Chapter 23_ the Elbow

5/13/2014 Chapter 23: The Elbow

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Chapter 23: The Elbow

Anatomy of the Elbow

Functional Anatomy

Complex that allows for flexion, extension,pronation and supination

145 degrees of flexion and 90 degrees of supination andpronation

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Bony limitations, ligamentous support andmuscular stability at the elbow help to protectit from overuse and traumatic injuriesElbow demonstrates a carrying angle due todistal projection of humerus

Normal in females is 10-15 degrees, males 5 degrees

Critical link in kinetic chain of upperextremity

Assessment of the Elbow

HistoryPast history



Mechanism of injuryWhen and where does it hurt?Motions that increase or decrease painType of, quality of, duration of, pain?Sounds or feelings?How long were you disabled?Swelling?Previous treatments?

ObservationsDeformities and swelling?Carrying angle

Cubitus valgus versus cubitus varusFlexion and extension

Cubitus recurvatumElbow at 45 degrees

Isosceles triangle (olecranon and epicondyles)



Palpation: Bony and Soft Tissue

HumerusMedial and lateral epicondylesOlecranon processRadial headRadiusUlnaMedial and lateral collateral ligamentsAnnular ligament

Biceps brachiiBrachialisBrachioradialisPronator teres



TricepsSupinatorWrist flexors and extensors

Special TestsCirculatory and Neurological Function

Pulse should be taken at brachial artery and radial arterySkin sensation should be checked - determine presence ofnerve root compression or irritation in cervical or shoulderregionTinel’s sign

Ulnar nerve testTap on ulnar nerve (in ulnar groove)Positive test is found when athlete complains of sensationalong the forearm and hand

Test for Capsular InjuryTested after hyperextension of elbow



Elbow is flexed to 45 degrees, wrist is fully flexed andextendedIf joint pain is severe, moderate/severe sprain or fractureshould be suspected

Valgus/Varus Stress TestAssess injury to the medial and lateral collateral ligaments,respectivelyLooking for gapping or complaint of pain

Medial and Lateral Epicondylitis TestsElbow flexed to 45 degrees and wrist extension or flexion isresistedPain at lateral or medial epicondyle, respectively indicates apositive test

Pinch Grip Test



Pinch thumb and index finger togetherInability to touch fingers together indicates entrapment ofanterior interosseous nerve between heads of pronator muscle

Pronator Teres Syndrome TestForearm pronation is resistedIncreased pain proximally over pronator teres indicates apositive test

Functional Evaluation

Pain and weakness are evaluated through AROM, PROM andRROM

Flexion, extension, pronation and supinationROM of pronation and supination are particularly noted



Recognition and Management of Injuries to theElbow

Subject to injury due to broad range ofmotion, weak lateral bone structure, andrelative exposure to soft tissue damageMany sports place excessive stress on jointLocking motion of some activities, use ofimplements, and involvement in throwingmotion make elbow extremely susceptible

Contusion



EtiologyVulnerable area due to lack of paddingResult of direct blow or repetitive blows

Signs and SymptomsSwelling (rapidly after irritation of bursa or synovialmembrane)

ManagementTreat w/ RICE immediately for at least 24 hoursIf severe, refer for X-ray to determine presence of fracture

Olecranon BursitisEtiology

Superficial location makes it extremely susceptible to injury(acute or chronic) --direct blow

Signs and SymptomsPain, swelling, and point tendernessSwelling will appear almost spontaneously and w/out usual



pain and heatManagement

In acute conditions, compression for at least 1 hourChronic cases require superficial therapy primarily involvingcompressionIf swelling fails to resolve, aspiration may be necessaryCan be padded in order to return to competition

StrainsEtiology

MOI is excessive resistive motion (falling on outstretchedarm), repeated microtears that cause chronic injuryRupture of distal biceps is most common muscle rupture of theupper extremity

Signs and SymptomsActive or resistive motion produces pain; point tenderness inmuscle, tendon, or lower part of muscle belly



