Non-Surgical treatment of elbow osteoarthritis – alternatives to elbow replacement
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
At our center, we see patients with elbow osteoarthritis who have been through years of treatments for tennis elbow or golfer’s elbow, and their elbow pain has progressed to a more painful, less functional situation with a significant loss of range of motion. This of course does not mean that people with elbow osteoarthritis are only people who played tennis or golf. We see the people who never played golf or tennis but do physically demanding work. They were told by their doctors that they had tennis elbow like symptoms and it has now progressed to degenerative elbow disease. We may also see the old baseball player who now has a loose elbow from years of throwing. We may also see the patient who may have had a terrible triad elbow injury, (dislocation, radial head fracture, and a coronoid process fracture) that despite pins and plates is still weak and unstable. We may see the patient who suffered from other past traumatic elbow injury. The typical story we hear goes something like this:
I have bone-on-bone arthritis in my elbow. It was diagnosed as tennis elbow, and then, golfer’s elbow. I never played either game. Diagnosed with both tennis and golfers elbow though I never played either. I was on a wide range of anti-inflammatories, I wore elbow braces, I had cortisone. My orthopedist tells me that I am running out of conservative care options.
If you are reading this article, these treatments probably have not been effective long-term treatments for you either.
Conservative Care Failures and Surgery
For many people, conservative care treatments for their elbow pain worked very well. For some patients, whose elbow pain has become chronic and life-altering, where the conservative care options stopped working, surgery was performed and it worked very well for them.
The conservative care and surgical success people are not the people we see at our center. We see the people for whom conservative care and surgery did not help and in some cases made the patient worse or at best, didn’t help at all. These people are now exploring, in many cases, last-ditch efforts to avoid an elbow replacement surgery or second elbow surgery that they do not have the utmost confidence in.
We understand that many people have severe elbow pain and they have to do something, many of these people have already made up their minds that they will proceed with surgery and for them, this is probably a good choice. The people we see, and perhaps yourself, someone who is continuing to read this article, may not be confident or have concerns about elbow replacement. This article presents information on options. If you have elbow replacement surgery the odds are you will have a good outcome.
Is your elbow ever too far gone?
To be able to avoid surgery and use non-surgical methods to alleviate your elbow pain you have to have a realistic outlook on what surgery can do and what non-surgical methods can do. Later in this article, we will explore various types of regenerative tissue building injection therapies. For non-surgical options to work in getting you back to work or sport, you have to have a careful examination of the range of motion in your elbow. If you have bony overgrowth and bone spurs in the elbow joint that prevents you from going through various ranges of motions or if the elbow joint is frozen or locked up, you may be too far gone. You can use the contact us email at the end of this article to ask us about your case. Bone spurs are Nature’s last resort in protecting your elbow by preventing you from the bending and rotating that caused your problems in the first place. Your body is saying, “don’t bend your elbow anymore, I can’t fix it.”
What are we seeing in this image?
The caption reads “Clinical stages of posterolateral instability of the elbow.” The image is explained below.
Look at the top row of elbow joint pictures as a type of computer image x-ray. Look at the bottom pictures of the elbow joint as a computer type image MRI. Combined we are presenting a graphic image of how elbow osteoarthritis can develop and we will introduce the idea that the elbow ligaments play a key role in the prevention or development of elbow osteoarthritis. We will also suggest briefly and cover this more thoroughly later in this article that by repairing the elbow ligaments, there can be a realistic expectation that elbow replacement surgery can be avoided in many cases.
In this image we start with a normal elbow, then we move through a progression of a mild elbow instability problem of supination.
Supination – the second images
- Your elbow, through wear and tear, has started to get “too loose,” your radius bone, the inner forearm bone, is now starting to rotate over the ulna, the other forearm bone. In the illustration above we show the white bands of ligaments that hold the elbow together. We represented injury by showing a reddening or inflammation of these ligaments.
