Question
QUESTION: 3yrs ago I damaged my right elbow conducting skull crusher exercises. after bringing my elbows to an acute angle of roughly 30 degrees, I experienced an acute 'pop' in my right elbow. I instantly felt discomfort in the medial(ulnar) area of the elbow joint. But, my arm was still usable and the pain remained fairly manageable. Over the course of the next 8 months, I would go on to reinjure the joint 6 times trying to rehab it, but pushing too hard.
The final straw came when I was challanged to an arm wrestling competition. After agreeing and pushing all of my might into an inward rotation arm wrestling match, my arm was in very solid pain. Swelling in the hand, cubital tunnel syndrome, a locking elbow, and a popping radial head were the result. I have been in pain for 3 years, and since then have accomplished an Unlar nerve transposition surgery to relieve the symptoms of my cubital tunnel pain. I have also attempted yoga, which improved my condition possibly due to the fact that closed kinetic chain exercises (CKC), are utilized in yoga more than Open Kinetic Chain (OKC). This improvement was short lived however, as my arm reverted back to serious pain after attempting to play 1 single game of volleyball.
I've regained solid strength in the arm, but I still feel as though my the biomechanics of my elbow are still off (subluxed). I still have the clicking/popping of my radial head when I pronate/supinate my hand, as well as slight popping in my elbow when attempting to extend it fully. The only clues I've found to correcting this problem have come accidentally. When stretching the lateral aspects of my arm (both distally and proximally of the elbow joint itself), I find that the popping of my radial head is almost completely stopped. By stretching, I mean rolling out with lacrosse balls and grabbing the R forearm (while fully extended and hypersupinated), with the L hand and pulling the distal arm from the lateral to the medial direction in a shearing force. It appears to open up the elbow joint on the lateral side and provide some form of space for the radial head to move and discontinue clicking/popping. But, when the elbow is in a full flexation attitude, that same pulling action (L arm pulling the R forarm towards the medial side), is more painful a the posterior point of the Olecranon process, but no pain is noted at the radial head.

I've been piecing together the clues of this puzzle for the last 3 years, and have found a couple of notable points.
1. The radial head appears to have some wiggle room within the annular ligament
2. Every morning I wake up, my elbow seems to be in a favorable position, but then once it is engaged, there is a regular popping shift in the elbow, and it appears to move into an unfavorable position internally
3. When there is any locking of my elbow, it occurs on the medial side of my elbow proximally. It's as though the medial edge of the olecranon process is catching something just before coming to full-extension rest in the olecranon fossa. Whether it be muscle or cartilage, I'm not sure. The times where the olecranon fossa has been irritated and swollen up (after volleyball), leads me to believe the cartilage has been damaged.

By the way, 2 MRI's in the last 2 years have shown no sign of noteworthy damage.

Like I said sir, this is an amazingly difficult puzzle. I kept this as short as I could to save you time. Please let me know if there is anything I can clear up, and I definitely look forward to your scholarly response to this enigma I call an elbow.

All the best,
Brendan King.

ANSWER: Hi Brendan,

A complex situation indeed. But a great detailed history and explanation by yourself has me initially thinking ligament laxity and capsular damage in the elbow. Everyhing you describe in terms of symtoms and aggravating factors such as volleyball points to a ligament soft tissue injury and associated instability of the radioulnar joint. Waking up in a "favorable" position for the elbow which then misaligns chronically after activity also justifies the laxity of ligament thought as bones that tend to consistently malalign are doing so due to joint instability. These finding will show inconclusive or negative on an MRI and require orthopedic and neuromuscular functional testing to conclude diagnosis. This tends to walk into my practice a lot with my throwing athletes and more recently with our Crossfitters who do many many reps of dips, press, or skull crushers.

Now lets talk the route you may wish to take. First, I would insist you find a sports and extremity chiropractor who deals with this on a daily basis and knows the comprehensive testing required. If the dx is ligament laxity and/or capular damage, I would suggest non invasive cold laser therapy or more invasive prolotherapy or PRP. Obviously try the more conservative cold laser first. Laser stimulates soft tissue healing in particlar, in your case collagen synthesis, which should help with healing and tightening of ligament.  Coupled with stabilization exercises aka yoga, you can get some great results. You may need a more invasive approach at this point in time but that can be determined through exam.

May I offer a suggestion for practitioner in your area. I noticed that you are in Idaho. Dr. Kevin Hearon is a top notched leader in extremety dx and treatment. He is in fact one of my instructors for extremity treatment. I believe he is in Boise. I believe wholeheartedly that he can get results with you. If he is not close, just look up sports chiropractors and extremity chiropractor in your area. I hope this information does you some good as I would really have loved to actually test you myself. Feel free to follow up and call me Vishal. Thanks.

---------- FOLLOW-UP ----------

QUESTION: Thank you for that solid feedback. The therapy methods and contact you gave were options I hadn't even heard of, and will be invaluable to my research and ultimate goal of elbow stabilization.

It's also refreshing to hear that you work with individuals with roughly the same ailment as I have. That give me more hope that this problem is definitely curable, it's just the precise diagnosis and effective therapy method to apply are a bit alluding. I've already completed my fair share of yoga (2-3 times per week, 45 min sessions), in order to help stabilize the elbow. I've seen a fair bit of progress, but I believe my normal workout routine with weights has been slightly counterproductive. Most of my workouts were open-kinetic-chain exercises, and it appears my arms stabilize better with closed-kinetic-chain (CKC), exercises. I expect to utilize CKC much more in the coming months as well as focused engagement of shoulder components when utilizing R arm for regular tasks.

My question for the moment is this: Should my diagnosis of my elbow be soft tissue damage and the associated elbow instability that comes with it, what is the approximate recovery time for those issues that you've experienced in your patients.

Thank you and regards,

Brendan King

Answer
Brendan,

Typical soft tissue healing times for the ligaments are 6-9 months depending on age and activity levels. If you are doing CKC exercises, you are actually helping yourself heal and of course lasers and prolo can only promote it even further. I suppose if you are going to throw a football or baseball or play volleyball, it increases healing times. In my office, I have seen pain levels subside within a month or so with laser therapy so I'm pretty sure you will notice relief sooner than the timeframe mentioned above but the actual healing of the collagen fibers requires time due to a slower blood supply.

May I suggest bodyweight CKC exercises such as push ups, pull ups, and straight arm planks with progression for upper body and elbow stabilization. In other words, assume a push up position and hold the top position for 10 secs, then descend to halfway down and hold another 10. Finally the bottom position for 10 and back up. Basically isometrics and do it with pull ups as well to allow your elbow joint to hold your bodyweight up in 3 positions. Even one arm side plank does the trick. This should be taxing enough but feel free to add a fitness ball or Bosu ball on your planks and push ups for added instability. We have progressed from isometrics to eccentric exercises for best results as it also strengthens the muscles as well. Anyway, just a way to progress your workouts and rehab. Good luck with it.