Dr. Budoff's Blog

Tennis Elbow

September 2nd, 2010

Tennis elbow is very common. It occurs most commonly on the outer side of your elbow, but may also occur on the inner side, and occasionally even in the back of the elbow. When it occurs on the inner side of the elbow it’s called “golfer’s elbow,” but it’s really the same problem. The problem is tendon over-use, leading to tendon breakdown. This is called tendinosis, which means tendon degeneration. We used to call it tendinitis, which means tendon inflammation, but we now know that this is incorrect. The pain comes from the breakdown and degeneration of overused tissue, not from inflammation.

Any activity that stresses these tendons, including tennis, golf, sports and manual labor (heavy lifting, etc) can lead to tennis elbow. Despite its name, up to 95 percent of cases of “tennis elbow” occur in non-tennis players, who subject themselves to repetitive stresses may develop tennis elbow.

There is a balance between the stresses you apply to your arm and the strength of the small muscles to handle these stresses. Once the applied stresses become too much, injury and pain can occur. Therefore, to get rid of your pain and avoid future injury you can either decrease the stresses on your elbow or increase the strength of the forearm muscles about the elbow.

For sports, proper technique is very important. For golf, tennis, throwing, etc. you’re supposed to generate the force to swing the racket or club, or throw the ball from the large muscles of your legs and trunk. The shoulder and elbow are simply supposed to transfer these forces to the ball, club or racket. If you’re using your shoulder or elbow to generate power, your form is incorrect and you’re putting yourself at risk of overuse injuries. At work, utilizing proper mechanics and avoiding provocative activities can be helpful.

“Counterforce” bracing has also been shown to be effective in reducing the stresses to your forearm muscles. Counterforce braces absorb some of the stress so that the tendons don’t have to.

The more important treatment is to increase the strength quality of your muscles and tendons. This is done through rehabilitative strengthening exercises. The muscle groups that you need to strengthen are the wrist extensors, wrist flexors and the forearm rotators. For strengthening, I prefer an elastic resistance, such as an isotube, rather than a dumbbell or free weight.

Exercise should not cause pain. If pain occurs during strengthening, you’re either using too much resistance or doing them too many times. The idea is to strengthen the weakened muscles, not to over-stress them. Wear the counterforce brace while exercising. To start, I recommend only one set of 10-12 repetitions per day for each exercise. During exercises, the elbow should be bent and the forearm supported.

Steroid injections provide temporary pain relief in over 50% of cases. Unfortunately, steroid injections do not provide a permanent cure, and are no better than placebo at 3 months. However, injections are useful to decrease pain enough so that you can perform the exercises better. Understand that the repeated use of cortisone injections is inappropriate. There is no advantage, and considerable disadvantage, in having more than two such injections. Repetitive injections may weaken the surrounding normal tissues, potentially leading to further damage.

Rehabilitative exercises, combined with appropriate bracing, successfully treats about 75-95% of patients with tennis elbow. The others continue to have pain that limits their activities. This occurs because the amount of tissue damage is too great for the body to repair. If you’re in this situation, then you can either accept the condition and limit your activities accordingly, or elect to undergo a simple surgical solution that is approximately 97% effective. It involves a small incision, only about 2″ long, through which the damaged, abnormal, unhealthy tendon is removed.

There are other, older surgeries still used that tried to “release” the origin of the tendons from the bone, repair the tendon, or take out the bone itself. Not only do these not work well, but they can hurt a lot, lead to stiffness and/or residual pain and can weaken the forearm muscles. Some of these operations leave some damaged and degenerated tissue behind. In addition, releases may damage the elbow ligaments located directly beneath the tendons, which may lead to further pain and elbow instability. And once you’ve had an unsuccessful surgery, the chances that an appropriate surgery can help you decreases to about 84%.