- In the next image, we move the elbow towards a more moderate instability and a “Vagus,” condition. At this point, the development of bone spurs can begin. Chips of bone or cartilage can dislodge and float in the elbow. If this situation continues, arthroscopic surgery may be called for. It is at this point that the person with this type of elbow injury will buy better braces and take more anti-inflammatories to help manage their problem.
You will see in the corresponding image below, more ligament damage is demonstrated. The strong ligament bands are no longer in optimal condition to hold the elbow together.
- The final of the four images depicts a dislocation. Dislocation can occur in many ways, we have the impact dislocation or the wear and tear dislocation. In the osteoarthritis wear and tear version, the ligaments have now reached a point of laxity or weakness and they have started to tear. At this point, the body may go into full “bone spur mode,” to prevent further excessive rotation of the elbow joint. Bone is going to try to do the job of a ligament. Bone is not flexible, a ligament is.
When we reach the point where the radius forearm bone is dislodged, in a state of subluxation (partial dislocation), or dislocated over the ulna, the person begins a more urgent assessment of elbow replacement surgery because of pain, stress, and instability at the elbow joint. In this final phase, elbow function may be significantly compromised.
As mentioned above, if the elbow has yet to be engulfed in bone spurs and bony overgrowth, there is a realistic expectation that the ligament damage and tear can be non-surgical repaired, providing there is not a complete ligament rupture.
Elbow stiffness and loss of function and range of motion
In December 2021, Dr. Joaquin Sanchez-Sotelo, Chair of the Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic published an intensive review of the problems of elbow osteoarthritis and stiffness in the Journal of experimental orthopaedics (1). These are some brief summary points of that review.
Dr. Sanchez-Sotelo writes:
“For orthopedic surgeons, elbow stiffness implies that the elbow joint has lost motion in one or more directions (flexion, extension, pronation and/or supination). Several factors may contribute to loss of motion, including fibrosis Tissue, scar tissue overgrowth impeding movement), osteophytes (bone spurs), ectopic bone formation (bone is forming in soft tissue where it does not belong, typical of surgical complication or traumatic injury), and changes to the joint articular surface (the smooth cartilage at the joint that allows for gliding motion has now been damaged and is causing impediment of movement).”
“Whereas conservative treatment may improve motion to some degree in patients recovering from a traumatic injury, oftentimes elbow motion can only be improved with surgery. Fortunately, arthroscopic elbow techniques have been refined to allow successful surgical management of the majority of stiff elbows.”
From here Dr. Sanchez-Sotelo describes various orthopedic options for elbow pain and stiffness. They include:
- Arthroscopic osteocapsular arthroplasty which removes bone that restrict motion and removing the majority of the anterior and posterior capsule. (The ligaments and soft tissue that surround the elbow joint.)
- Heterotopic ossification removal. This is a somewhat complicated procedure as described in another article from surgeons at the University of Michigan, Ann Arbor (2). Heterotopic means bone where it should not be. It is bone that grows to help stabilize a loose elbow but grows sufficiently enough that it starts to create a natural fusion preventing the elbow from achieving its range of motion. The surgery removes this bone. The University of Michigan researchers however point out: “Trauma‐induced heterotopic ossification occurs after severe musculoskeletal injuries and burns, and presents a significant barrier to patient rehabilitation. Interestingly, the incidence of heterotopic ossification significantly increases with repeated operations and after resection of previous heterotopic ossification. Treatment of established heterotopic ossification is challenging because surgical excision is often incomplete, with evidence of persistent heterotopic bone.”
In his paper, Dr. Sanchez-Sotelo summarizes: “Arthroscopic contracture release (removal of bone and tissue causing elbow problems), typically combined with in situ decompression of the ulnar nerve (removing tissue that may be pressing on the ulnar nerve), has become the procedure of choice for the majority of elbows with primary, posttraumatic, and inflammatory arthritis. Staged surgery (as it sounds surgery in different stages at different times) is commonly considered for neurogenic contractures. Surgeons with advanced arthroscopic skills may be able to tackle more complex procedures, such as arthroscopic removal of ectopic bone, release of forearm rotation contractures, and even osteoid osteoma removal (small tumors that develop in the bone).”
