ELBOW OSTEOARTHRITIS

What is Elbow Arthritis?

• Elbow osteoarthritis (OA) is a degenerative joint disease characterized by pain, stiffness, and mechanical symptoms such as locking or catching.
• While arthritis usually affects the weight-bearing hip and knee joints, in uncommon cases it can affect the elbow. Unlike OA in weight-bearing joints, elbow OA often preserves joint space and articular cartilage, but it is marked by the formation of hypertrophic osteophytes and capsular contracture [Cheung et al, 2008; Gramstad & Galatz, 2006].
  • Specific changes to the cartilage include:
    • Articular Cartilage Degeneration: The articular cartilage undergoes significant degenerative changes, including loss of proteoglycans and collagen network disruption. This leads to fissuring and eventual loss of cartilage [Aigner & McKenna, 2002].
    • Subchondral Bone Changes: There is increased subchondral bone turnover, characterized by bone remodeling and sclerosis. Osteoclast activity is heightened, leading to bone resorption and formation of osteophytes [Chen et al, 2024; Suri & Walsh, 2012].
    • Synovial Inflammation: Synovitis, or inflammation of the synovial membrane, is often present and contributes to the overall joint pathology. This inflammation can exacerbate cartilage degradation through the release of pro-inflammatory cytokines [Coaccioli et al, 2022; Wang et al, 2018].

What are common causes of Elbow Arthritis?

• Elbow osteoarthritis (OA) primarily affects middle-aged men who engage in strenuous manual labor or repetitive elbow use, such as athletes.
  
  • Middle-aged to Elderly Populations: The prevalence of elbow OA increases with age, with notable increases in individuals aged 50-89 years [Nakayama et al, 2022].
  • Manual Laborers and Athletes: Those involved in activities that place repetitive stress on the elbow joint, such as heavy manual laborers and athletes, are at higher risk [Gramstad & Galatz, 2006].
    
• Common causes of elbow OA include:
  • Age: The risk of developing elbow OA increases with age. Studies have shown that individuals in their 50s, 60s, 70s, and 80s have significantly higher odds of developing elbow OA compared to those in their 40s [Oya et al, 2018; Nakayama et al, 2022].
  • Sex: Male sex is a significant risk factor for elbow OA, with men being more likely to develop the condition than women [Oya et al, 2018; Nakayama et al, 2022; Stanley, 1994].
  • History of Elbow Trauma: Previous elbow injuries, such as fractures or dislocations, significantly increase the risk of developing elbow OA [Oya et al, 2018; Guitton et al, 2010].
  • Occupational and Athletic Stress: Repetitive stress and heavy manual labor are associated with a higher risk of elbow OA. Occupational exposure to heavy work, force, vibration, and repetitive movements are significant risk factors [Spahn et al, 2017; Desmoineaux et al, 2019].
  • Body Mass Index (BMI): Higher BMI has been associated with an increased prevalence of primary elbow OA [Nakayama et al, 2022].

How do you know if you have Elbow Arthritis?

• Elbow arthritis can be diagnosed through a combination of clinical evaluation, imaging studies, and patient history.
  
  • The primary symptoms of elbow arthritis include pain, stiffness, mechanical symptoms (such as locking or clicking), and weakness. These symptoms are often exacerbated by activity and relieved by rest [Cheung et al, 2008; Gramstad & Galatz, 2006; Del Core & Koehler, 2023].
  • Clinically, patients may present with pain at the terminal extents of motion, particularly during elbow flexion and extension. Physical examination may reveal tenderness along the joint line, reduced range of motion, and palpable osteophytes [Cheung et al, 2008; Gramstad & Galatz, 2006].
    
• Imaging studies can help confirm the diagnosis:
  • Plain radiographs, can show osteophyte formation, joint space narrowing, and other degenerative changes.
    
  • Advanced imaging modalities like MRI or CT arthrography can provide detailed information about cartilage integrity and the presence of loose bodies [Lenoir et al, 2019; Thomas et al, 2022].
  • Ultrasound can be useful in detecting joint effusion and synovial hyperperfusion, particularly in cases of inflammatory arthritis [Schafer et al, 2020].

What are the treatments for Elbow Arthritis?

Non-surgical treatments

• Activity modification: Reducing activities that exacerbate symptoms.
• Anti-inflammatory medications: NSAIDs to reduce pain and inflammation.
• Hand therapy: Physical therapy to maintain range of motion and strength.
• Corticosteroid injections: To provide temporary relief from inflammation and pain [Del Core & Koehler, 2023].

Orthobiologics Treatments

• Most of the available literature on PRP for the elbow focuses on tendinopathies and other elbow conditions rather than osteoarthritis specifically.
• The American Medical Society for Sports Medicine (AMSSM) has noted that while PRP injections are more effective than steroids or hyaluronic acid for knee osteoarthritis, there is insufficient evidence to determine their efficacy for osteoarthritis in other joints, including the elbow [Finnoff et al, 2021].
  

Surgical treatments are considered when non-surgical methods fail to provide adequate relief. The choice of surgical intervention depends on the underlying etiology and severity of the arthritis.