The take home message is this: tennis elbow is relatively common, but can be minimized by using proper techniques, both during athletics and at work. The vast majority of people with tennis elbow can be treated with a counterforce brace and a good muscle strengthening program. And for the minority of patients who do come to surgery, modern techniques of tennis elbow excision have an excellent rate of success.

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Endoscopic Carpal Tunnel Release – There are Different Types

August 28th, 2010

Endoscopic carpal tunnel release (ECTR) provides the same cure from carpal tunnel syndrome as does open carpal tunnel release (open CTR), but with less pain, less problems and a quicker return to work and other activities. Compared to open CTR, ECTR leads to less pain and weakness, and a quicker return to work.1-3

However, many people are not aware that there are two different types of ECTR: the one-incision technique and the two-incision technique. Both techniques use an incision over the wrist. But the two-incision ECTR places ana second incision in the palm of your hand. This palmar wound causes additional discomfort. In addition, this wound needs to be protected, meaning that immediately after surgery your hand is wrapped, decreasing how much you can do. For the one-incision ECTR there are no bandages over your hand because there are no incisions in your hand. Because of this, there is less palmar tenderness, and most patients regain motion and return to work and other activities quicker following single-incision ECTR compared to following two-incision ECTR.1 So while the two-incision ECTR may be shown in more advertisements, the one-incision ECTR is currently the least invasive technique for carpal tunnel release, the one that can get you back the quickest.

So if you want to get back to the activities you like to do the fastest, forget the hype and focus on the facts. The one-incision ECTR is the way to go.

References:
1) Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD: Endoscopic carpal tunnel release: a comparison of two techniques with open release. Arthroscopy 9:498-508, 1993.
2) Feuerstein M, Burrell LM, Miller VI, Lincoln A, Huang GD, Berger R: Clinical management of carpal tunnel syndrome: a 12-year review of outcomes. Am J Ind Med 35:232-45, 1999.
3) Kerr CD, Gittins ME, Sybert DR: Endoscopic versus open carpal tunnel release: clinical results. Arthroscopy 10:266-9, 1994.

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Mallet Finger

August 21st, 2010

Mallet finger refers to an injury that causes the finger tip to droop. These are very common injuries that occur when the extensor tendon on the back of the finger tears off the small joint (the distal interphalangeal joint or DIJ) near the finger tip. Mallet fingers can occur with minimal trauma, such as banging your finger against a hard object or sometimes just pulling hard on something

Mallet fingers can be treated in a full-time splint for 6 weeks. That means ‘full-time’ in the strictest sense of the phrase, because any time the DIJ flexes down all of the scar that has formed to try to heal the tendon gets torn. The splint has to fit well in order to prevent this. Getting a good fitting splint is like getting a good fitting suit; if ‘off-the-rack’ works, that’s great. Otherwise, you need to have a custom splint made by a therapist. I always give patients two splints. The reason is because ‘full-time’ means that you even have to shower or bathe with the splint on. After the shower, place a dry washcloth down on a flat surface. Place your wet finger, palm side down, on the wash cloth so that the flat surface supports the finger and prevents it from drooping. Then remove the splint and use the sides of the washcloth to dry your finger. Then place the 2nd (dry) splint on and tape it in place. The wet splint can be allowed to air dry, or a hair dryer can be used.

Except in rare cases, the DIJ will not become permanently stiff from this splinting. Even if it did, it’s really not a functional issue. However, if the adjacent larger joint, the proximal interphalangeal joint (PIJ) in the middle of your finger, gets stiff that’s a real problem. And the PIJ loves to get stiff. So make sure that you don’t tape over the PIJ and that you use the finger fairly normally to keep it moving.

The 6 weeks of full-time splinting is followed by 6 weeks of part-time splinting. The part-time protocol: wear the splint 3 hours on, 3 hours off, 3 hours on, 3 hours off, etc. during the day and then when asleep for 3 weeks. After that, just wear the splint at night for the next 3 weeks. Then you’re done. If the deformity recurs at any point during part-time splinting, then place the splint back on for one week of full-time splinting before resuming part-time splinting.

