“It’s a mess ain’t it sheriff?” “If it ain’t it’ll do til the mess gets here”
from the movie “No Country for Old Men”
Arthritis can occur in any joint in the body. Arthritis is very common in the hands, a little less common in the wrist, and even less common in the elbow. Nonetheless elbow arthritis can be a painful process that can be difficult to treat. In other blogs I have discussed the treatment of arthritis in the hands and the wrist, so now I would like to look at the elbow and try to give an update on how arthritis of the elbow can be treated.
The main problem people have when they get arthritis in the elbow is pain, although the main problem may be stiffness. Most people notice a soreness in their elbows that gets worse with use and activity. Usually the pain is worse with just about any activity, which helps to distinguish arthritis from the most common causes of elbow pain, which is elbow tendonitis (tennis elbow and golfers elbow). In elbow tendonitis there are usually very specific motions and activities which cause the pain. In addition, people with elbow arthritis usually lose a little bit of mobility while people with tennis and golfers elbow rarely lose motion. The pain in arthritis is usually deeper, and more of an aching pain versus the shaper discomfort on tendonitis. Sometimes people will feel a pulling or popping inside of their joint.
The most common type of arthritis in the elbow is osteoarthritis, although patients with rheumatoid arthritis will often have problems with their elbow. Patients with rheumatoid arthritis usually have multiple joints involved and most often both arms are involved. It would be very unlikely for elbow arthritis to be the first sign of rheumatoid arthritis. Most of the time elbow arthritis starts to show up around age 50, and it seems to be much more common in men than women, although I see a fair number of women with elbow arthritis.
Elbow arthritis is usually easy to diagnose. Usually with an exam and plain x-rays the physician can figure out if elbow pain and stiffness are due to arthritis or some other problem such as tendonitis. In some cases an MRI or CT scan may be needed, usually to see if there are lose pieces of cartilage, or loose bodies in the joint. Loose bodies would be suspected if the elbow was popping or clunking and the patient had the sensation that something was floating around inside of the joint.
Once the diagnosis is made then the question turns to treatment. In early cases rest, ice, avoiding aggravating activities and over the counter non-steroidal medications such as Alleve or Advil are helpful. If the pain gets bad enough a cortisone injection can be very helpful. People start thinking about surgery if they are having problems with loose bodies and their elbows are locking up, if they are having enough stiffness that their elbow isn’t working well for them, or if the pain is starting to interfere with things they want to do.
There are a number of ways to treat elbow arthritis. In milder cases elbow arthroscopy can be performed to remove loose bodies and small spurts from the elbow. This seems to be a reasonable procedure to consider in very early cases. If the stiffness is the main problem then sometimes the joint can be loosened up by releasing the scar tissue around the elbow and removing some of the spurs which are present. There is a third procedure which is very successful at helping relieve elbow pain from arthritis. It is called an ulno-humeral arthroplasty. This surgery is based on the fact that the main spurs in elbow arthritis occur in the middle of the elbow. A usually thin area of bone in the elbow gets really thick which makes the arthritis worse. In the ulno-humeral arthroplasty the spurs in the back of the elbow are removed and the thick bone in the elbow is drilled out with a core drill. The surgeon can then take out the spurs in the front of the elbow through the hole he just drilled and he can also often remove loose bodies as well. This is a pretty big operation but I think it works well for a lot of patients.
When we talk about arthritis in other joints the conversation usually turns to joint replacements. In the hip, knee and shoulder joint replacements have been found to be very effective in relieving pain and restoring motion to arthritic joints. Unfortunately elbow replacements don’t seem to work as well. In general elbow replacements are best done in patients with rheumatoid arthritis who don’t put too many demands on the arms. Most surgeons recommend not lifting more than 5-10 pounds after an elbow replacement to decrease the chance of the elbow coming loose. This is usually too much of a restriction for most people, so an elbow replacement for arthritis is usually a last resort where all the risks and benefits really need to be evaluated by the patient and the surgeon before going down this road. I very rarely recommend an elbow replacement for patients with osteoarthritis of the elbow.
The good news about elbow arthritis is that it is pretty rare and usually doesn’t get so bad that patients need to have surgery. The bad news is that if the arthritis is really bad, there are only a limited number of options available to take care of the problem.