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Bad Elbow case.

Exit forum ID Forum Discussion Bad Elbow case.

This topic contains 3 replies, has 3 voices, and was last updated by   Brandon Cohen DC, CSCS August 9, 2018 at 5:03 am.

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  • #3702

    Andrew Wengert
    Participant

      44 year old male with Right elbow pain. Location is deep in the elbow joint. Pain is sharp and numbing.  Currently rated a 7/10 but can get up to a 10/10.  Flexion and extension are painful. Keeping the elbow in mid range is palliative.

      Pain started 4 years ago with the inability to fully extend elbow.  Imaging showed nothing per patient but surgeon went in and found and removed a small fragment of bone or cartilage.  Since then condition has worsened. He has had another arthroscopic surgery. 2 manipulations under anesthesia. 3 capsular releases, Stem cells, PRP, even went for a consult with Dr. James Andrews, who could not give him an answer.  With all surgical procedures the arm straightens out for abut half a day the goes back to original position.  He has also seen a rheumatologist who prescribed methotrexate, which he has not taken yet.

      On physical examination if the patient starts with his elbow at his side flexed 90 degrees, he can get 5 degreees of flexion and 45 degreees of extension then it is severely painful.  This guy is otherwise totally healthy.

      I asked him about imaging and per the patient, nothing abnormal.  I got the report and it is a mess.

      It was a comparison MRI.

      Findings:

      1) Marrow edema of the proximal ulna with increasing intensity and extent since the last MRI, now involves the proximal 6.8cm including olecranon, coronoid, and proximal shaft. Also minor marrow edema of posterior ulnar region of the trochlea.

      2) Moderate sized elbow joint effusion, with synovitis and surrounding soft tissue edema especially over the proximal posterior ulna.

      3) Marrow edema findings may be due to transient regional migratory osteoporosis.

      4) Minor ulnotrochlear DJD

      I know this is not a case that my treatment is ideal for, but I have some questions.

      Can these MRI findings produce such a limitation in motion if the capsule has been released?

      How can a capsule be released more than once?

      Is it a protective tension that keeps bringing the elbow back into flexion after each surgical procedure?

      The patient has been doing aggressive strengthening and stretching over the past 4 years to try to avoid losing any more function in the elbow.  I advised him to stop to try to stop the irritation to the already damaged joint.  Is that advice correct?

      The diagnosis of Transient regional migratory osteoporosis does not make sense to me as what i have ready says it is self limiting and typically lasts 3-6 months and this guy has had symptoms for 4 years.

      Any help would be appreciated as I am not sure where to send this guy at this point.

      #3720

      Christopher Stepien
      Participant

        Tough case Andy.

        Can these MRI findings produce such a limitation in motion if the capsule has been released?

        Yes, because the “limitation in motion” obviously wasn’t coming from the capsule.

        How can a capsule be released more than once?

        Someone more knowledgeable than me can answer this. My best guess is because the doctors don’t know what else to do. Kind of like doing 2 or 3 cortisone shots when the 1st one didn’t work.

        Is it a protective tension that keeps bringing the elbow back into flexion after each surgical procedure?

        Yes. If it were truly a bony stop, there would be no even temporary increase in range.

        The patient has been doing aggressive strengthening and stretching over the past 4 years to try to avoid losing any more function in the elbow. I advised him to stop to try to stop the irritation to the already damaged joint. Is that advice correct?

        Yup. His elbow is overloaded. He’s more likely to lose more function doing those things, loading the damaged tissue more, than he is resting.

        The diagnosis of Transient regional migratory osteoporosis does not make sense to me as what i have ready says it is self limiting and typically lasts 3-6 months and this guy has had symptoms for 4 years.

        I perceive “marrow edema” to be at least moderate joint damage with active inflammation (due to overload). I don’t know what TRMO means, but it sounds relatively straight forward to me.

        The best you can do here is communicate truth and manage load.

        Someone can double-check my perspective.

        #3721

        Andrew Wengert
        Participant

          Thank you Chris

          #3723

          Brandon Cohen DC, CSCS
          Participant

            This is terrible. This appears to fall into the not much to do as far as conservative management and no longer a surgical candidate area. Super sucky. Absolutely he needs to manage his loads. More is not better. Living with that elbow on its terms and within its current limits is likely as good as it will get.

            Also, multiple capsule releases don’t sound that odd to me. I don’t imagine they go in and rip out the whole thing, but that is just me.

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