Chapter 15Chapter 15

The Elbow ComplexThe Elbow Complex

OverviewOverview

The elbow complex is an inherently The elbow complex is an inherently strong and stable compound joint, which strong and stable compound joint, which is enclosed within the capsule of the is enclosed within the capsule of the cubital articulation. The stability of the cubital articulation. The stability of the elbow complex, gives it very little in the elbow complex, gives it very little in the way of compensatory adjustments, way of compensatory adjustments, making it prone to overuse injuriesmaking it prone to overuse injuries

The primary function of the elbow The primary function of the elbow complex is to work together with the complex is to work together with the shoulder to position the hand for shoulder to position the hand for functional activitiesfunctional activities

AnatomyAnatomy

The elbow complex is comprised The elbow complex is comprised of three distinct articulations:of three distinct articulations:– The humeroulnar jointThe humeroulnar joint– The humeroradial jointThe humeroradial joint– The proximal radioulnar joint The proximal radioulnar joint

Humeroulnar JointHumeroulnar Joint

A uniaxial hinge jointA uniaxial hinge joint formed formed between between the trochlear notchthe trochlear notch of of the the proximal ulna and the spool-proximal ulna and the spool-shaped trochlea of the humerusshaped trochlea of the humerus

The angulation of this joint forms The angulation of this joint forms the “carrying angle”the “carrying angle”

The carrying angle is The carrying angle is approximately 11-14° in males approximately 11-14° in males and 13-16° in females and 13-16° in females

Humeroradial Joint Humeroradial Joint

A uniaxial hinge joint formed A uniaxial hinge joint formed between the spherical capitellum between the spherical capitellum of the humerus, and the concave of the humerus, and the concave head of the radiushead of the radius

The design of this joint allows the The design of this joint allows the elbow to flex and extend, and for elbow to flex and extend, and for the radius to rotatethe radius to rotate

Proximal Radioulnar Proximal Radioulnar JointJoint The proximal (superior) radioulnar joint The proximal (superior) radioulnar joint

is a uniaxial pivot joint formed is a uniaxial pivot joint formed between the periphery of the convex between the periphery of the convex radial head, and the fibrous osseous radial head, and the fibrous osseous ring formed by the concave radial ring formed by the concave radial notch of the ulnanotch of the ulna

The annular ligament forms 80% of the The annular ligament forms 80% of the articular surface of the proximal articular surface of the proximal radioulnar jointradioulnar joint

Joint CapsuleJoint Capsule

The joint capsule of the elbow The joint capsule of the elbow complex is thin but strongcomplex is thin but strong

The capsule of the joint does not The capsule of the joint does not respond well to injury or respond well to injury or prolonged immobilization, and prolonged immobilization, and often forms thick scar tissue, often forms thick scar tissue, which may result in flexion which may result in flexion contractures of the elbowcontractures of the elbow

Medial (Ulnar) Medial (Ulnar) Collateral LigamentCollateral Ligament The fan-shaped MCL is functionally the The fan-shaped MCL is functionally the

most important ligament in the elbow most important ligament in the elbow for providing stability against valgus for providing stability against valgus stress, particularly in the range of 20-stress, particularly in the range of 20-130° of flexion and extension130° of flexion and extension

There are three distinct components of There are three distinct components of the MCLthe MCL::– Anterior bundleAnterior bundle– Transverse bundleTransverse bundle– Posterior bundlePosterior bundle

Medial (Ulnar) Medial (Ulnar) Collateral LigamentCollateral Ligament Anterior bundleAnterior bundle

– Anterior bandAnterior band The strongest and stiffest of the elbow The strongest and stiffest of the elbow

collateral ligamentscollateral ligaments Primarily stabilizes the elbow against Primarily stabilizes the elbow against

valgus stress in the ranges of 20-120° valgus stress in the ranges of 20-120° of flexion, and becomes a secondary of flexion, and becomes a secondary restraint with further flexionrestraint with further flexion

Medial (Ulnar) Medial (Ulnar) Collateral LigamentCollateral Ligament Anterior bundleAnterior bundle

– The posterior bandThe posterior band Taut beyond 55° of elbow flexionTaut beyond 55° of elbow flexion A secondary restraint to valgus stress at A secondary restraint to valgus stress at

lesser degrees of flexionlesser degrees of flexion An equal co-restraint with the anterior An equal co-restraint with the anterior

band at terminal elbow flexionband at terminal elbow flexion A primary restraint to passive elbow A primary restraint to passive elbow

extension extension

Medial (Ulnar) Medial (Ulnar) Collateral LigamentCollateral Ligament The transverse bundleThe transverse bundle

