Chronic Elbow Instability

Chronic Elbow Instability

When we think about performing tasks with the upper extremities, what usually comes to mind is our hands and wrists. But without the elbow, so much of what you do each day would be impossible. Think about it: Without your elbow, which governs the placement of your hand in space, much of your upper body movement would have to come from your shoulders and wrists. If chronic elbow instability is left untreated, it can lead to significant pain, decreased range of motion in the elbow, early development of arthritis in the joint, and potentially severe functional limitations, making it difficult to perform everyday activities due to instability and recurrent dislocations, especially for individuals involved in sports requiring repetitive arm movements; in severe cases, this could even end a person’s athletic career. Medical intervention from highly competent and accomplished surgeons like those at Colorado Center of Orthopaedic Excellence in Colorado Springs, Colorado, is crucial.

OVERVIEW

A little-known fact about chronic elbow instability is that it can often be caused by repetitive microtrauma from activities like overhead throwing, even without a significant initial injury. This can lead to gradual ligament damage and a feeling of looseness in the elbow joint, especially in athletes. This is often referred to as “subtle instability” and might not be readily detected on a standard physical exam alone. Chronic elbow instability is a condition characterized by the repeated displacement or abnormal movement of the elbow joint, resulting in a feeling of not just looseness but of weakness or giving way during normal activities. A “loose” elbow can feel like it catches, pops, or slides out of place. It usually means that the stability of the elbow is compromised, often due to injury of the bone or surrounding ligaments. Young adults 15-35 are the most vulnerable age group with a slightly higher incidence in males. It is most common in athletes and manual workers.

ABOUT THE ELBOW

The elbow is a hinge joint system formed by the junction of the humerus (upper arm bone), and radius and ulna (forearm bones). These three bones articulate to form the elbow joint, which is held and supported by muscles and strong ligaments called the lateral ligament (on the outer side) and ulnar collateral ligament (on the inner side). The bones are held together with ligaments that form the joint capsule. The elbow flexes to bend the arm. It can move in four directions:

  • Extension: Straightening the arm out further away from the body to reach objects.
  • Flexion: The opposite of extension — bending in the lower arm toward the body.
  • Supination: Moving the palm up.
  • Pronation: Moving the palm down.

Functionally, the elbow is both a hinge joint and a pivot joint. Joints move just like the hinges that hold a door in place. They have a few parts that don’t move, but other pieces travel a specific distance to open and close. The elbow hinges to bend and straighten the arm.

It’s also a pivot joint. Pivot joints rotate in place without moving out of their original position. The elbow pivoting is what lets one turn the forearm over to move the palm up and down.

WHAT IS CHRONIC ELBOW INSTABILITY?

Elbow instability is a sense of looseness in the elbow joint that may cause the joint to catch, pop, or slide out of place during certain arm movements. It most often occurs as the result of an injury — typically, an elbow dislocation. A dislocation is an event when the joint stays out of place. This type of injury can damage the bone and ligaments that surround the elbow joint.

The term subluxation refers to a partial dislocation, which means the joint partially slips out but then goes back in place. When the elbow is loose and repeatedly feels as if it might slip out of place, it is called recurrent or chronic elbow instability.

There are three common types of recurrent elbow instability:

  1. Posterolateral rotatory instability: The most common type of chronic elbow instability is caused by an injury to the lateral collateral ligament complex. This can cause the elbow to slide in and out of the joint. Symptoms include lateral elbow pain, or mechanical symptoms when the elbow is flexed and supinated.
  2. Valgus instability: Caused by an injury to the medial collateral ligament, this type of instability can occur after trauma or repetitive overuse. Symptoms include pain in the medial elbow, especially during throwing activities.
  3. Varus posteromedial rotatory instability: This type of instability is caused by an injury to the lateral collateral ligament complex, along with a fracture of the coronoid of the ulna bone. It’s usually caused by trauma. 