The elbow replacement option
We do not offer surgery at our center, we offer regenerative medicine injections. We have been doing this work for 29 years now. Elbow replacement is usually reserved for patients who suffered a severe traumatic injury to the arm that made an elbow repair impossible. It is also offered to patients who have had numerous arthroscopic surgeries, as outlined above, where failed surgery and complication offered the patient little to no option. It can also be offered to patients with inflammatory arthritis or degenerative arthritis in which case the elbow would be seen as the knee or hip that is considered “too far gone.” Later in this article we will discuss whether “too far gone” is an accurate portrayal of the patient’s elbow.
Now when discussing any joint replacement, it is always best to bring in orthopedic surgeons to have them help us explain the reasons for recommending a total elbow replacement to patients.
In this October 2021 paper published in the journal Shoulder and elbow, (3) researchers in the United Kingdom offered this assessment of elbow replacement.
- Total elbow replacement is not a common procedure (for the various reasons of high complication rate and low success rates). We aimed to evaluate complication rates and cumulative percentages associated with the most frequently used contemporary implants and for the commonest indications.
How was the study conducted? The researchers examined previously published research, 12 studies in total, that compiled date on 815 patients who had a total elbow replacement.
- The average follow-up with the patient was 3.8 years.
- The overall complication cumulative percentage was 60.7%, significantly higher than that seen in other joint arthroplasty, including a 6.5% deep infection rate.
- Nerve injury was comparable between implants at around 4.1%.
- Radiographic loosening had a cumulative rate of 17.2%.
- Revision for symptomatic aseptic loosening was 6.3%.
Conclusion of the researchers: “This is the largest systematic review of the complications of total elbow replacement. Surgeons should be aware of differing complications related to their implant of choice, each having its own specific complication. Trauma as an indication appears to have an increased complication rates compared to inflammatory (joint disease). There is a lack of literature regarding the independent results of osteoarthritis as a specific indication for total elbow replacement.”
The last sentence on the lack of data on the “independent results of osteoarthritis as a specific indication for total elbow replacement” is also indictive of research surround other non-surgical forms of treatment as we will see below.
Here is December 2019 paper published in the journal Clinics in Orthopedic Surgery. (4) Let’s let these orthopedists discuss the surgery.
“Total elbow arthroplasty (replacement) is a common surgical procedure used in the management of advanced rheumatoid arthritis, post-traumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge.”
The common problems of joint replacement
Let’s point out that many people have very successful elbow replacement surgeries. The challenges pointed out by the surgeons “infection, aseptic loosening, instability, and periprosthetic fracture” are however common problems of all types of joint replacements. Let the authors of this study help us understand more.
“Because it is a relatively rare procedure, most surgeons have less experience with total elbow arthroplasty than hip and knee arthroplasty, and few long-term outcome data are available. Therefore, to avoid iatrogenic errors (these would be surgical errors that would make the patient’s condition worse following the surgery), surgeons should carefully review the previous literature on total elbow arthroplasty.”
In this study, the authors set out to help their fellow orthopedic surgeons by laying out the information at hand to help the surgeons have better outcomes. Here are some of the suggestions:
An unlinked total elbow arthroplasty
- Some patients would benefit from an unlinked total elbow replacement: In this type of replacement, the humeral (upper arm component) and ulnar (forearm component) are unlinked, not connected. This would allow for more normal elbow kinematics (range of motion) and preservation of the patient’s bone. You don’t have to cut away as much bone.
The linked total elbow arthroplasty
- Some patients would benefit from a linked total elbow replacement: In this type of replacement, the humeral (upper arm component) and ulnar (forearm component) are linked together and connected. This would allow for some movement but there is a need to protect the spot where the cement is applied to the bone and the hardware attached for excessive sheer or rotational force. We want to directly quote the authors here so you know that this next statement is coming from these surgeons:
- “This design has been used to treat conditions including rheumatoid arthritis, degenerative arthritis, and trauma reconstruction, and satisfactory outcomes have been reported with long-term follow-up. . . However, aseptic loosening together with bushing wear (the implant is wearing away) is a leading complication of implant failure, and reducing the complication rate remains a challenge.”