– Also known as Also known as Cooper’sCooper’s ligament ligament– Fibers both originate and insert on Fibers both originate and insert on

the ulnathe ulna and therefore and therefore have little have little role in elbow stabilityrole in elbow stability

Medial (Ulnar) Medial (Ulnar) Collateral LigamentCollateral Ligament Posterior bundlePosterior bundle

– Appears to be a thickening of the Appears to be a thickening of the posterior elbow capsuleposterior elbow capsule

– Provides only secondary restraint to Provides only secondary restraint to valgus stress at flexion beyond 90°. valgus stress at flexion beyond 90°.

Lateral (Radial) Lateral (Radial) Collateral LigamentCollateral Ligament Consists of:Consists of:

– The annular ligamentThe annular ligament– The fan-like radial collateral ligament The fan-like radial collateral ligament – The accessory collateral ligamentThe accessory collateral ligament– The lateral ulnar collateral ligamentThe lateral ulnar collateral ligament

The LCL functions to maintain the The LCL functions to maintain the ulnohumeral and radiohumeral joints ulnohumeral and radiohumeral joints in a reduced position when the elbow in a reduced position when the elbow is loaded in supinationis loaded in supination

Annular LigamentAnnular Ligament

The annular ligament functions to The annular ligament functions to maintain the relationship between maintain the relationship between the head of the radius and the the head of the radius and the humerus and ulnahumerus and ulna

BursaeBursae

The olecranon bursa is the main bursa The olecranon bursa is the main bursa of the elbow complex and lies of the elbow complex and lies posteriorly between the skin and the posteriorly between the skin and the olecranon processolecranon process

Under normal conditions the bursa Under normal conditions the bursa does not communicate with the elbow does not communicate with the elbow joint, although its superficial location joint, although its superficial location puts it at high risk for injury from puts it at high risk for injury from direct trauma to the elbowdirect trauma to the elbow

Elbow FlexorsElbow Flexors

The prime movers of elbow flexion The prime movers of elbow flexion are the biceps, brachialis, and are the biceps, brachialis, and brachioradialisbrachioradialis

The pronator teres, flexor carpi The pronator teres, flexor carpi radialis (FCR), and flexor carpi radialis (FCR), and flexor carpi ulnaris (FCU), and the extensor carpi ulnaris (FCU), and the extensor carpi radialis longus (ECRL) muscles are radialis longus (ECRL) muscles are considered as weak flexors of the considered as weak flexors of the elbowelbow

Elbow ExtensorsElbow Extensors

There are two muscles that There are two muscles that extend the elbow: the triceps and extend the elbow: the triceps and the anconeus the anconeus

Forearm PronatorsForearm Pronators

Pronator teresPronator teres Pronator quadratusPronator quadratus Flexor carpi radialisFlexor carpi radialis

Forearm SupinatorsForearm Supinators

BicepsBiceps SupinatorSupinator

Cubital tunnelCubital tunnel

A fibro-osseous canal that contains the ulnar A fibro-osseous canal that contains the ulnar nervenerve– The floor of the tunnel is formed by the MCLThe floor of the tunnel is formed by the MCL– The roof is formed by an aponeurosis, the The roof is formed by an aponeurosis, the

arcuate ligamentarcuate ligament– The medial head of the triceps constitutes the The medial head of the triceps constitutes the

posterior border of the tunnelposterior border of the tunnel– The anterior and lateral borders are formed by The anterior and lateral borders are formed by

the medial epicondyle and olecranon, the medial epicondyle and olecranon, respectivelyrespectively

The volume of the cubital tunnel is greatest The volume of the cubital tunnel is greatest with the elbow held in extensionwith the elbow held in extension

Cubital FossaCubital Fossa

The cubital fossa represents the The cubital fossa represents the triangular space, or depression, triangular space, or depression, which is located over the anterior which is located over the anterior surface of the elbow joint, and surface of the elbow joint, and which serves as an ‘entrance’ to which serves as an ‘entrance’ to the forearm, or antebrachiumthe forearm, or antebrachium