If chronic elbow instability is left untreated, several serious complications can develop:

  • Increased Joint Damage
  • Continued instability causes abnormal wear and tear on the elbow joint
  • Cartilage breakdown accelerates, leading to early-onset osteoarthritis
  • The joint surfaces become progressively more damaged with each unstable movement
  • Reduced Range of Motion
  • Repeated instability can cause stiffening of the joint
  • Ligaments may become stretched or scarred
  • Muscle and Tendon Complications
  • Surrounding muscles work harder to compensate for joint instability
  • This can cause chronic muscle fatigue and potential strain
  • Higher likelihood of acute injuries during physical activities
  • Increased risk of falls or accidents due to joint unpredictability

Without treatment, the elbow may progressively lose its ability to perform normal functions

CAUSES

There are different causes for each of the different patterns of recurrent elbow instability:

  • Posterolateral rotatory instability is typically caused by trauma, such as a fall on an outstretched hand. It may also develop as a result of a previous surgery, or longstanding elbow deformity.
  • Valgus instability is most often caused by repetitive stress as seen in overhead athletes (such as baseball pitchers). Like the other forms of recurrent elbow instability, it may also result from a traumatic event.
  • Varus posteromedial rotatory instability is typically caused by a traumatic event, such as a fall.

The risk factors for chronic elbow instability are many:

  • Athletes include baseball, softball, handball, gymnasts, tennis players, wrestlers, martial artists, rock climbers, weightlifters, and basketball players. It can be caused by high-stress sports participation seen in professional athletes in competitive environments.

It can be caused by high-impact movements of workers:

  • Manual labor workers, construction workers, painters, mechanics, warehouse workers, people carrying heavy equipment, military personnel, and those in combat training.
  • There are people with specific medical conditions predisposing to instability, connective tissue disorders, history of joint instability, inherited connective tissue weakness, or joint hypermobility, also known as joint laxity or hyperlaxity. This is a condition where some or all of a person’s joints have an unusually large range of movement. 

SYMPTOMS

  • “Popping” or “sliding” sensation
  • A sensation of the elbow “giving way”
  • A feeling of looseness in the joint
  • Recurrent partial or complete dislocations
  • Pain during movement
  • Reduced strength in the arm
  • Decreased range of motion
  • Occasional swelling or inflammation
  • A feeling of instability during lifting or throwing

NON-SURGICAL TREATMENTS

  • Over-the-counter anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen
  • Ice and heat therapy
  • Kinesiology taping
  • Massage therapy
  • Dry needling
  • Soft tissue mobilization
  • Activity modification
  • Ergonomic adjustments at work
  • Using proper lifting techniques
  • Isometric exercises
  • Custom elbow braces
  • Compression sleeves
  • Stability supports that limit joint movement, provide external support, and reduce stress on damaged ligaments

WHEN IS SURGERY INDICATED?

Surgery for chronic elbow instability is usually recommended when non-surgical treatments fail or if the instability persists for 6-12 months. Other indications for surgery include: 

  • Recurrent dislocations  – Instability that isn’t corrected by limiting elbow extension and supination. 
  • Radiological signs of humeroradial or humeroulnar diastasis refer to an abnormal separation or widening of the joint space between the humerus and either the radius or ulna at the elbow joint. This condition usually indicates a disruption of the normal anatomical relationship in the elbow joint due to trauma or other pathological processes. 

The type of surgery performed depends on the underlying cause of the instability, such as a ligament injury, bone fracture, or other damage: 

  • Ligament repair: Sutures or surgical anchors can reattach mildly injured ligaments to the correct position. 
  • Ligament reconstruction: A tendon graft from the patient or a donor can reconstruct a damaged ligament. This is also known as Tommy John surgery. 
  • Fracture repair: Surgical screws realign broken bones into the correct position. 
  • Elbow dislocation repair: Surgery is used to repair severe dislocations, especially if they’re accompanied by other injuries. 

GETTING THE RIGHT DIAGNOSIS.  GETTING THE RIGHT DOCTOR.

Elbow instability is often quite subtle and requires expert evaluation to arrive at the correct diagnosis. Having the best surgeon for chronic elbow instability is crucial for several critical reasons. The elbow is an intricate joint with multiple ligaments and structures. It requires precise surgical intervention. It involves a delicate balance of stability and mobility. Even minor surgical errors can significantly impact long-term function. Ligament reconstruction demands extreme technical skill and requires the exact placement of grafts or repairs. Millimeter differences can dramatically affect joint stability, range of motion, future functionality, and long-term pain levels. The best surgeons like those at CCOE in Colorado Springs, Colorado, use advanced surgical approaches and stay current with the latest innovations, minimally invasive approaches, and advanced reconstruction techniques. They have lower complication rates, a better understanding of potential surgical risks, and the ability to make critical intraoperative decisions. At CCOE you get the most personalized and comprehensive patient care for the best results possible.

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