After all of this, the amount the finger tip droops (the ‘lag’) will be improved roughly 50%, although some peole do much better. There’s almost always some residual lag, but in the vast majority of cases it’s not worth surgery to fix the tendon.

There are certain exceptions. If the mallet injury occurs because the tendon got cut by a sharp object, then the tendon should be repaired surgically. Splinting can only work for roughly 3-6 months following injury. After 6 months, surgery may be required. If the thumb is involved, the tendon should be repaired in most patients. The healing and ultimate function is not the same in the thumb as it is in the fingers; the thumb’s extensor muscle is stronger, causing the torn tendon to retract and not heal as well. In addition, lack of full thumb extension can result in a significant loss of dexterity, making it hard to pinch accurately.

If there is a fracture involved and the DIJ subluxes partially out of joint, these are often better treated surgically in young, active patients. These more severe injuries are often caused by a ball hitting the tip of the thumb. These injuries can often be treated in a minimally invasive manner without a surgical incision for up to roughly one month following injury. After one month, a formal open repair is usually required.

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Frozen Shoulder (Adhesive Capsulitis)

August 12th, 2010

Frozen shoulder is a very painful condition in which the shoulder freezes up and becomes stiff. It may or may not be due to trauma. People with diabetes, thyroid dysfunction or gout are more commonly affected. While the reason this happens is unclear (many blame a virus), it is an inflammatory condition and is often due to an underlying rotator cuff problem.

Frozen shoulder may go through phases. The ‘freezing’ phase lasts roughly 3-9 months. The ‘frozen’ phase can lasat for 4-12 months or longer. Some shoulders may then ‘thaw’ over 1-4 years, during which time motion improves, but not necessarily completely. If untreated, the average amount of time for the shoulder to go through this cycle before comfort and some motion returns is 2.5 years. If untreated, 7-42% of patients will have significant permanent stiffness.

In my opinion the best way to treat the frozen shoulder is to ‘hit it early and hit it hard’. The earlier you’re seen, the better. I inject a steroid (cortisone) into the shoulder and prescribe a medrol dose pack (steroids taken by mouth) for 6 days. While long-term steroids can potentially lead to ulcers or arthritis, that is incredibly rare from a 6-day medrol dose pack. The real side effects include increased appetite and water retention, so there may be a slight weight gain. Steroids by mouth may keep some people from sleeping well at night, so I also prescribe a sleeping pill along with it.

The third mainstay of treatment is therapy, which is optimally performed 3 days/week until motion improves. The therapist will use ultrasound on the shoulder and perform stretching exercises. In addition, rotator cuff strengthening exercises with an elastic resistance are prescribed, as the rotator cuff is often involved. It is also extremely important to perform a home stretching and strengthening program. It’s best if the steroid injection, medrol dose pack and therapy all occur at the same time. The vast majority of my patients who follow these instructions improve significantly, and often attain full or near-full motion within 1-2 months. Very few patients require surgery for frozen shoulder.

However, if 3-6 months of nonoperative treatment is unsuccessful, surgery may be considered. If surgery is pursued, a manipulation under anesthesia is usually not enough. In most cases, if a manipulation is all that’s needed, then a good nonoperative management program would have been successful. The most effective surgical treatment for frozen shoulder is an arthroscopic capsular release, in which a small scissor-like instrument is used to cut the joint capsule (balloon) around the shoulder joint. In addition, any inflamed tisssue and pathologic rotator cuff tissue is removed. After the joint capsule has been released the shoulder can then be manipulated, which is less traumatic and more effective. This surgery is not especially painful. Some patients with frozen shoulder due to former surgery or fractures may also need an open incision to release additional scarred tissue planes. Post-operative therapy is critical and begins within 1-3 days. Therapy with a knowledgeable therapist is performed 5 days a week for 4 weeks, and then decreased over the next couple months depending on how motion progresses.