Cubital FossaCubital Fossa

The contents of the fossa include:The contents of the fossa include:– The tendon of the biceps brachii lies The tendon of the biceps brachii lies

as the central structure in the fossaas the central structure in the fossa– The median nerveThe median nerve– The brachial arteryThe brachial artery– The radial nerveThe radial nerve– The median cubital or intermediate The median cubital or intermediate

cubital cutaneous vein cubital cutaneous vein

NervesNerves

UlnarUlnar RadialRadial MedianMedian

The Arcade of Fröhse The Arcade of Fröhse

The arcade of Fröhse is an inverted The arcade of Fröhse is an inverted arched structure that lies within 1 arched structure that lies within 1 cm distal of the fibrous edge of the cm distal of the fibrous edge of the ECRB and approximately 2 to 4 cm ECRB and approximately 2 to 4 cm distal to the radiohumeral jointdistal to the radiohumeral joint

It represents the proximal border of It represents the proximal border of the superficial head of the supinator, the superficial head of the supinator, through which the radial nerve through which the radial nerve passespasses

The Radial The Radial Tunnel/Supinator Tunnel/Supinator CanalCanal The radial tunnel lies on the The radial tunnel lies on the

anterior aspect of the radius, and is anterior aspect of the radius, and is approximately three to four finger approximately three to four finger breadths long, beginning just breadths long, beginning just proximal to the radiohumeral joint, proximal to the radiohumeral joint, and ending at the site where the and ending at the site where the nerve passes deep to the nerve passes deep to the superficial part of the supinator superficial part of the supinator musclemuscle

BiomechanicsBiomechanics

Biomechanically, the elbow Biomechanically, the elbow predominantly functions as an predominantly functions as an important link in the upper important link in the upper extremity kinetic chain, allowing extremity kinetic chain, allowing the generation and transfer of the generation and transfer of forces which occur in the upper forces which occur in the upper extremity. extremity.

Humeroulnar JointHumeroulnar Joint

The resting, or open pack, position The resting, or open pack, position for the humeroulnar joint is 70for the humeroulnar joint is 70 of of flexion with 10° of forearm flexion with 10° of forearm supinationsupination

The closed pack position is full The closed pack position is full extension and maximum forearm extension and maximum forearm supinationsupination

The capsular pattern is much more The capsular pattern is much more limitation in flexion than extensionlimitation in flexion than extension

Humeroradial JointHumeroradial Joint

The resting, or open pack, position of the The resting, or open pack, position of the humeroradial joint is extension and humeroradial joint is extension and forearm supinationforearm supination

The closed pack position is approximately The closed pack position is approximately 90° of elbow flexion and 5° of supination90° of elbow flexion and 5° of supination

There is no true capsular pattern at this There is no true capsular pattern at this joint, although clinically an equal joint, although clinically an equal limitation of pronation and supination is limitation of pronation and supination is observedobserved

Proximal Radioulnar Proximal Radioulnar JointJoint The resting, or open pack, position The resting, or open pack, position

for the proximal radioulnar joint is for the proximal radioulnar joint is 7070 flexion and 35 flexion and 35 of forearm of forearm supinationsupination

The closed pack position is 5The closed pack position is 5 of of forearm supinationforearm supination

The capsular pattern is minimal to The capsular pattern is minimal to loss of motion, with pain at the end loss of motion, with pain at the end ranges of pronation and supinationranges of pronation and supination

Force Couples of the Force Couples of the ElbowElbow The triceps/biceps during arm The triceps/biceps during arm

extension and flexionextension and flexion Flexor carpi radialis (FCR), flexor carpi Flexor carpi radialis (FCR), flexor carpi

ulnaris (FCU), flexor digitorum ulnaris (FCU), flexor digitorum communis (FDC)/Extensor carpi communis (FDC)/Extensor carpi radialis longus (ECRL), extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor radialis brevis (ECRB), extensor communis (EC) during wrist flexion communis (EC) during wrist flexion and extensionand extension

Force Couples of the Force Couples of the ElbowElbow Pronator teres, pronator Pronator teres, pronator

quadratus/supinator during quadratus/supinator during forearm pronation and supinationforearm pronation and supination

Triceps/biceps, brachioradialis; Triceps/biceps, brachioradialis; pronator teres/supinator; FCR, pronator teres/supinator; FCR, FCU/ECRB, ECRL during activities FCU/ECRB, ECRL during activities requiring elbow stabilizationrequiring elbow stabilization

ExaminationExamination

HistoryHistory– During the history, the clinician must During the history, the clinician must

determine the chief complaint and determine the chief complaint and whether there is a specific whether there is a specific mechanism of injurymechanism of injury Where is the pain?Where is the pain? Was there any antecedent trauma or Was there any antecedent trauma or

overuse?overuse? Is there any paresthesia?Is there any paresthesia? What makes the symptoms better/worseWhat makes the symptoms better/worse

