15
ELBOW ARTHRITIS AND REMOVAL OF
LOOSE BODIES AND SPURS, AND
TECHNIQUES FOR RESTORATION OF
MOTION
KYLE ANDERSON
Athletic activities can lead to joint degeneration, stiffness,
and formation of loose bodies. Loose body removal is the
most common use of elbow arthroscopy in this population
(1). Frequently, relatively modest arthrosis and con-
tractures, which would be well tolerated in the general pa-
tient, can be significantly disabling to an athlete. The degree
of motion that is tolerable depends on the patient, the sport,
and the position played. Chondral damage is usually the
result of repetitive trauma with a gradual decline in func-
tion. In many instances, there is an associated ligamentous
injury. Patients must be made aware of the possible underly-
ing causes of the spurs, loose bodies, or contracture so their
expectations and rehabilitation are appropriate.
PHYSICAL EXAMINATION
The history usually provides the most important informa-
tion in athletic patients. Symptoms are usually most promi-
nent during the involved activity. Patients will report me-
chanical symptoms such as catching, locking, or popping.
Pain at rest is usually a late, and sometimes ominous, find-
ing. Specific timing of pain exacerbation during the activity
is important. Pain in later innings or after a number of
pitches can indicate ligamentous pathology, which is un-
masked by muscular fatigue. Arthrosis may be more stiff
and painful early and loosen up after a period of throwing.
Patients can often identify the stage of the throwing cycle
that is problematic. Evaluation should always include a brief
examination of the cervical spine, the shoulder, and the
wrist before focusing on the elbow. Several conditions of
the neck or shoulder may present as elbow pain. Both active
and passive range of motion should be noted, as the differ-
Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Mich-
igan 48202.
ence between them may be particularly amenable to con-
servative treatment. Tenderness posteromedially in throw-
ing athletes with the valgus hyperextension test has been
well described (2). Often there will be an accompanying
loss of extension due to posterior olecranon osteophytes.
Loss of flexion is commonly seen with anterior compart-
ment loose bodies or osteophyte formation (Fig. 15.1). Pal-
pation for joint effusion or crepitation must be done care-
fully and repeatedly, as these can occasionally be very subtle
signs. It is important to assess stability in these patients, as
this may yield important clues as to the underlying pathol-
ogy. For example, posteromedial fragmentation that leads
to loose bodies or loss of extension is frequently caused
by medial collateral ligament deficiency. Stability testing
requires a relaxed patient and examiner. Clinical tests for
ulnar collateral ligament disruption can be extremely chal-
lenging. Partial injuries may have no valgus opening (3).
Even complete ruptures may only increase the valgus open-
ing by 1 to 3 mm (4,5). Valgus testing is done in pronation
to unlock the elbow in the coronal plane. The valgus stress
has been traditionally applied at 30 degrees of elbow flexion
(enough to bring the olecranon out of the fossa), but there
is now evidence that the anterior bundle is best isolated at
90 degrees of flexion (4). Clinically, humeral rotation can
be difficult to control with this amount of flexion.
INDICATIONS/CONTRAINDICATIONS
Few absolute indications exist when dealing with athletic
injuries of the elbow. Relative indications are usually based
primarily on the severity and duration of the athlete’s symp-
toms. In terms of motion, relatively small deficits that would
ordinarily be well tolerated can be disabling in high-demand
athletes. The necessary range of motion varies with the spe-
cific sport, position, and individual mechanics. Thus, clear
and concrete indications for surgery are not possible. Pain
220 The Athlete’s Elbow

FIGURE 15.1. Lateral radiograph of a 28-year-old pitcher show-

ing an anterior osteophyte, which limits flexion but does not in-
terfere with throwing.

