In the last 5 years I have been seeing more and more young active patients present with painful and stiff elbow joints. All of these patients have been heavily involved in the practice of mixed martial arts (MMA) or Jiu-Jitsu. Most of them have been professional fighters.
These patients present with a stiff elbow that no longer straightens out. Since the elbow cannot fully straighten they have problems with reach and with generating a good jab. Some of these patients have experienced too much difficulty with the loss of motion but they have experienced episodic severe pain at the time of making contact after throwing a cross or a hook punch. Sometimes they come see me because their jab has lost its snap. Another reason is because the bend in the elbow was becoming more apparent and lit was causing a loss of performance. Usually the stiff elbow is actually a painless issue.
The history of the problem is usually one which involves numerous small traumatic events or perhaps a single bad fall onto the mat or an arm bar type of injury (subluxation). Typically the fighter will have taken the usual precautions of resting, icing, anti-inflammatories and immobilization. As time went on the elbow became more and more stiff. Due to the strenuous training schedule the elbow eventually becomes injured again and again. The stiffness is something that develops over a few months or a couple of years. Just like cauliflower ears of fighters, these injuries occur over long stretches of time, are associated with heavy combat training sessions and typically worsen over time; They tend to get a bit worse with each new injury; hence the name “Cauliflower Elbow”.
When I examine these fighters they all have various levels of elbow joint tightness. Usually it’s a loss of extension and some loss of flexion. There might be some tenderness but usually not. The X-rays will show post traumatic degeneration in all compartments. What this means is that the joint shows visible wear. There will be spurs, loose bodies, and wearing down of the normal contours of the joint. Sometimes a loose body or impinging spur, aka osteophyte, will be seen either anteriorly or posteriorly next to the olecranon tip. An MRI or CT is usually not needed to make the diagnosis. Essentially the diagnosis is made with history, exam and a simple X-ray.
The treatment of a tight painful elbow depends on the issues causing the problem: Is it painless loss of motion or is there something causing pain? Sometimes the pain is just from capsule fibrosis (a tight capsule) or the pain can also be from a loose body, spur or inflammation from the wear. For example I have had a couple of patients with minimal stiffness but with a big loose body. These patients were treated with surgery to retrieve the loose fragment. However most of the patients I am describing as having “cauliflower elbow” have a significant loss of extension.
The treatment in most cases is started by reducing the inflammation of the capsule and the joint. This is done with one to two steroid injections into the joint, a short course of anti-inflammatories, and anti-inflammatory topical gel. I tend to be a bit holistic and also focus on anti-inflammatory diets and nutrition to keep the GI tract healthy. It seems like these latter two issues are somewhat far away from the stiff elbow however my goal is to decrease any and all sources of inflammation, chemical regulators and factors which may be playing a role in the capsular fibrosis.
I will refer patients for aggressive therapy, especially if they have less than 30 degrees of extension. This will also include therapy at home with a stretching type of brace called a JAS brace. They are instructed to stretch daily. As the tissue stretches the load required to maintain the stretched state reduces and the load is easier to handle and hence the load can be sequentially increased to generate greater effectiveness. Biological tissue is viscoelastic, i.e., It will increase in length (creep) with the application of constant load for a prolonged period of time. The longer one can maintain the painful stretch position the more effective the exercise. It’s not about the number of times you push the elbow it’s all about the duration of the push. It is a painful process however when progress is being made it can be seen within 4 weeks of diligent treatment.
If after approximately 2 months there is limited progress I will discuss a surgical option and a post operative program. The goal of the surgery is twofold: Clean up the joint and loosen the capsule. These goals can usually be achieved with elbow arthroscopy. This outpatient procedure is done while the patient is asleep and through 4-6 small stab incisions around the elbow joint. By using the slim arthroscopic camera I am able to directly see the inside of the joint and remove all impinging spurs and remove loose bodies. I call this part of the surgery housecleaning. This is a very important component because the spurs and loose fragments of bone or cartilage act as mechanical blocks to movement and they can also generate inflammation. In the cases of cauliflower elbows I have treated, I have not had to do complex procedures that we do for other arthritic elbows in non fighters such as radial head excision or replacement. The main problem of the cauliflower elbow is capsular stiffness rather than pain due to joint degeneration.
Once the arthroscopic housekeeping is done, I focus on the tight capsule. Most of the time I can do a capsular release with the same arthroscopic instruments through the same key-hole incisions made for the housekeeping portion of the procedure. Arthroscopic capsular release is a challenging procedure due to the close proximity of the nerves that cross the elbow. A few patients have required an “open release”. An open release is done in cases of severe loss of extension and those which did not improve with the arthroscopic release or those cases which have so much deformity that doing it through the tiny incisions is too risky. An open release requires a 3-4 inch incision on the outer side of the elbow.
If the fighter also complained of tingling and numbness of the small and ring finger I would plan on doing an ulnar nerve “transposition”. A 4 inch incision is made around the area of the “funny bone”. The nerve is taken out of the groove and placed a bit forward so that it stops getting stretched in the groove.
Joint stiffness occurs in phases. It starts with post op (or post injury) bleeding, swelling, granulation tissue formation and later fibrosis. Therefore, my goals after surgery is to control pain, limit swelling and bleeding. To help with recovery after the surgery, I will have the anesthesiologist do a nerve block so that pain can be diminished and movement can be started right away. When the arm is not being exercised it is kept in the sling only for the first week after surgery. A cold therapy unit is used to control swelling and decrease pain. I will make an extension splint which the patient will use at night to keep the arm straight while sleeping. Night time splinting continues for up to 3-6 months. No one likes sleeping with a hard splint. It is extremely frustrating but unfortunately important. I will also send all the fighters to an excellent therapist to work on the soft tissues and joint stretching. Once the range of motion is restored the therapist will focus on strength. Good nutrition after surgery is also imperative. The patient maintains an anti-inflammatory diet, takes multivitamins, vitamin C, and Zinc.
I have had success treating high level athletes involved in combat sports such as MMA and Jiu-Jitsu with stiff and painful elbows using the above program. If I have one recommendation to a fighter with a stiff elbow it is to see a sports medicine physician as soon as they can before it gets worse. The sooner that the elbow motion is restored the sooner the fighter will be effective again in the ring.
Steve A. Mora, M.D.
Orthopaedic Surgeon specializing in sports medicine, knee, elbow and shoulder.
I focus on injuries related to combat sports. For appointments please call 714 639-3750
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