Manipulation following arthroscopic release leads to normal or near normal motion with minimal pain in 75-83%. The prognosis is better for patients who have experienced stiffness for less than 6 months. Patients with frozen shoulders following surgery or a shoulder fracture typically have a more complex and severe problem, with less satisfactory results. That’s one reason why the first surgical procedure performed often sets the tone for that patient’s ultimate outcome and should be done by a specialist.

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Mucous Cysts

August 1st, 2010

I recently wrote an article on mucous cysts for the Journal of Hand Surgery. These are a very common cause of finger masses. Mucous cysts are actually ganglion cysts of the small joint of the finger closest to the tip.

Much like ganglion cysts around the wrist (please see my last blog for more information on these), I initially treat mucous cysts by aspirating the fluid inside them. Please don’t try this yourself. The cyst connects to the underlying joint, and if an infection occurs it can spread to the underlying joint, causing a serious problem. Injecting steroids has not been shown to increase the cure rate, and may predispose to an infection.

Unfortunately, 30-70% (approximately half) of the mucous cysts return following aspiration. As these are just hernations of joint fluid, usually from an arthritic joint, they are benign and can often be observed without further treatment.

However, if pain persists or the skin starts to thin, it is very reasonable to have the cyst surgically excised. Thinned skin may make the underlying joint more susceptible to infection. If the skin thins enough, a local flap (soft tissue rearrangement) may become necessary. Many people don’t like the way the cyst looks and desire to have them removed. In addition, the cysts can cause a nail deformity. Removing the cyst can improve or resolve the nail deformity in 60-100%, depending on how long it has been present.

In order to permanently remove the cyst, the underlying joint must be addressed. Many dermatologists and non-hand surgeons often just try to just cut out the cyst or freeze it. That doesn’t usually work too well and recurrences are common follow these inadequate techniques. As for wrist ganglions, the balloon around the joint (the joint capsule) must have a section removed to prevent reformation of the one-way valve that causes these cysts in the first place (please see previous blog). In addition, the bone spurs must often be partially removed to allow a larger open space to prevent rescarring of the tissues around the joint with the recreation of a one-way valve and a recurrence of the cyst. The surgery should be performed by a fellowship-trained hand surgeon, as injury to the tendons, ligaments, and/or nail bed about the joint, with resultant deformity, may occur when surgery in this area is performed by those less well-versed in the anatomy and techniques of hand surgery.

The surgery can be performed under local anesthesia. The dressing can be removed after one week and most activities resumed, including getting the wound wet. However, the finger should not be submerged under water for two weeks. Patients should be aware that at least part of the pain my be due to the underlying joint arthritis, and that removing the cyst won’t cure that part of the pain.

If the skin is very thinned, a flap may be required to provide adequate soft tissue coverage over the joint. This requires rearranging some of the skin and underlying fat on top of the finger, but can also be performed under local anesthesia. Fortunately, this works very well and doesn’t slow down rehabilitation very much.

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Wrist Ganglions

July 30th, 2010

Gangions are the most common cause of a bump or mass around the wrist. These are 100% benign. They’re simply herniations of fluid from an underlying joint caused by a weakness in its ligaments. When there is damage to the ligaments or the joint capsule (balloon) around the joint, an area of weakness is created. The joint fluid that lubricates your joint can herniate through this area of weakness, forming a fluid-filled cyst called a ganglion. A one-way valve mechanism forms from the joint lining and prevents the fluid from going back into the wrist, trapping it in the cyst. Because they come from your joints, ganglions can sometimes get bigger during periods of heavy activity and get smaller during periods of rest.

