Chapter 23: The Elbow

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Chapter 23 The Elbow
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Anatomy of the Elbow
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Functional Anatomy

• Complex that allows for flexion, extension,
  pronation and supination
• 145 degrees of flexion and 90 degrees of
  supination and pronation
• Bony limitations, ligamentous support and
  muscular stability at the elbow help to protect
  it from overuse and traumatic injuries
• Elbow demonstrates a carrying angle due to distal
  projection of humerus
• Normal in females is 10-15 degrees, males 5
  degrees
• Critical link in kinetic chain of upper extremity

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Assessment of the Elbow

• History
• Past history
• Mechanism of injury
• When and where does it hurt?
• Motions that increase or decrease pain
• Type of, quality of, duration of, pain?
• Sounds or feelings?
• How long were you disabled?
• Swelling?
• Previous treatments?

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• Observations
• Deformities and swelling?
• Carrying angle
• Cubitus valgus versus cubitus varus
• Flexion and extension
• Cubitus recurvatum
• Elbow at 45 degrees
• Isosceles triangle (olecranon and epicondyles)

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Palpation Bony and Soft Tissue

• Humerus
• Medial and lateral epicondyles
• Olecranon process
• Radial head
• Radius
• Ulna
• Medial and lateral collateral ligaments
• Annular ligament

• Biceps brachii
• Brachialis
• Brachioradialis
• Pronator teres
• Triceps
• Supinator
• Wrist flexors and extensors

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• Special Tests
• Circulatory and Neurological Function
• Pulse should be taken at brachial artery and
  radial artery
• Skin sensation should be checked - determine
  presence of nerve root compression or irritation
  in cervical or shoulder region
• Tinels sign
• Ulnar nerve test
• Tap on ulnar nerve (in ulnar groove)
• Positive test is found when athlete complains of
  sensation along the forearm and hand
• Test for Capsular Injury
• Tested after hyperextension of elbow
• Elbow is flexed to 45 degrees, wrist is fully
  flexed and extended
• If joint pain is severe, moderate/severe sprain
  or fracture should be suspected

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• Valgus/Varus Stress Test
• Assess injury to the medial and lateral
  collateral ligaments, respectively
• Looking for gapping or complaint of pain

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• Medial and Lateral Epicondylitis Tests
• Elbow flexed to 45 degrees and wrist extension or
  flexion is resisted
• Pain at lateral or medial epicondyle,
  respectively indicates a positive test
• Pinch Grip Test
• Pinch thumb and index finger together
• Inability to touch fingers together indicates
  entrapment of anterior interosseous nerve between
  heads of pronator muscle
• Pronator Teres Syndrome Test
• Forearm pronation is resisted
• Increased pain proximally over pronator teres
  indicates a positive test

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Functional Evaluation

• Pain and weakness are evaluated through AROM,
  PROM and RROM
• Flexion, extension, pronation and supination
• ROM of pronation and supination are particularly
  noted

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Recognition and Management of Injuries to the
Elbow

• Subject to injury due to broad range of motion,
  weak lateral bone structure, and relative
  exposure to soft tissue damage
• Many sports place excessive stress on joint
• Locking motion of some activities, use of
  implements, and involvement in throwing motion
  make elbow extremely susceptible

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• Contusion
• Etiology
• Vulnerable area due to lack of padding
• Result of direct blow or repetitive blows
• Signs and Symptoms
• Swelling (rapidly after irritation of bursa or
  synovial membrane)
• Management
• Treat w/ RICE immediately for at least 24 hours
• If severe, refer for X-ray to determine presence
  of fracture

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• Olecranon Bursitis
• Etiology
• Superficial location makes it extremely
  susceptible to injury (acute or chronic) --direct
  blow
• Signs and Symptoms
• Pain, swelling, and point tenderness
• Swelling will appear almost spontaneously and
  w/out usual pain and heat
• Management
• In acute conditions, compression for at least 1
  hour
• Chronic cases require superficial therapy
  primarily involving compression
• If swelling fails to resolve, aspiration may be
  necessary
• Can be padded in order to return to competition

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• Strains
• Etiology
• MOI is excessive resistive motion (falling on
  outstretched arm), repeated microtears that cause
  chronic injury
• Rupture of distal biceps is most common muscle
  rupture of the upper extremity
• Signs and Symptoms
• Active or resistive motion produces pain point
  tenderness in muscle, tendon, or lower part of
  muscle belly
• Management
• RICE and sling in severe cases
• Follow-up w/ cryotherapy, ultrasound and exercise
• If severe loss of function encountered - should
  be referred for X-ray (rule out avulsion or
  epiphyseal fx