that may be absent while the arm is at rest can still be a

reasonable indication for surgery if it fails to respond to
conservative treatment. Intraarticular bodies, seen on radio-
graphs, would seem to be an obvious indication for surgery.
However, these may be covered by synovium or adhered to
the capsule. They may not necessarily be loose and not
necessarily the cause of symptoms. Magnetic resonance im-
aging (MRI) can help delineate the position of an ossified
fragment relative to the elbow capsule (Fig. 15.2). Typically,
closely correlated mechanical symptoms and radiographic
evidence of loose bodies are a sufficient indication for sur-
gery. In the setting of a planned ligament reconstruction in
an athlete, a diagnostic arthroscopy at the beginning of the
procedure can demonstrate important and treatable pathol-
ogy that was not appreciated on preoperative examination
or imaging.
FIGURE 15.2. Magnetic resonance imaging can demonstrate the
position of a loose body relative to the capsule. This sagittal view
magnetic resonance image clearly shows a loose body within the
elbow capsule.
felt the brace was better tolerated than dynamic splints.
Serial casting has also had reported good results (9) but can
be time intensive.
Dynamic splints have received more attention in the re-
cent literature (Fig. 15.3) (10,11). In a case report of bilat-
eral contractures, the dynamic splint was superior to the

MANAGEMENT
Nonoperative
Initial treatment of most elbow pathology should be con-
servative. Splinting and physical therapy can be remarkably
effective even for severe soft tissue contractures. There is
some debate as to the type of splinting that is most effective.
In one report, the turnbuckle splint (a static, progressive
splint) resulted in an improvement of nearly 40 degrees after
20 weeks of treatment (6). In another study of this splint,
only half of the 22 patients regained a functional arc of
30 degrees to 130 degrees. An additional six patients were
satisfied enough to decline surgical release (7). Bonutti et al.
FIGURE 15.3. Dynamic splint used to correct a soft tissue con-
(8) reported favorable results with a newer static progressive tracture. (From Dynasplint Systems, Inc., Severna Park, Massachu-
splint. Motion was improved by a mean of 31 degrees. They setts, with permission.)
 15. Elbow Arthritis 221

FIGURE 15.4. Arthroscopy in the supine position facilitates con- FIGURE 15.5. The prone position allows broad access to the
version to open procedures such as a ligament reconstruction. elbow, particularly posteriorly.

static in restoring extension (11). It is worth mention that
most studies document substantial improvement and satis-
faction for patients who have very large contractures. These
excellent results may not necessarily translate to athletes
with relatively small, but refractory, contractures.
geons use two posterior portals and two or three anterior
portals. Several studies and reports have focused on the safest
and most useful portal placement (13–20). The most com-
monly used portals are described in Table 15.1.

Arthroscopy
Position
The supine position is used if arthroscopy is planned in
combination with a reconstructive procedure (Fig. 15.4) or
prone if arthroscopy is performed alone. The supine posi-
tion allows easier transition to open procedures, such as
collateral ligament reconstruction, without the need for re-
preparation. The prone position allows complete access to
the joint with easier exposure to the posterior compartment
(Fig. 15.5). Alternatively, the arthroscopy can be performed
in the lateral decubitus position if a padded arm holder is
available.
In either position, arthroscopy is begun with joint disten-
sion usually through the lateral soft spot (Fig. 15.6). This
has been shown to increase the distance from the portals to
neurovascular structures by up to 1 cm (12).

Portals
FIGURE 15.6. Before the surgeon establishes the first arthro-
Degenerative disease, loose bodies, and contractures require scopic portal, the joint is distended with a saline injection through
the surgeon to be familiar with multiple portals. Most sur- the midlateral soft spot.
222 The Athlete’s Elbow

TABLE 15.1. COMMONLY USED PORTALS

Nearest Neurovascular
Portal Authors Description Structure
Midlateral Adolfson (13) ‘‘soft spot’’—center of triangle between 7 mm (posterior anterobrachial
olecranon, radial head, capitellum cutaneous nerve)
Proximal lateral Field et al (15) 2 cm proximal, 1 cm anterior to lateral 7.9 mm extended, 13.7 mm
epicondyle flexed (radial nerve)
Anterolateral Andrews and Carson (21) 3 cm distal, 1 cm anterior to lateral 1.4 mm extension, 4.9 mm
epicondyle flexed (radial nerve) (22)
Proximal medial Poehling et al (18) 2 cm proximal, just anterior to medial 12 mm (22) ⳮ23mm (16)
epicondyle (median nerve)
Anteromedial Andrews and Carson (21) 2 cm distal, 2 cm anterior to medial 2 mm extended, 7 mm flexed
epicondyle (median nerve) (22); 4 mm
(median nerve) (12)
Posterolateral Burman (14) Proximal to olecranon, lateral edge of ⬎15–20 mm (22)
triceps
Posterocentral Andrews and Carson (21) Proximal to olecranon, through triceps ⬎15–20 mm (22)
(transtriceps) tendon