It’s important to understand that not every bump is a ganglion. However, ganglions can be diagnosed fairly easily. Ganglions on the back of the wrist can be aspirated in the clinic. This involves numbing the overlying skin with a small needle and some lidocaine, similar to the novocaine used by dentists. A larger needle is then placed through the numbed skin to draw out the gelatinous fluid inside. This causes the ganglion to disappear or at least decrease in size, and in 1/3-1/2 of cases provides a permanent cure. Sometimes the ganglion has separations and subcompartments within it that make it difficult to fully aspirate. These ganglions with multiple compartments have a lower rate of cure by aspiration.

Ganglions on the palmar surface of the wrist are not usually aspirated. They are usually intertwined with the radial artery, and a large needle could injure the artery or the nearby median nerve. Ganglions can also occur in the fingers, in unusual locations about the wrist, or over other joints.

Once a ganglion is diagnosed, it does not have to be removed. Except in rare cases where it presses directly on a nerve, it will not cause any damage. However, ganglions can cause pain with activity and many people want them removed because they often look unsightly.

Ganglion excision surgery is quick and highly effective. While the literature quotes a 5-10% rate of recurrence for ganglions on the back of the wrist and a 10-20% rate of recurrence for ganglions on the palmar surface of the wrist, as far as I know, I’ve never had a wrist ganglion recur in an adult after I have personally removed it. The key is to remove enough of the joint capsule (the balloon around the joint) that the capsule can’t scar back to itself and so it remains partially open. This prevents the reformation of a one-way valve and creates a permanent “two-way valve” which prevents the recurrence of the ganglion.

After surgery, activity is fairly unrestricted. The wound should be kept clean and dry for 4 days, at which time the dressing can be removed and the wound can get wet in the shower and pat dry. A band-aid can be placed over it. The wound should not be submerged under water for two weeks.

Ganglions in children have a much higher recurrence rate following both aspiration and surgical removal. Strong consideration should be given to not operating in children until they’ve reached ‘skeletal maturity’, around the age of 16 years. However, the mass should be evaluated by a hand surgeon to ensure that it is, in fact, a ganglion and not another type of lesion.

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Elbow Arthritis

July 18th, 2010

Elbow arthritis can be due to osteoarthritis (wear and tear arthritis), post-traumatic arthritis (after a fracture or dislocation) or due to rheumatoid arthritis (a systemic, inflammatory disease). Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm.

Initial treatment should be nonoperative, with an injection, activity modification, and occasionally physical therapy. If that is ineffective, then options depend on how advanced the arthritis is and the symptoms it is causing. Pain at terminal motion (at full flexion or full extension) is usually due to bone spurs, which are the body’s reaction to arthritis. Pain during mid-motion is usually due to loss of the joint’s normal slippery cartilage surface. Pain during rest is usually due to reactive synovitis (inflammation of the joint lining in response to the mechanical irritation of the arthritis). Catching, locking, and feelings like something is ‘loose’ in the joint are often due to loose bodies, which are pieces of bone spurs and damaged cartilage that have broken off and are floating around the joint.

If the arthritis is mild, an arthroscopic debridement can help. Arthroscopy can remove bone spurs, inflammation, and any loose bodies in the joint. This often relieves pain during terminal motion and often at rest. Mid-motion pain will usually not be improved, and if the arthritis is significant, the inflammation and rest pain will recur. In some patients, such as those who have already had their ulnar nerve moved (putting it at risk unless it’s visualized), or those who are undergoing additional surgeries, elbow debridement may be better performed through an open incision.

If stiffness is a problem, release of the restraining joint capsule (the balloon around the joint) may be performed, either openly or arthroscopically. In order to maintain the motion that is gained during surgery, extensive physical therapy will be required after surgery. When significant stiffness is present, the ulnar nerve will usually be scarred in, and should be released or transposed (moved) to avoid problems with traction on the nerve once motion is restored.

If mid-motion pain is prominent, then cartilage loss has probably occurred. Simple debridement of bone spurs will not provide pain relief. In older patients, a total elbow replacement is an effective option. Total elbow replacement usually involves a hospital stay of 1-2 nights. The elbow is splinted for approximately 2 weeks, and then motion is begun. Pain relief and function are very good, but elbow replacements can loosen over time. To protect against this, there is a lifetime lifting limit of 1-2 pounds repetitively and 5-10 pounds for a single time once in a while.