ManagementRICE and sling in severe casesFollow-up w/ cryotherapy, ultrasound and exerciseIf severe loss of function encountered - should be referred forX-ray (rule out avulsion or epiphyseal fx

Ulnar Collateral Ligament InjuriesEtiology

Injured as the result of a valgus force from repetitive traumaCan also result in ulnar nerve inflammation, or wrist flexortendinitis; overuse flexor/pronator strain, ligamentous sprains;elbow flexion contractures or increased instability

Signs and SymptomsPain along medial aspect of elbow; tenderness over MCLAssociated paresthesia, positive Tinel’s signPain w/ valgus stress test at 20 degrees; possible end-pointlaxity



X-ray may show hypertrophy of humeral condyle,posteromedial aspect of olecranon, marginal osteophytes;calcification w/in MCL; loose bodies in posteriorcompartment

Ulnar Collateral Ligament Injuries (cont.)Management

Conservative treatment begins w/ RICE and NSAID’sW/ resolution, strengthening should be performed; analysis ofthe throwing motion (if applicable)Surgical intervention may be necessary (Tommy Johnprocedure)

Throwing athlete can return to activity 22-26 weeks postsurgery



Lateral Epicondylitis (Tennis Elbow)Etiology

Repetitive microtrauma to insertion of extensor muscles oflateral epicondyle

Signs and SymptomsAching pain in region of lateral epicondyle after activityPain worsens and weakness in wrist and hand developElbow has decreased ROM; pain w/ resistive wrist extension

Lateral Epicondylitis (continued)Management

RICE, NSAID’s and analgesicsROM exercises and PRE, deep friction massage, handgrasping while in supination, avoidance of pronation motionsMobilization and stretching in pain free rangesUse of a counter force or neoprene sleeve



Mechanics training

Medial EpicondylitisEtiology

Repeated forceful flexion of wrist and extreme valgus torqueof elbow

Signs and SymptomsPain produced w/ forceful flexion or extensionPoint tenderness and mild swellingPassive movement of wrist seldom elicits pain, but activemovement does

ManagementSling, rest, cryotherapy or heat through ultrasoundAnalgesic and NSAID'sCurvilinear brace below elbow to reduce elbow stressingSevere cases may require splinting and complete rest for 7-10days



Elbow Osteochondritis DissecansEtiology

Impairment of blood supply to anterior surface resulting indegeneration of articular cartilage, creating loose bodiesRepetitive microtrauma in movements of elbow rotation,extension, valgus stress causing compression of the radial headad shearing of the radiocapitular jointSeen in young athletes involved in throwing motionPanner’s disease in incidents of children age <10

Signs and SymptomsSudden pain, locking; range usually returns in a few days

Signs and Symptoms (continued)Swelling, pain at radiohumeral joint, creptitus, decreasedROM (full extension); grating w/ pronation and supination



X-ray may show flattening and crater of capitulum w/ loosebodies

ManagementActivity restriction for 6-12 weeks; NSAID’sSplint and cast applied for cases of extensive deteriorationIf repeated locking occurs, loose bodies are removedsurgically

Little League ElbowEtiology

Caused by repetitive microtraumas that occur from throwing(not type of pitch)May result in numerous disorders of growth in the pitchingelbow

Signs and Symptoms Onset is slow; slight flexion contracture, including tightanterior joint capsule and weakness in triceps



Athlete may complain of locking or catching sensationDecreased ROM or forearm pronation and supination

Little League Elbow (continued)Management

RICE, NSAID’s and analgesicsThrowing stops until pain resolved and full ROM is regainedGentle stretching and triceps strengtheningThrowing under supervision w/ good technique to preventrecurrence

Cubital Tunnel SyndromeEtiology

Pronounced cubital valgus may cause deep friction problemUlnar nerve dislocation



Traction injury from valgus force, irregularities w/ tunnel,subluxation of ulnar nerve due to lax impingement, orprogressive compression of ligament on the nerve