Loose Bodies removed as soon as they are encountered, rather than con-
Intraarticular bodies, which may or may not be loose, re- ducting a complete inspection before removal; visualization
main the most common indication for elbow arthroscopy. may change or the loose fragment may move to an area less
There are many potential sources of these bodies including accessible, which can make subsequent removal unnecessar-
arthrosis, osteochondritis dissecans, osteochondral fracture, ily difficult. Strict control of fluid flow (both in and out)
and synovial chondromatosis. In athletes, loose bodies is essential once the body has been localized. A spinal needle
usually result from acute or repetitive trauma. Proposed can be used to control the fragment (Fig. 15.8A–D). An
mechanisms for the generation of loose bodies include frag- arthroscopic grasper or shaver is used for smaller loose bod-
mentation of joint surfaces, fractured osteophytes, and os- ies or those adherent to the capsule or periosteum. The
teochondral nodule proliferation in periarticular soft tissues
(23). In one report, loose bodies were found within the
joint in less than half of the cases at arthroscopy (24). Often
radiographs will depict an ossified fragment that appears to
be within the elbow joint. MRI, ultrasonography, or com-
puted tomographic arthrography can be used to demon-
strate the relationship of the fragment to the elbow capsule
(25,26). Conversely, mechanical symptoms with normal ra-
diographs are suspicious for a cartilage injury, which may
also require these advanced imaging modalities. It should
also be mentioned that there may be more fragments than
counted on preoperative imaging, so a thorough arthro-
scopic inspection is always necessary (27,28).
There are a variety of methods described for safely estab-
lishing the first portal. The important point is that the sur-
geon should establish a routine that is thorough and can
be performed consistently. It is wise to be familiar with
the anatomy for many portals even if some are not used
frequently. When the procedure is started from the proximal
lateral portal, inspection is carried out first in the medial
gutter anteriorly (Fig. 15.7). The search for loose fragments
then extends across the anterior compartment from medial
FIGURE 15.7. Photograph demonstrating the proximal lateral
to lateral. If loose bodies are present, a medial portal is portal. The portal is placed just anterior to the humerus where
established under direct visualization. Fragments should be the supracondylar ridge meets the lateral epicondyle.
 15. Elbow Arthritis 223

A B

C D
FIGURE 15.8. Loose body removal. A: Axial magnetic resonance image demonstrating a large
loose body in the coronoid fossa of the humerus, which was causing intermittent locking. B: At
arthroscopy, the loose body is visualized through a proximal lateral portal. C: A spinal needle is
inserted anteromedially to guide portal placement and prevent movement of the loose body. D:
A cannula placed in a proximal medial portal, through which the large loose body was removed
in two fragments.