In young patients who cannot live with this restriction, the best operation may be a fascial-interposition arthroplasty, where the achilles tendon from a cadaver is used to resurface the elbow joint. This tendon is broad and slippery, and may provide a pain-free surface for the reconstructed elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to maximize healing and motion, an external fixator is placed about the elbow. This involves placing 2 metal screws into the humerus (the large bone above the elbow) and 2 metal screws into the ulna (one of the forearm bones), connected by a hinge to allow motion. The fixator remains in place for 3-6 weeks, and is then removed under general anesthesia as a second procedure. While fascial-interposition arthroplasty is not as predictable as a total joint replacement, it does very well in select patients without ligament or bone loss. And unlike a total elbow replacement, once the fascial-interposition arthroplasty is healed, the elbow can be used within the limits of pain, without lifting restrictions.

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Shoulder Instability and Dislocations

July 18th, 2010

The shoulder is the most mobile joint in the body. Consequently, it is also the most commonly dislocated large joint in the body. There are things you should know if you or someone you care about has dislocated his or her shoulder. For example, the first shoulder dislocation leads to a 20% rate of future arthritis, and each subsequent dislocation increases that risk.

Young patients, 20-25 years old or less at the time of the initial dislocation, especially those engaged in contact sports or who use their arms at or above chest level, have a 90-95% risk of recurrent instability (ie. another dislocation or subluxation/partial dislocation). On the other hand, recurrent instability is uncommon in older patients who first dislocate their shoulder at the age of 40 years or older.

Following a single dislocation in young patients <20-25 years old, especially if they are contact athletes, arthroscopic stabilization decreases the rate of recurrent instability. Following arthroscopic stabilization the rate of recurrent instability is 7-10%, compared to 46-58% for those treated without surgery. A government-sponsored review noted a 68-80% reduction in the risk of recurrent instability in those young patients that had surgery compared to those who didn’t. Patients who underwent arthroscopic surgery had significantly better outcomes, better function, less joint damage, were more satisfied, had a better chance to return to sports , had an improved quality of life and even had lower overall treatment costs. Allowing multiple subluxations or dislocations to occur causes additional damage to the shoulder’s ligaments, increases the risk of arthritis, and erodes the bone from the humeral head (the ‘ball’ of the shoulder) and/or the glenoid socket that keeps the shoulder located.

Therefore, arthroscopic stabilization surgery should probably be performed following even a single dislocation in young athletes 25 years old or younger, professional athletes, or in those in whom a recurrent dislocation could be disastrous, such as mountain climbers and construction workers that work at heights. Arthroscopic surgery should also be performed if the shoulder dislocates a 2nd time, or if there is pain due to recurrent subluxations that is not resolved by therapeutic strengthening exercises and acceptable activity limitations. Modern arthroscopic techniques lead to 92-97% good-excellent results, with 91% of high-demand contact athletes returning to sport.

In older patients who have had only a single dislocation and who are not engaged in contact sports, physical therapy to strengthen the muscles about the shoulder may be enough to decrease symptoms and prevent further instability. And while immobilization in a sling or other similar device does not decrease redislocation rates, avoiding bringing the arm up and back (as when throwing a ball) and avoiding sports for six weeks can help decrease re-dislocation rates

The problems created by shoulder dislocations are different for people over 40 years of age. While older patients don’t usually suffer re-dislocations, 54% have their rotator cuffs torn by the dislocation, leading to pain and weakness. Patients over 40 years old who have dislocated their shoulder should have an MRI to diagnose any rotator cuff tear. If the rotator cuff is torn, it should be fixed to maximize function, minimize pain and lower the chance of recurrent instability. This can be done very effectively arthroscopically.