ExaminationExamination

Systems ReviewSystems Review– The clinician should be able to determine The clinician should be able to determine

the suitability of the patient for physical the suitability of the patient for physical therapytherapy

– If the clinician is concerned with any signs If the clinician is concerned with any signs or symptoms of a visceral, vascular, or symptoms of a visceral, vascular, neurogenic, psychogenic, spondylogenic or neurogenic, psychogenic, spondylogenic or systemic disorder that is out of the scope of systemic disorder that is out of the scope of physical therapy, the patient should be physical therapy, the patient should be referred to an appropriate healthcare referred to an appropriate healthcare providerprovider

ExaminationExamination

ObservationObservation– The affected elbow should be The affected elbow should be

inspected for scars, deformities, and inspected for scars, deformities, and swellingswelling

– The clinician should observe the The clinician should observe the ‘carrying angle’ of the elbow and ‘carrying angle’ of the elbow and compare it to the other sidecompare it to the other side

ExaminationExamination

PalpationPalpation– Because they are superficial, most of Because they are superficial, most of

the elbow structures are easily the elbow structures are easily palpable, making it easier for the palpable, making it easier for the clinician to pinpoint the specific area clinician to pinpoint the specific area of painof pain

ExaminationExamination

Active range of motion with passive Active range of motion with passive overpressureoverpressure– It is important to determine how much range It is important to determine how much range

of motion (ROM) is necessary for the patient of motion (ROM) is necessary for the patient to perform his or her job and recreational to perform his or her job and recreational activitiesactivities

– The patient is asked to perform active The patient is asked to perform active flexion, extension of the elbow, pronation flexion, extension of the elbow, pronation and supination of the forearm, and wrist and supination of the forearm, and wrist flexion and extension. The ranges are flexion and extension. The ranges are recorded recorded

ExaminationExamination

Resistive testingResistive testing– In addition to all of the shoulder In addition to all of the shoulder

muscles that insert at or near the muscles that insert at or near the elbow (biceps, brachialis, triceps), elbow (biceps, brachialis, triceps), the clinician must also test the the clinician must also test the muscles responsible for elbow muscles responsible for elbow flexion, and extension, forearm flexion, and extension, forearm supination, pronation, and wrist supination, pronation, and wrist flexion and extensionflexion and extension

ExaminationExamination

Functional assessmentFunctional assessment– A number of tests have been A number of tests have been

designed to assess elbow functiondesigned to assess elbow function

ExaminationExamination

Passive articular motion testingPassive articular motion testing– The ulnohumeral jointThe ulnohumeral joint– The radiohumeral jointThe radiohumeral joint– The proximal radioulnar jointThe proximal radioulnar joint– The distal radioulnar joint The distal radioulnar joint

ExaminationExamination

Stress testsStress tests– Medial (ulnar) collateral ligament Medial (ulnar) collateral ligament

(valgus test)(valgus test)– Lateral (radial) collateral ligament Lateral (radial) collateral ligament

(varus test)(varus test)

ExaminationExamination

Special testsSpecial tests– Tennis elbow testsTennis elbow tests

Cozen’s testCozen’s test Mill’s testMill’s test

– Golfer’s Elbow testGolfer’s Elbow test– Cubital tunnel syndrome testsCubital tunnel syndrome tests

Elbow flexionElbow flexion Pressure provocative testPressure provocative test

– Tinel’s Sign (at the elbow) Tinel’s Sign (at the elbow)

Intervention Intervention StrategiesStrategies

Acute PhaseAcute Phase– Protection of the injury siteProtection of the injury site– Restoration of pain-free range of motion in the Restoration of pain-free range of motion in the

entire kinetic chainentire kinetic chain– Improve patient comfort by decreasing pain and Improve patient comfort by decreasing pain and

inflammationinflammation– Retard muscle atrophyRetard muscle atrophy– Minimize detrimental effects of immobilization Minimize detrimental effects of immobilization

and activity restrictionand activity restriction– Maintain general fitnessMaintain general fitness– Patient to be independent with home exercise Patient to be independent with home exercise

programprogram

Intervention Intervention StrategiesStrategies Functional PhaseFunctional Phase

– Attain full range of pain free motionAttain full range of pain free motion– Restore normal joint kinematicsRestore normal joint kinematics– Improve muscle strength to within Improve muscle strength to within

normal limitsnormal limits– Improve neuromuscular controlImprove neuromuscular control– Restore normal muscle force couplesRestore normal muscle force couples