cannula should allow outflow, as this will bring the loose
bodies toward the arthroscopic grasper (Fig. 15.9). Larger
bodies may need to be broken into smaller pieces that can
be removed through the cannula. One piece that is too large
for the cannula can be removed by grasping the fragment
and removing it with the cannula in one maneuver. The
portal incision at the skin can be carefully extended with a
scalpel and the portal dilated by spreading a clamp within
the portal before attempting removal. A larger portal is pref-
erable to having a loose body caught in the soft tissue during
extraction. The camera can actually be used to help push
the fragment out as it is pulled with a grasper.
224 The Athlete’s Elbow
The posterior compartment is viewed through a postero-
lateral portal, which is located just radial to the triceps ten-
don at the level of the tip of the olecranon (Fig. 15.10).
Debridement and removal of loose bodies can be preformed
through a posterocentral (transtriceps) portal. If a shaver is
used, suction should be used very carefully due to the prox-
imity of the ulnar nerve posteromedially (Fig. 15.11). Occa-
sionally, the scope can be advanced through the radial gutter
into the midlateral area to view the more posterior aspect
of the radial head and distal capitellum. Alternatively, the
midlateral portal can be established to view this zone. A
smaller scope (2.7 mm) or a 70 degrees scope may be useful
for maximum visualization in this confined space.
There is substantial variability in the literature with re-
gard to outcome after loose body removal. Ogilvie-Harris
FIGURE 15.9. Fluid outflow through a cannula side
port can help bring the intraarticular loose body to-
ward the grasper.
and Shemitsch (29) reported improvements in pain, lock-
ing, and swelling in most patients. Only half had improve-
ments in crepitus. In O’Driscoll’s report, 75% of patients
with loose bodies improved (30). They attributed the 25%
failure rate to associated degenerative joint disease. Athletes
have had similar outcome after loose body and spur removal
with 2 years follow-up (1).
Osteochondritis Dissecans/Osteochondral Fractures
The pathoetiology of osteochondritis dissecans remains un-
clear. Among the many postulates are vascular compromise,
osseous compartment syndrome, immune anomalies, and
physeal or epiphyseal abnormalities. It is associated with
repetitive activity such as in baseball or gymnastics (31,32).
FIGURE 15.10. Arthroscopy of the posterior elbow.
The camera is in the posterolateral portal, and the
shaver and instrumentation are in the transtriceps (pos-
terior) portal. Inflow can be delivered either through
the scope or through the anterior or midlateral portal.
 15. Elbow Arthritis 225

lacked a drilling debridement control group, they felt the

treatment decreased the subsequent arthritis (36).
Panner disease should be distinguished from osteochon-
dritis dissecans. This phenomenon involves pathologic en-
dochondral ossification of the capitellum. It usually occurs
about the time of maturation of this ossific nucleus, which
is around 5 to 10 years of age. The importance of this
distinction is that this condition often heals with conserva-
tive treatment. However, one report suggests that arthros-
copy can lead to a faster recovery (37).

FIGURE 15.11. Shaver suction should be used carefully in the
posteromedial elbow, as the ulnar nerve lies adjacent to the joint
capsule in this area.
Posteromedial Impingement/Fragmentation
This entity is usually the result of valgus hyperextension
overload in throwing athletes. Often these patients have
some degree of valgus laxity due to tearing or attenuation
of the medial collateral ligament (Fig. 15.12). With valgus
laxity, compression occurs across the radiocapitellar joint
and in the posteromedial aspect of the elbow. Spurs and
fragmentation develop on the posteromedial olecranon.
Chondromalacia of the posterior humeral trochlea is an as-
sociated finding. Additionally, the capsule and synovium
become thickened and may become inflamed. Pain from
this lesion can be very difficult to discern from pain from

Symptoms such as pain and swelling are usually exacer-

bated with activity. Mechanical symptoms are not necessar-
ily present. Radiographs may demonstrate a defect or irregu-
larity of the articular surface. Devascularized fragments may
have a sclerotic appearance. MRI with appropriate cartilage
sequencing can provide detailed information about the size
and depth of the lesion (33). The presence of joint fluid
between the fragment and bed is also useful. Finally, the
marrow signal in the fragment may indicate the likelihood
of debridement and in situ fixation of the fragment versus
excision. The classification and treatment options are simi-
lar to those of other joints. Certainly, location of the lesion
affects the degree of difficulty of treatment. Distal and me-
dial capitellar lesions can be very difficult to access. Debride-
ment, removal of small fragments, and drilling or microfrac-
ture remain the mainstay of surgical treatment. Drilling can
be performed percutaneously through a few small punctures
from posterior.
Jackson et al. (31) reported a poor rate of return to com-
petition in female gymnasts with drilling and debridement.
Baumgarten et al. (34) had more encouraging results, with
seven out of nine returning to throwing sports and four out
of five returning to gymnastics. In a long-term follow-up
study (35), most patients developed degenerative changes.
These authors also noted an increase in the size of the radial
head in these patients. The utility of more complex proce-
dures such as osteochondral plug transfer (mosaicplasty), FIGURE 15.12. Posteromedial impingement often occurs in the
chondrocyte transplant, or allograft reconstruction have not setting of medial collateral ligament insufficiency. This magnetic
resonance image demonstrates high signal in the medial collat-
been thoroughly evaluated. One encouraging study showed eral ligament, indicating that the ligament, although intact, has
good results with a bone-peg technique. Although this study been injured and undergone a remodeling process.
226 The Athlete’s Elbow