Following multiple dislocations or if a shoulder is left dislocated for a number of hours, bone loss of either the humeral head (ball) or glenoid socket may occur. It should be noted that a CT scan is needed to accurately diagnose bone loss, as MRI notoriously underestimates the degree of bone loss or misses it entirely. If less than approximately 1/5 of the glenoid is eroded, the shoulder may still be treated arthroscopically with good success. However, if >1/5-1/4 of the socket has been eroded away, open surgery with a bone graft taken from another part of the shoulder is needed. While this is open surgery, it is still an outpatient procedure and leads to good or excellent results in 83-95%. If the humeral head (ball) is damaged, unless the bone defect is very large, this can still be treated arthroscopically by repairing part of the rotator cuff into the bony defect.

So, if you or someone you care about has dislocated their shoulder, or has an unstable shoulder, get them evaluated by an orthopaedic shoulder specialist before more damage is done and the risk of future problems increases.

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Cubital Tunnel Syndrome (Does your small finger go numb?)

July 2nd, 2010

While carpal tunnel syndrome is the most common nerve problem, cubital tunnel syndrome is the second most common nerve problem. Cubital tunnel syndrome occurs when the ulnar nerve (the “funny bone” nerve) gets pinched at the elbow. It is a common source of nerve pain, especially at night.

What are the symptoms of cubital tunnel syndrome?
Cubital tunnel syndrome leads to tingling and numbness of the small finger, and often the ring finger. If the other fingers are involved, then carpal tunnel syndrome may also be present, as these problems often occur together. The ulnar nerve gets pinched more when the elbow is bent. Symptoms may also occur when the nerve is pressed on, such as when resting the elbow on a hard surface.

How is the diagnosis of cubital tunnel syndrome made?
The diagnosis of cubital tunnel syndrome is made by your physician asking you specific questions and examining your arm. A symptom that is classic for cubital tunnel syndrome is waking up in the middle of the night with the small finger tingling or “numb”. This occurs mainly because we all sleep in the fetal position, with our elbows bent. This numbness also occurs other times when the elbow is bent, like when talking on the phone. If bending your elbow or pressure on your elbow causes the small and/or ring finger to tingle, then you have cubital tunnel syndrome. Nerve conduction studies are usually obtained, but are not especially accurate, and may miss the diagnosis of cubital tunnel syndrome in up to 40-50% of cases.

How is cubital tunnel syndrome treated?
Unless your ulnar nerve is damaged, treatment for cubital tunnel syndrome starts with avoiding pressure over the cubital tunnel/funny bone area by not resting the elbow on desks or other hard objects when using the computer or driving. Prolonged elbow flexion should also be avoided. If you’re on the phone a lot, use your other hand to hold it, or get a hands-free device.
At night, try to prevent the elbow from fully bending during sleep. This is very difficult to do, and many people have trouble sleeping like this. Strategies that can be tried are rolling a towel around the elbow, wearing a tennis elbow brace over the elbow, or cutting a hole in a pillow case and putting the arm through it next to the pillow so that the pillow prevents the elbow from fully bending. If this fails and the symptoms are bothersome, surgical treatment is very successful.