• Arthroscopic or open synovectomy and debridement: This approach is typically recommended for younger, active patients with mild to moderate disease. These procedures aim to remove inflamed synovium and loose bodies, and to smooth out rough cartilage surfaces [Papatheodorou et al, 2013]
  

• Interposition arthroplasty: This approach is also recommend for younger patients with more advanced disease who are not candidates for total elbow arthroplasty. This procedure involves placing a soft tissue graft between the joint surfaces to reduce pain and improve function [Papatheodorou et al, 2013; Gallo et al, 2008].
• Total elbow arthroplasty (TEA) or Elbow Replacement Surgery: This approach is generally reserved for elderly, low-demand patients with end-stage arthritis. A replacement can provide significant pain relief and improved function but comes with a risk of implant loosening and instability, particularly in younger, more active patients [Papatheodorou et al, 2013; Cheung et al, 2008].

References

1. Aigner T, McKenna L. Molecular pathology and pathobiology of osteoarthritic cartilage. Cell Mol Life Sci. 2002 Jan;59(1):5-18.
   
2. Chen W, Wang Q, Tao H, Lu L, Zhou J, Wang Q, Huang W, Yang X. Subchondral osteoclasts and osteoarthritis: new insights and potential therapeutic avenues. Acta Biochim Biophys Sin (Shanghai). 2024 Apr 25;56(4):499-512.
   
3. Cheung EV, Adams R, Morrey BF. Primary osteoarthritis of the elbow: current treatment options. J Am Acad Orthop Surg. 2008 Feb;16(2):77-87.
4. Coaccioli S, Sarzi-Puttini P, Zis P, Rinonapoli G, Varrassi G. Osteoarthritis: New Insight on Its Pathophysiology. J Clin Med. 2022 Oct 12;11(20):6013.
5. Del Core MA, Koehler D. Elbow Arthritis. J Hand Surg Am. 2023 Jun;48(6):603-611.
   
6. Desmoineaux P, Carlier Y, Mansat P, Bleton R, Rouleau DM, Duparc F; French Arthroscopic Society. Arthroscopic treatment of elbow osteoarthritis. Orthop Traumatol Surg Res. 2019 Dec;105(8S):S235-S240.
   
7. Finnoff JT, Awan TM, Borg-Stein J, Harmon KG, Herman DC, Malanga GA, Master Z, Mautner KR, Shapiro SA. American Medical Society for Sports Medicine Position Statement: Principles for the Responsible Use of Regenerative Medicine in Sports Medicine. Clin J Sport Med. 2021 Nov 1;31(6):530-541.
   
8. Gallo RA, Payatakes A, Sotereanos DG. Surgical options for the arthritic elbow. J Hand Surg Am. 2008 May-Jun;33(5):746-59.
   
9. Guitton TG, Zurakowski D, van Dijk NC, Ring D. Incidence and risk factors for the development of radiographic arthrosis after traumatic elbow injuries. J Hand Surg Am. 2010 Dec;35(12):1976-80.
   
10. Lenoir H, Carlier Y, Ferrand M, Vidil A, Desmoineaux P; French Arthroscopic Society. Can preoperative imaging predict the outcomes after arthroscopic release for elbow arthritis? Orthop Traumatol Surg Res. 2019 Dec;105(8S):S229-S234.
    
11. Nakayama K, Kato H, Ikegami S, Hayashi M, Hashimoto S, Sakai N, Takahashi J, Taneichi H. Prevalence and associated factors of primary elbow osteoarthritis in the Japanese general elderlypopulation: a Japanese cohort survey randomly sampled from a basic resident registry. J Shoulder Elbow Surg. 2022 Jan;31(1):123-132.
    
12. Oya N, Tajika T, Ichinose T, Sasaki T, Yamamoto A, Kuboi T, Endo F, Takagishi K, Chikuda H. The prevalence of elbow osteoarthritis in Japanese middle-aged and elderly populations: the relationship between risk factors and function. J Shoulder Elbow Surg. 2018 Jun;27(6):1086-1091.
13. Papatheodorou LK, Baratz ME, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2013 Mar;38(3):605-13.
14. Schäfer VS, Recker F, Vossen D, Geffken I, Matuschek E, Hartung W. Prevalence of Elbow Joint Arthritis and Enthesitis in Rheumatoid Arthritis. J Clin Med. 2020 May 24;9(5):1590.
15. Spahn G, Lipfert JU, Maurer C, Hartmann B, Schiele R, Klemm HT, Grifka J, Hofmann GO. Risk factors for cartilage damage and osteoarthritis of the elbow joint: case-control study and systematic literature review. Arch Orthop Trauma Surg. 2017 Apr;137(4):557-566.
    
16. Stanley D. Prevalence and etiology of symptomatic elbow osteoarthritis. J Shoulder Elbow Surg. 1994 Nov;3(6):386-9.
    
17. Suri S, Walsh DA. Osteochondral alterations in osteoarthritis. Bone. 2012 Aug;51(2):204-11.
    
18. Thomas JM, Chang EY, Ha AS, Bartolotta RJ, Bucknor MD, Caracciolo JT, Chen KC, Flug J, Kumaravel M, Raizman NM, Ross AB, Silvis ML, Surasi DS, Beaman FD. ACR Appropriateness Criteria® Chronic Elbow Pain. J Am Coll Radiol. 2022 Nov;19(11S):S256-S265.
    
19. Wang H, Wang Q, Yang M, Yang L, Wang W, Ding H, Zhang D, Xu J, Tang X, Ding H, Wang Q. Histomorphology and innate immunity during the progression of osteoarthritis: Does synovitis affect cartilage degradation? J Cell Physiol. 2018 Feb;233(2):1342-1358.
    

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Other Elbow Conditions

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