The elbow is a particularly complicated joint as it involves three bones; the upper arm bone is called the humerus and the two bones of the forearm are called the radius and ulna. The bones of the elbow are perfectly matched to their opposing bones. This helps maintain the elbows stability, which unlike other joints, is involved in both a hinge like movement as well as forearm rotation. This complexity can however make it prone to degenerative conditions such as osteoarthritis, particularly if the joint surfaces are damaged.
Osteoarthritis is a chronic degenerative disorder that results in the softening and disintegration of the cartilage that lines the joint surface. It is also accompanied by the formation of new, but abnormal, cartilage and bone at the margins of the joint (osteophytes) as well as scarring of the capsule, which surrounds the joint. In early stages of elbow arthritis, usually only the radio-capitella joint is affected. However as it progresses it will also affect the ulna-humeral joint. In advanced cases there can be a loss of bone affecting both the distal humerus (upper arm) as well as the ulna (the main bone of the forearm). The affect of all these changes is that the previously smooth elbow becomes rough such that elbow stiffness and pain develops.
The symptoms associated with elbow arthritis include;
- Pain; the pain associated with osteoarthritis is often described as a deep ache within the elbow, which is initially made worse by movement and eased by rest. As the condition deteriorates, the pain may also be felt even when at rest and at night, such that sleep is affected.
- Locking and ‘clunking’ of the joint may be noticed by those affected and can be due to the development of loose bodies, which impede joint movement. Episodes of locking will often settle spontaneously but will also often recur.
- Stiffness; restrictions in the range of elbow movement is common.
- Ulna nerve irritation
Causes & Risk factors
There are several different types of arthritis that affect the elbow but the most common is primary osteoarthritis. Osteoarthritis is a degenerative condition with no obvious cause but if arthritis develops as a result of another condition it is called secondary. Examples of this form of arthritis include:
- post traumatic arthritis (as occurs following a fracture)
- instability arthropathy (following recurrent elbow instability / dislocations)
- rheumatoid arthritis secondary to chronic inflammatory joint disease.
- septic arthritis following a joint infection
The diagnosis of elbow arthritis is largely made on a history and examination however it is confirmed by x-rays which reveal irregular joint surfaces, osteophytes and possibly bone loss. CT scans can also prove helpful, as the anatomy of the joint surfaces can sometimes be difficult to interpret with plain x-rays. Loose bodies and osteophytes restricting movement can also be noted more easily on CT scans.
The treatment for elbow arthritis is always tailored to the particular patient.
- Rest, activity modification, pain relief and physiotherapy can all give good benefit, particularly in the early stages of the disease. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibruprofen, can help control the pain but should only be used regularly under the guidance of your General Practitioner.
- Physiotherapy can prove beneficial in the early stages of the disease and can help maintain motion and strength of the elbow. It is however, less effective in advanced disease and may actually exacerbate the pain.
- Injection treatments can occasionally have a role. A corticosteroid injections directly into the elbow joint can improve pain however the affect is always temporary and multiple injections can have a deleterious affect on the elbow. The use of sodium hyaluronatemay also have a role in managing the symptoms of elbow arthritis however it is in the early stages of its evaluation when used in the lebow.
- Elbow debridement and arthrolysis; this is a surgical procedure performed either as a keyhole or open procedure. The aim of the operation is to assess the severity of the cartilage damage following which any loose bodies and osteophytes can also be removed to allow greater movement. At the same time, the capsule enveloping the elbow can be released which, combined with the osteophyte removal, usually results in an improved range of elbow movement. When the disease is too advanced an elbow replacement will be necessary.
- Elbow replacement; An elbow replacement can come in a variety of different designs. In very early, but significantly symptomatic, disease a lateral elbow replacement can be undertaken. This involves replacing only the capitellum and radial head. However in more advanced case of degenerative disease, a total elbow replacement will be necessary. If such cases, the elbow replacement acts in such a way that it is described as a ‘sloppy hinge’ such that flexion and forearm rotation can be achieved in a pain free manner after the operation. The choice of implant will be made based on the nature of your disease and on what implant will give you the best clinical result.