- Some people, if they have been in a horrible accident or suffered a catastrophic injury will need this type of replacement.
The convertible total elbow arthroplasty
- Some patients may benefit from a convertible replacement. A convertible replacement allows surgeons to choose between a non-constrained (unlinked) and semi-constrained (semi-linked) prosthesis. If the surgeon has concerns regarding collateral ligament insufficiency or implant stability, a semi-constrained hinge can be created by applying a modular component to the ulnar prosthesis.
What the authors say here, are points of interest to our practice and the types of patients we see. Let’s go to the bullet points for emphasis:
- A convertible replacement allows for more movement in a more damaged elbow.
- Less mobility will be offered if the surgeon has concerns about collateral ligament insufficiency. Ligament insufficiency can be one of the elbow ligaments that have not survived a traumatic injury or it could just be a loose or damaged ligament as we demonstrated in the above image. Loose, damaged ligaments are something we can deal with utilizing injection treatments. This is discussed below.
The reality is if you are a manual laborer, a throwing athlete, a wheelchair-assisted individual, the chances are that you will wear out this replacement or cause hardware failure.
Finally, the problems with elbow replacement and degenerative arthritis.
The study authors suggest: “Because the elbow is not a weight-bearing joint, the incidence of primary osteoarthritis is rarer than that in other joints. The incidence is higher in the overused upper extremities (in manual laborers, throwing athletes, wheelchair-assisted individuals). Patients with primary osteoarthritis typically have higher functional demands and capabilities than those with inflammatory arthritis.) Thus, it is critical to communicate with the patient regarding postoperative management, with the surgeon stressing that the risk of complications could increase if the patient continues to have the same habitual pattern of elbow use.”
The reality is if you are a manual laborer, a throwing athlete, a wheelchair-assisted individual, the chances are that you will wear out this replacement or cause hardware failure.
Again we point out that people do have success with elbow replacement surgery.
What are we seeing in this image?
The vagus rotation or hypermobility of the elbow joint causes compressive and stress forces on the elbow. This can lead to the development, as demonstrated in item three of this image, of the compression and degeneration of the radiohumeral joint and the development of bone on bone osteoarthritis. In item four we see compression of the olecranon in the fossa, this is a notch in the upper arm bone that allows the elbow the ability to bend. If this area develops bone spurs, bending the elbow will be extremely problematic and a surgical suggestion may be offered.
The long-term success of elbow replacement
A January 2021 study in the Journal of Shoulder and Elbow Surgery (5) evaluated the long-term success of elbow replacement. Here the researchers examined the results of 23 previously published studies that included 1429 elbows (60.4% were the linked elbow replacement type).
Of the patients in this study:
- 1276 patients (79.0% female), with an average age of 64.7 years (youngest being 19- oldest being 93) and an average follow-up of a little more than eleven years.
- At the final follow-up, 63.3% of patients reported having no pain.
- The rates of aseptic loosening 12.9%,
- infection 3.3%,
- implant dislocation 4.2% and
- nerve injury 2.1%
- The overall complication rate: 16.3%
- The need for revision surgery was 14.6%.
Discussion and conclusion: (The authors say) “Our systematic review established that total elbow arthroplasty offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short- and medium-term.”
But what about the 36.7% who still had pain?
Revision of Revision of Total Elbow Replacement – That is three surgeries on the same elbow
A November 2020 study in the Journal of Shoulder and Elbow Surgery (6) looked at 14 patients who had a revision of revision surgery after failed total elbow replacement.
The average age of these 14 patients was 73 with the youngest being 57 and the oldest being 83. They were assessed two to seven years following the final surgery.
These patients had an average of three major complications that necessitated the need for two more surgeries following the total elbow replacement:
- aseptic loosening (60%),
- bushing wear (16%),
- fracture (14%)
- and infection (10%).
