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Osteoarthritis of the Elbow

What is it?

Osteoarthritis of the elbow occurs when the cartilage surface of the elbow is damaged or becomes worn. Cartilage normally covers the ends of bones and forms a smooth gliding surface. Cartilage damage may occur because of a previous injury such as elbow dislocation or fracture. It may also be the result of degeneration of the joint cartilage from age. Osteoarthritis usually affects the weight-bearing joints, such as the hip and knee. The elbow is one of the least affected joints because of its well matched joint surfaces and strong stabilizing ligaments. As a result, the elbow joint can tolerate large forces across it without becoming unstable.

Elbow osteoarthritis that occurs without previous injury is more common in men than women. Onset typically occurs in patients 50 years of age or older, but some patients can have symptoms earlier.

What are the Symptoms?

Pain, particularly during or after activity. This is usually localised to the elbow itself and in the muscles around the elbow.
Loss of range of movement, commonly the elbow will not straighten fully and you will notice difficulty reaching behind your head.

Both of these symptoms may not occur at the same time. Patients usually report a "grating" or "locking" sensation in the elbow. The "grating" is due to loss of the normal smooth joint surface. This is caused by cartilage damage or wear. The "locking" may be caused by loose pieces of cartilage or bone that dislodge from the joint and become trapped between the moving joint surfaces, blocking motion. Locking may also be due to the roughened bone surfaces themselves catching.

Stiffness

Swelling of the joint may also occur, but this does not usually happen at first. Swelling occurs later, as the disease progresses.

In the later stages of osteoarthritis of the elbow, patients may notice numbness in their ring finger and small finger. This can be caused by the arthritis in the elbow pinching or compressing the ulnar nerve as it courses around the inside of the elbow.

Diagnosis

A doctor can usually diagnose osteoarthritis of the elbow based on symptoms and X-rays. Advanced diagnostic imaging, such as CT (computed tomography) or MRI (magnetic resonance imaging), is typically not needed to diagnose osteoarthritis of the elbow. If your main problem is locking of the elbow and a loose body is suspected a CT will be organised. Many “loose bodies” seen on X-rays are not actually loose but attached to the synovial lining of the joint.

Treatment

Treatment options depend on the stage of the disease, prior history, what the patient desires, overall medical condition, and the results of diagnostic X-rays.

Nonsurgical Treatment

For the early stages of osteoarthritis of the elbow, the most common treatment is nonsurgical. This includes oral analgesic’s and non steroidal anti inflammatories (NSAID’s ), to reduce or alleviate pain. This is combined with modification of activities and sometimes physiotherapy.

Corticosteroid injections are sometimes used to treat osteoarthritis symptoms. Steroid medication has typically been used with good results. Although the effects of injections are temporary, they can provide significant pain relief until symptoms progress enough to need additional treatment.

An alternative to steroids has been the injection of hyaluronic acid in various forms. This is known as viscosupplementation, by surrounding the diseased cartilage with a thicker and more "cushioned" environment. This treatment has been recently studied in people with osteoarthritis of the knee. Although there was initial enthusiasm for this treatment, research has not shown it to be better than traditional steroid injections. The long-term results of these "viscosupplementation" injections in the elbow or other joints have not yet been investigated.

Surgical Treatment

Surgery may be used for pain relief, to improve locking by removing loose bodies and to improve movement when the main problem is lack of bend and or straightening without significant pain.
By the time arthritis can be seen on X-rays, there has been significant wear or damage to the joint surfaces.

Elbow Arthroscopy

If the wear or damage is limited, arthroscopy can offer a minimally invasive surgical treatment. It may be an option for patients with earlier stages of arthritis.

Arthroscopy has been shown to provide symptom improvement at least in the short term. It involves removing any loose bodies or inflammatory/degenerative tissue in the joint. It also attempts to smooth out irregular surfaces. Multiple small incisions are used to perform the surgery. It can be done as a day case procedure, and recovery is reasonably rapid.
Joint Capsule Release, loose body removal, bone excision.
This is undertaken where lack of movement is causing significant functional impairment to the elbow but pain is not a major problem. It involves an operation with one or two incisions on the elbow. The contracted joint lining is removed together with any loose bodies. Any prominent areas of bone or osteophytes may also be removed. This is a major operation and takes months to fully recover from. It can however lead to very useful improvements in movement for many years.
If the joint surface has worn away completely, it is unlikely that anything other than a joint replacement would bring about relief. There are several different types of elbow joint replacement available.

In appropriately selected patients, the improvement in pain and function can be dramatic. With an experienced surgeon, the results for elbow joint replacement are typically good and can give many years relief of pain. The elbow replacement we use is the Coonrad-Morrey Total Elbow Replacement. See section on elbow replacement.