FIGURE 15.13. A hyperflexion lateral radiograph demonstrating

olecranon and posterior humeral pathology.

the medial collateral ligament, flexor-pronator muscles, and

the ulnar nerve. Frequently, these patients will have pain
with the follow-through phase of the throwing motion,
whereas the others will most commonly occur during late
cocking or early acceleration. The valgus hyperextension A
test is a helpful diagnostic clinical test. Radiographs may
show irregularity or apparent loose bodies at the posterome-
dial olecranon. A hyperflexion view brings the olecranon
out of the fossa and can improve visualization (Fig. 15.13).
The best available imaging modality is MRI (Fig. 15.14A).
This can demonstrate capsular thickening, chondral thin-
ning, loose bodies, and edema. It is not uncommon for the
extent of pathology to be underappreciated until the time
of arthroscopy. Careful inspection from the posterolateral
portal will reveal loose bodies, spurs, chondromalacia, and
fibrous debris (Fig. 15.14B). The olecranon should be care-
fully probed, as fibrous tissue can often cover fragmentation
that could be the source of persistent pain (Fig. 15.15). The
arthroscopic shaver and suction should be used carefully in
the posteromedial compartment because the ulnar nerve lies
adjacent to the scarred capsule.

Arthritis in Athletes
In contrast to the general population in whom the elbow B
accounts for only 2% of degenerative joint disease, elbow FIGURE 15.14. A: Sagittal magnetic resonance image demon-
involvement is not uncommon in athletes. In this popula- strating fibroosseous debris within the posterior elbow. B: At ar-
throscopy, chondromalacia of the posteromedial humeral con-
tion, joint destruction is usually the result of cumulative dyle is seen.
trauma. The role of arthroscopy has expanded dramatically
in the last two decades. Debridement, spur, and loose body
removal, synovectomy, and capsular release are now amena-
ble to arthroscopy. Although these procedures are techni-
cally demanding, particularly when anatomy has been dis-
torted, they have the potential to achieve the same surgical