At the final clinical assessment:
- Of the 14 patients, 81% were satisfied with their revision of revision surgery after failed total elbow replacement.
- Complications included infection in 2 (1 superficial, 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulna nerve symptoms in 2, radial nerve injury in 1.
- One patient required ulna nerve release (4th surgery).
Conclusions: “Revision surgery of a revision surgery after failed total elbow replacement is a satisfactory treatment option in these complex cases with good short to mid-term survival rates but with a relatively high complication rate.”
There are more studies on the challenges and complications of elbow replacement surgery, the point has been made. Let’s now look at non-surgical options.
Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C gives a brief introduction to our treatment protocols for healing chronic elbow pain
Above we spoke about the possibility that regenerative medicine injections may help the person with elbow osteoarthritis avoid elbow surgery. In this video and the summary explanation below, Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C gives us an introduction.
Summary transcript and learning points:
- When patients have chronic elbow pain and this injury does not heal or resolve in a few weeks and seems to ” never get better,” and becomes a chronic, years-long problem, we have to suspect what is happening is that the tendons of the elbow are suffering from tendinosis or degeneration of that tendon. This is elbow pain and loss of function usually without any inflammation. (Tendinosis – pain without inflammation).
Ligaments and tendons
Above we spoke about damaged ligaments’ inability to hold the radius and ulna bones together. When these bones move out of position, they can cause the tendons to stretch as well. Let’s point out that the run-up to elbow osteoarthritis is a stretching and tearing of the soft tissue of the elbow including the ligaments and tendons.
What are we seeing in this image?
When you have tendon breakdown, it takes the elbow ligaments with it. When you have an elbow ligament breakdown it takes the elbow tendons with it. Here we have a situation of tendinosis, pain in the elbow where the body has given up trying to heal it. The “osis” part is pain without inflammation. If your body was trying to heal the elbow it would be an “itis,” pain with inflammation.
Back to Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C’s video summary:
Treatments that do not help:
- Patients with chronic elbow pain, whether it is Tennis Elbow or Golfer’s Elbow will often try programs of ice, anti-inflammatory medications, KT Tape or Kinesio tape on it, physical therapy, rest, the whole gamut of conservative care options. This is when these people come to see us. When everything else has not worked or even helped and they are looking for another option to help their chronic elbow pain.
Injections beyond cortisone
- Prolotherapy or proliferation therapy is an injection technique that can work to regenerate the degenerated tendon. The injection of simple dextrose initiates a signaling response that recreates and mimics a natural healing response. The injections stimulate healing growth factors and repair platelets from the blood and immune response that makes healthy new tissue.
Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatment’s effectiveness in treating the problems of chronic pain.
In this video Ross Hauser, MD and Prolotherapy clinician student demonstrates Prolotherapy medial elbow treatment
The treatment begins at 1:12
- Chronic elbow pain is a very prominent problem that we see in our clinic.
- I’m Dr. Ross Hauser here I’m teaching a student how to inject the medial elbow area which is commonly called golfer’s elbow. It’s also known as ulnar collateral ligament injury which occurs in people who do overhead activities like tennis or baseball pitchers.
- (1:47) You’ll see here that I have the student put their index finger over the ulnar nerve, this is very key so the injection is done at the right place and not done into or around the ulnar nerve, see how I’m showing the student the right angle of the needle to inject the medial epicondyle area as well as other areas around the ulna bone where the ulnar collateral ligament attaches so the students going to mainly be treating the attachment the medial epicondylitis attachment of the wrist and hand flexors these are the muscles that contract the fingers.
- (2:43) The average number of treatment/visits is 3 – 6 treatments spread out over 4 -6 weeks per treatment.
- The student is injecting the various attachments of the ulnar collateral ligament which is the main stabilizer of the elbow the insider medial elbow and she has left index finger where the ulnar is.
- So we treat the ulnar collateral ligament thoroughly and this is a much better treatment option for some patients than Tommy John’s surgery and as you can see it just takes a couple of minutes.
