular protraction, elbow extension, and pronation and supination are encouraged, elbow flexion resistance is avoided because of the biceps contraction that it generates and the need to protect the labral repair for at least six weeks. A sling may be worn, as needed, for comfort.
Phase 2, occupying weeks 4 through 6, involves progression of strength and range of motion, attempting to achieve progressive abduction and external rotation in the shoulder joint.
Phase 3, usually weeks 6 through 10, permits elbow flexion resistive exercises, now allowing the biceps to come into play on the assumption that the labrum will have healed sufficiently to avoid injury.
Thereafter, isokinetic exercises may be commenced from weeks 10 through 12 to 16, for advanced strengthening leading to return to full activity based on post surgical evaluation, strength, and functional range of motion. The periods of isokinetics through final clearance are sometimes referred to as phases four and five.
For some people with hypermobility, lifestyle changes decrease symptom severity. In general activity that increases pain is to be avoided. For example:
- Typing can reduce pain from writing.
- Voice control software or a more ergonomic keyboard can reduce pain from typing.
- Bent knees or sitting can reduce pain from standing.
- Unwanted symptoms are frequently produced by some forms of yoga and weightlifting.
- Use of low impact elliptical training machines can replace high-impact running.
- Pain-free swimming may require a kickboard or extra care to avoid hyperextending elbow and other joints.
- Weakened ligaments and muscles contribute to poor posture, which may contribute to other medical conditions.
- Isometric exercise avoids hyperextension and contributes to strength.
The RICE method is an effective procedure used in the initial treatment of a soft tissue injury.
Rest: It is suggested that you take a break from the activity that caused the injury in order to give the injury time to heal.
Ice: The injury should be iced on and off in 20 minute intervals, avoiding direct contact of the ice with the skin.
Compression: Bandaging the injury will compress it, and prevent any further bleeding or swelling from occurring.
Elevation: Elevating the injury above the heart while resting will aid in the reduction of swelling.
Manual therapy is another commonly used treatment modality in which the joints or muscles of patients are manipulated with the intention of restoring the range of motion of the joint or increasing the flexibility of the muscles around the joint. Intervention techniques:
- Kaltenborn Mobilization Technique
- Maitland's Mobilization
- Neurodynamic Techniques
Following inspection and determination of the extent of injury, the basic labrum repair is as follows.
- The glenoid and labrum are roughened to increase contact surface area and promote re-growth.
- Locations for the bone anchors are selected based on number and severity of tear. A severe tear involving both SLAP and Bankart lesions may require seven anchors. Simple tears may only require one.
- The glenoid is drilled for the anchor implantation.
- Anchors are inserted in the glenoid.
- The suture component of the implant is tied through the labrum and knotted such that the labrum is in tight contact with the glenoid surface.