FIGURE 15.15. Posteromedial fragmentation of the olecranon
can be covered by fibrous tissue and easily missed. The olecranon
must be carefully inspected and probed to avoid leaving small,
but painful, fragments, such as this one adjacent to the olecranon.
objectives as those of open methods but with decreased mor-
bidity rates.
Symptoms include pain at the end range of motion, loss
of motion, catching or locking, and soft tissue irritation.
The most common presentation is loss of extension due to
posterior osteophytes on the olecranon or humerus (38).
Pain in the mid range of motion is a late finding. Anterior
osteophytes on the coronoid or in its fossa present with
loss of flexion. Radiocapitellar osteophytes can limit both
flexion/extension and pronation/supination. Radiographs
(anteroposterior, lateral, and oblique) are usually sufficient
to develop a treatment plan (Fig. 15.16A and B). Arthro-
scopic removal of spurs and loose bodies can improve mo-
tion, relieve pain, and relieve mechanical symptoms. Pain
at mid range of motion may be less likely to be improved
by arthroscopic debridement. Fenestration of the humerus
(Outerbridge procedure) (39) can improve both flexion and
extension and can be performed open or arthroscopically.
Long-term follow-up after arthroscopic treatment of elbow
arthritis is limited. Patients should be advised of the poten-
tial for spur reformation. O’Driscoll and Morrey reported
on 71 arthroscopies (30). Although the presence of arthrosis
adversely affected the results of loose body removal, more
than 80% had relief of symptoms with debridement. Oka
(40) reported their experience with spur and loose body
removal in athletes. Pain and motion were improved, al-
though most patients had some minor residual symptoms.
Arthroscopic humeral fenestration was studied by Redden
and Stanley (41). They found that all patients had reduced
pain and relief of locking. Interestingly, they did not have
improvements in motion. In contrast, Savoie et al. (42) had
marked improvement in motion (average increase was 81
15. Elbow Arthritis 227
degrees) with this procedure. They also excised the radial
head in most cases.
Capsular Contracture (Arthrofibrosis)
Contractures can occur as a result of trauma, arthritis, burns,
upper motor neuron lesions (spasticity), heterotopic ossifi-
cation, ligamentous contracture/ossification, and after ex-
tensive surgical procedures such as collateral ligament recon-
struction. Most are from trauma, with subsequent pain,
hemarthrosis, and immobilization. Morrey et al. (43) have
demonstrated that a flexion-extension arc of 30 degrees to
130 degrees is sufficient for activities of daily living. Many
patients can tolerate flexion contractures of up to 40 degrees.
Athletes, however, can have significant disability from much
smaller losses of motion. Indications are usually based on
clinical impairment, rather than advanced imaging. MRI
has been shown, however, to be useful in the evaluation of
soft tissue contractures (44). As discussed already in this
chapter, splinting can be notably effective for improving
motion from soft tissue contractures. Certainly, duration of
the contracture and the injury leading to the contracture
affect this prognosis.
Capsular release requires a thorough knowledge of neu-
rovascular anatomy. Extensive open procedures can be per-
formed while avoiding damage to the collateral ligaments
(Fig. 15.17) (45–51). Occasionally, contracture or ossifica-
tion of the collateral ligaments requires release or excision
(Fig. 15.18) (52). Arthroscopic release is now a reasonable
treatment option for arthrofibrosis (Fig. 15.19) (53–55).
Presumably, because dissection and surgical trauma are re-
duced, the morbidity rate and potential for recurrence are
diminished. This has not been demonstrated in a controlled
study. Although the brachialis muscle separates the neuro-
vascular structures from the capsule, serious complications
such as nerve transection have been reported (56). It appears
that release from the humeral is safer if performed at the
humeral insertion of the capsule, rather than through the
middle of the anterior capsule (57). Extrinsic causes of con-
tractures such as heterotopic ossification still require sur-
geons to be adept at open release. Also, muscle-tendon con-
tracture may require splinting after open or arthroscopic
release. If there is articular congruity, ligament release can
be performed with instability. However, a hinged external
fixator is necessary when osseous stability is lacking.
COMPLICATIONS
Complications from elbow arthroscopy for removal of loose
bodies, debridement, or release are uncommon and usually
minor. The major concern is the potential for nerve injury.
This can occur from overdistension and swelling (12), direct
laceration of a nerve (56), or compression of a nerve due
to suboptimal portal placement with levering of the instru-
ments (58).
After contracture release, a small degree of motion loss
228 The Athlete’s Elbow

A B
FIGURE 15.16. Anteroposterior and lateral radiographs of a 29-year-old pitcher. Note both ante-
rior and posterior humeral spurs. This patient experienced increasing pain and gradual loss of
motion until he was unable to throw.

A B
FIGURE 15.17. Through a lateral approach, both the anterior capsule (A) and the posterior cap-
sule (B) can be released without injury to the lateral collateral ligament.

FIGURE 15.18. Excision of this ossified medial collateral liga-
ment was necessary before elbow motion was improved.
can persist. Patients should be warned of the potential resid-
ual contracture that many patients experience. They also
must be made aware that some gains are not seen immedi-
ately after surgery but require extensive effort with their
rehabilitation.
For loose body removal, the underlying pathology affects
the potential for further loose body formation. Patients with
underlying arthrosis are at higher risk of recurrence.
Portal drainage occurs not infrequently, but deep infec-
tion is rare.
FIGURE 15.19. Arthroscopy will occasionally reveal intraarticu-
lar adhesions, such as this fibrotic band, which contributed to the
patient’s flexion contracture.
15. Elbow Arthritis 229
POSTOPERATIVE MANAGEMENT
The initial postoperative phase involves the reduction of
inflammation. For motion restoration procedures, more ag-
gressive protocols may be advisable. Continuous passive mo-
tion and progressive splinting may have a role immediately
after surgery. The second phase focuses again on motion but
strengthening begins. More advanced strengthening with
resistive exercises comprises the third phase. By the end of
this stage, patients should be able to perform activities of
daily living. The remaining rehabilitation involves sport-
specific training such as a toss or throwing program. During
this phase, strengthening of adjacent joints, as well as the
trunk and the legs, should be emphasized.
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