Caring Medical research on elbow ligament damage and elbow instability
The problem of joint instability and in this case elbow instability is a problem of the elbow ligaments. In 2014 we published our article “Structural Basis of Joint Instability as Cause for Chronic Musculoskeletal Pain and Its Successful Treatment with Regenerative Injection Therapy (Prolotherapy)”(7) In that article our research team wrote:
“Ligaments are specialized dense bands of tough, fibrous collagenous connective tissue bundles that attach one bone to another. Ligaments function to hold bones in approximation, assist joint proprioception (keeping the joint where it should be and not hyperextended) and provide mechanical support and stability.”
The keyword is stability. The excitement exhibited by the above research about instability is something that Prolotherapists have discussed for decades. Weak ligaments lead to joint instability and tendinopathy, strong ligaments lead to pain-free joint stability and healed tendons.
In our published research in the medical journal Practical Pain Management, (8) our Caring Medical team found that:
- “Prolotherapy helps decrease pain and stiffness and improve the quality of life in patients with unresolved elbow pain.
- The treatment gave 64% percent of patients greater than 75% pain relief with 94% of them having 50% or more of their pain relieved.
- One hundred percent of the patients stated their pain and their life was better after prolotherapy.
- Notable improvements in other quality of life issues—including range of motion, depression, anxiety, sleep, exercise ability, and medication usage—was also seen with prolotherapy.”
Our research results for treating tennis elbow at a Prolotherapy charity clinic were analyzed and reported. In this study, patients were treated with dextrose Prolotherapy.
- The results of this retrospective, uncontrolled, observational study show that prolotherapy helps decrease pain and stiffness and improve the quality of life in patients with unresolved elbow
pain. The Hackett-Hemwall dextrose prolotherapy gave 64% percent of patients greater than 75% pain relief with 94% of them having 50% or more of their pain relieved. One hundred percent of the patients stated their pain and their life was better after prolotherapy.
These results were reported as part of our larger study “Evidence-Based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review.” Published in the Journal of Prolotherapy 2011. (9)
While the normal proliferant used in prolotherapy is dextrose-based, PRP prolotherapy (Platelet Rich Plasma as demonstrated in the video below) is gaining in popularity. In PRP prolotherapy, a concentrated amount of one’s own platelets which contain growth factors are injected into the injured tissue to promote and speed up the body’s natural healing process.
Prolotherapy and PRP injections for Tennis Elbow. The treatment here is explained by Danielle R. Steilen-Matias, MMS, PA-C, who is also performing the treatment on the patient.
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.
This is a transcript summary of the above video.
- This patient came to see us for chronic lateral elbow pain. His pain had been previously diagnosed as tennis elbow. His complaints were elbow pain when playing hockey and lifting weights. After these activities, he would notice that his elbow would swell and get warm and the pain would take a couple of days to calm down.
- The patient told us that he tried pain management and cortisone injections, neither seemed to help him so he came to our office to see Prolotherapy would help with his pain.
- After examination, we determined that he was a good candidate for treatment.
- Initially, we treated him with standard dextrose Prolotherapy treatment. The Prolotherapy treatment’s healing did not respond as quickly as we hoped so at the next treatment, Platelet Rich Plasma PRP was added as a more aggressive option to the treatment plan. The PRP treatment did not replace the Prolotherapy treatment, they were done simultaneously.
- In the video, the clear solution is the Prolotherapy being injected.
- In the combined treatment the Prolotherapy injections are given at the lateral epicondyle, the head, and neck of the radius, the annular ligament, the radial collateral ligament, the common extensor muscle origins, the common extensor tendon, making sure we treat all of these in a comprehensive manner.
- Notice that the patient is not sedated for all these injections. He did take pain medication ahead of time to help him kind of get through the treatment but no intravenous sedation or anything like that. Most patients tolerate the treatment really well even though it is a lot of shots. When the PRP is injected we may or will numb the area ahead of time just because the PRP solution is thicker than the normal Prolotherapy solution.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding your elbow problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated November 25, 2021