Signs and SymptomsPain medially which may be referred proximally or distallyTenderness in cubital tunnel on palpation and hyperflexionIntermittent paresthesia in 4th and 5th fingers

Cubital Tunnel Syndrome (continued)Management

Rest, immobilization for 2 weeks w/ NSAID’sSplinting or surgical decompression or transposition ofsubluxating nerve may be necessaryAthlete must avoid hyperflexion and valgus stresses



Dislocation of the ElbowEtiology

High incidence in sports caused by fall on outstretched handw/ elbow extended or severe twist while flexedBones can be displaced backward, forward, or laterallyDistinguishable from fracture because lateral and medialepicondyles are normally aligned w/ shaft of humerus

Signs and SymptomsSwelling, severe pain, disabilityComplications w/ median and radial nerves and blood vesselsOften a radial head fracture is involved

ManagementCold and pressure immediately w/ slingRefer for reductionNeurological and vascular fxn must be assessed prior to andfollowing reduction



Physician should reduce - immediatelyImmobilization following reduction in flexion for 3 weeksHand grip and shoulder exercises should be used whileimmobilizedFollowing initial healing, heat and passive exercise can beused to regain full ROMMassage and joint movement that are too strenuous should beavoided before complete healing due to high probability ofmyositis ossificansROM and strengthening should be performed and initiated byathlete (forced stretching should be avoided

Elbow Dislocation

Fractures of the Elbow



EtiologyFall on flexed elbow or from a direct blowFracture can occur in any one or more of the bonesFall on outstretched hand often fractures humerus abovecondyles or between condyles

Condylar fracture may result in gunstock deformityDirect blow to ulna or radius may cause radial head fractureas well

Signs and SymptomsMay not result in visual deformityHemorrhaging, swelling, muscle spasm

Elbow Fractures (continued)Management

Decrease ROM, neurovascular status must be monitoredSurgery is used to stabilize adult unstable fracture, followedby early ROM exercises



Stable fractures do not require surgeryRemovable splints are used for 6-8 weeks

Volkmann’s ContractureEtiology

Associate w/ humeral supracondylar fractures, causing musclespasm, swelling, or bone pressure on brachial artery,inhibiting circulation to forearmCan become permanent

Signs and SymptomsPain in forearm - increased w/ passive extension of fingersPain is followed by cessation of brachial and radial pulses,coldness in armDecreased motion

ManagementRemove elastic wraps or castsClose monitoring must occur



Rehabilitation of the Elbow

General Body ConditioningMust maintain pre-injury fitness levels - cardiovascular andstrength (lower body)

FlexibilityRestoring ROM is critical in elbow rehabVariety of approaches can be used as long as they don’t force thejoint

Joint MobilizationsLoss of proper arthrokinematics following immobilization isexpectedJoint mobilization and traction can be very useful to increasemobility and decrease pain through restoration of accessorymotions



StrengtheningAchieved through low-resistance, high-repetition exercises - mustbe pain freeShoulder and grip exercises should also be performedContinuous passive motion units followed by dynamic splinting isideal following surgeryIsometrics can be used while elbow is immobilizedPNF and isokinetics are useful in early and intermediate activestages of rehabA graded PRE program w/ tubing, weights or manual resistanceshould be includedClosed kinetic chain activities should also be incorporated -assist in both static and dynamic stability to the elbowProprioceptive training should also incorporated



Functional ProgressionsWill enhance healing and performance

PNF, swimming, pulley machines and rubber tubingto simulate sports activities

Should include stepsWarm-upGradual build up to activity, becoming increasingly moredifficult

Return to ActivityCan re-engage in activity when criteria has successfully beencompletedROM w/in normal limits, strength should be equal w/ nocomplaint of painReturn should progress with use of restrictions in an effort toobjectively measure activity progression



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Protective Taping and BracingShould be continued until full strength and flexibility have beenrestoredChronic conditions usually cause gradual debilitation ofsurrounding soft tissue

Must restore maximum state of conditioning w/outencouraging post-injury aggravation

Chapter 23_ the Elbow

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