What are the different surgeries for cubital tunnel syndrome?
There are many different surgeries for cubital tunnel syndrome. Some involve removing bone (ie. a medial epicondylectomy) and are very painful. Some involve transposing (moving) the ulnar nerve to the front of the elbow. The nerve can be placed under the skin or under the muscle. These work well, but there are less-invasive options available.
The literature since 2005 has shown that patients with cubital tunnel syndrome do just as well following a simple cubital tunnel release as following the bigger, more invasive, more painful operations. A cubital tunnel release is a simple, less invasive and less painful operation. It is very similar to a carpal tunnel release, in that it simply releases the fascia (ligament-like tissue) over the nerve. This releases the nerve’s compression and allows the nerve to heal and stops the pain.
Just like a carpal tunnel release, a cubital tunnel release can be performed endoscopically, through a small incision. This is an outpatient procedure. No splint is needed, and after surgery activities can be resumed within the limits of pain. Typing and computer use can be performed immediately. In order to minimize pain and swelling, heavy activiites should probably be avoided for 2-3 weeks. .
The nerve recovers just as well as it does following the bigger operations, with less pain and sufferering, a quicker return to activies and a lower complication rate in skilled hands. A video of this procedure can be viewed at www.Rearmyourselftexas.com. Occasionally, a patient’s nerve may sublux (move) following release. While this is uncommon, I always check to see if this occurs, and if it does I transpose (move) the nerve to the front of the elbow.
Results are mainly affected by how damaged the nerve is from the compression that occurred prior to the surgery. In other words, those who had cubital tunnel syndrome longer and had more nerve damage recovered less following surgery than those with lesser degrees of nerve damage. As with most things in life, it’s usually easier and better to address problems early on, when they are still small.

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Basilar Thumb Arthritis

June 28th, 2010

The base of the thumb (the trapeziometacarpal joint) is commonly affected by arthritis. The arthritis often causes pain during pinching and gripping. It may be especially severe when opening jars or turning a key. It may progressively worsen until most/all hand activities become painful.
The basilar thumb joint is especially stressed by pinching and gripping small objects. When gripping or pinching a small object, for every 1 pound of force you apply to your thumb tip, the basilar joint experiences 12 pounds of force. To decrease stress on this joint it’s better to avoid manipulating small objects and to pinch and grip big. Big, thick pens with rubber grips on them are much easier on your joint than are small, metal pens. Kitchen-aid or simlar devices can slip over jar lids to make them larger and easier to grasp. You can buy devices that slip over keys to make turning them easier. Whatever you grab with your arthritic thumb, try to make it bigger.
A splint can also be helpful. Most patients prefer a soft, neoprene, rubber-like splint that doesn’t interfere much with hand function. A steroid injection can also provide good relief. If the symptoms are mild, these measures may be all that you need. However, unfortunately, they will not provide permanent relief from the pain of significant arthritis.
If nonoperative management is not effective and the pain is significant, surgery can be a very effective cure. There are many different types of surgery for this problem. I prefer the LRTI (ligament reconstruction tendon interposition). It is the current ‘gold standard’, the most popular and most effective procedure, with a low complication rate. It’s been around since the mid-1980s. It uses your body’s natural tissues to provide both stability and a new joint.
This is one case where newer procedures that use artificial materials to create artificial joints are less effective with a higher complication rate. Artificial joint replacements almost always have a higher complication rate and a lower success rate than the LRTI procedure.
During the LRTI, the arthritic bone that your thumb rests on (the trapezium) is removed. A small cut is made in the forearm to release a tendon, which is moved to the base of the thumb to fill in the area from which the trapezium bone was removed. So now instead of your thumb resting on a hard piece of arthritic bone (which is painful), it rests on a soft tendon pillow. A small suture anchor is placed into a thumb bone. It’s like a small harpoon with stitches on it to hold everything together. It stays in forever.
Basilar thumb arthritis often co-exists with carpal tunnel syndrome. If this happens, an endoscopic carpal tunnel release can be performed at the same time.
Following the LRTI, a post-operative splint is worn for one week, then a cast is worn for three weeks. Once the case is removed, you may get the hand wet. Some patients may need some hand therapy to regain thumb motion, but most don’t need much therapy at all. The stitches are absorbable, and there are no stitches to remove. Once the cast is removed a removeable splint is worn full-time for two weeks, except when bathing, and then only as needed.
While some patients note a fair amount of pain for the first few days after surgery, the surgical pain quickly decreases. It is important to avoid forceful gripping and heavy lifting for 3-4 months after this surgery. Typing and computer use are fine, and may be performed the day after surgery.

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