Orthopedic surgeon and hand expert, Dr. Jeffrey E. Budoff, MD

Arthroscopic and open surgery of the hand, wrist, elbow and shoulder

Snapping Elbow (Plica)

One of the most common causes of a snapping elbow is a plica. A plica is an inflamed part of the joint lining that catches in between the bones of the elbow with motion. A plica can be caused by anything that inflames the elbow, typically either an injury or overuse.

Although symptoms may vary, the snapping usually occurs when the elbow is bent approximately 90 degrees, with the palm of the hand facing away from the body. The popping usually hurts on the outside of the elbow and may be associated with swelling. Other conditions that may cause elbow popping include loose bodies from arthritis, trauma, or osteochondritis dissecans.

The diagnosis of a plica is best made on physical examination. A steroid injection placed into the elbow serves two purposes: 1) diagnostic: if an injection inside the joint decreases elbow pain, then the problem is located inside the elbow, 2) therapeutic: the anti-inflammatory effects of the plica can reduce its size, decreasing symptoms.

While MRIs are very good at detecting arthritis, they miss plicas 25% of the time, and cannot be relied upon to diagnose a plica.

If the pain recurs following an injection, the plica can usually be very well treated with an arthroscopic excision. This is an outpatient procedure that is not very painful. In order to maximize treatment results and minimize complications, this procedure should be performed only by experienced elbow arthroscopists. Please note that just because a surgeon performs many arthroscopies of the knee and shoulder, that does not mean that they are skilled elbow arthroscopists. This is a separate skill set and involves an understanding of elbow arthroscopy’s more complex anatomy. The plica needs to be removed in both the front and the back of the elbow.

Figure 1. Plica in Front of Elbow Figure 2. Shaving Front of Plica Figure 3. Front of Plica Removed
 
Figure 4. Plica in Back of Elbow Figure 5. Shaving Back of Plica Figure 6. Back of Plica Removed

Figure 1 shows the plica and inflammation (which looks like seaweed) at the front of the elbow. This inflamed tissue became entrapped between the bones of the joint with motion, leading to painful snapping. Figure 2 shows the motorized shaver used to remove the plica and its associated inflammation. Figure 3 shows the front of the elbow joint with the plica and its associated inflammation removed. Figure 4 shows the plica in the back of the joint. The plica needs to be removed in both the front and the back of the elbow in order to eliminate the symptoms. Figure 5 shows the motorized shaver used to remove the plica from the back of the elbow. Figure 6 shows the back of the elbow joint with the plica removed.

After surgery, the elbow should be kept clean and dry for 3 days. After 3 days the dressing can be removed and the elbow can get wet in a shower. Elbow motion is begun to regain full motion. Band-aids are applied to the arthroscopy portals and submersion under water is avoided until the stitches are removed at the first post-operative appointment at 2 weeks.

In conclusion, painful elbow snapping and popping is often due to an inflamed plica. Fortunately, plicas can be easily treated by arthroscopic excision.