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• Ulnar Collateral Ligament Injuries
• Etiology
• Injured as the result of a valgus force from
  repetitive trauma
• Can also result in ulnar nerve inflammation, or
  wrist flexor tendinitis overuse flexor/pronator
  strain, ligamentous sprains elbow flexion
  contractures or increased instability
• Signs and Symptoms
• Pain along medial aspect of elbow tenderness
  over MCL
• Associated paresthesia, positive Tinels sign
• Pain w/ valgus stress test at 20 degrees
  possible end-point laxity
• X-ray may show hypertrophy of humeral condyle,
  posteromedial aspect of olecranon, marginal
  osteophytes calcification w/in MCL loose bodies
  in posterior compartment

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• Ulnar Collateral Ligament Injuries (cont.)
• Management
• Conservative treatment begins w/ RICE and NSAIDs
• W/ resolution, strengthening should be performed
  analysis of the throwing motion (if applicable)
• Surgical intervention may be necessary (Tommy
  John procedure)
• Throwing athlete can return to activity 22-26
  weeks post surgery

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• Lateral Epicondylitis (Tennis Elbow)
• Etiology
• Repetitive microtrauma to insertion of extensor
  muscles of lateral epicondyle
• Signs and Symptoms
• Aching pain in region of lateral epicondyle after
  activity
• Pain worsens and weakness in wrist and hand
  develop
• Elbow has decreased ROM pain w/ resistive wrist
  extension

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• Lateral Epicondylitis (continued)
• Management
• RICE, NSAIDs and analgesics
• ROM exercises and PRE, deep friction massage,
  hand grasping while in supination, avoidance of
  pronation motions
• Mobilization and stretching in pain free ranges
• Use of a counter force or neoprene sleeve
• Mechanics training

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• Medial Epicondylitis
• Etiology
• Repeated forceful flexion of wrist and extreme
  valgus torque of elbow
• Signs and Symptoms
• Pain produced w/ forceful flexion or extension
• Point tenderness and mild swelling
• Passive movement of wrist seldom elicits pain,
  but active movement does
• Management
• Sling, rest, cryotherapy or heat through
  ultrasound
• Analgesic and NSAID's
• Curvilinear brace below elbow to reduce elbow
  stressing
• Severe cases may require splinting and complete
  rest for 7-10 days

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• Elbow Osteochondritis Dissecans
• Etiology
• Impairment of blood supply to anterior surface
  resulting in degeneration of articular cartilage,
  creating loose bodies
• Repetitive microtrauma in movements of elbow
  rotation, extension, valgus stress causing
  compression of the radial head ad shearing of the
  radiocapitular joint
• Seen in young athletes involved in throwing
  motion
• Panners disease in incidents of children age lt10
• Signs and Symptoms
• Sudden pain, locking range usually returns in a
  few days

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• Signs and Symptoms (continued)
• Swelling, pain at radiohumeral joint, creptitus,
  decreased ROM (full extension) grating w/
  pronation and supination
• X-ray may show flattening and crater of capitulum
  w/ loose bodies
• Management
• Activity restriction for 6-12 weeks NSAIDs
• Splint and cast applied for cases of extensive
  deterioration
• If repeated locking occurs, loose bodies are
  removed surgically

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• Little League Elbow
• Etiology
• Caused by repetitive microtraumas that occur from
  throwing (not type of pitch)
• May result in numerous disorders of growth in the
  pitching elbow
• Signs and Symptoms
• Onset is slow slight flexion contracture,
  including tight anterior joint capsule and
  weakness in triceps
• Athlete may complain of locking or catching
  sensation
• Decreased ROM or forearm pronation and supination

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• Little League Elbow (continued)
• Management
• RICE, NSAIDs and analgesics
• Throwing stops until pain resolved and full ROM
  is regained
• Gentle stretching and triceps strengthening
• Throwing under supervision w/ good technique to
  prevent recurrence

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• Cubital Tunnel Syndrome
• Etiology
• Pronounced cubital valgus may cause deep friction
  problem
• Ulnar nerve dislocation
• Traction injury from valgus force, irregularities
  w/ tunnel, subluxation of ulnar nerve due to lax
  impingement, or progressive compression of
  ligament on the nerve
• Signs and Symptoms
• Pain medially which may be referred proximally or
  distally
• Tenderness in cubital tunnel on palpation and
  hyperflexion
• Intermittent paresthesia in 4th and 5th fingers

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• Cubital Tunnel Syndrome (continued)
• Management
• Rest, immobilization for 2 weeks w/ NSAIDs
• Splinting or surgical decompression or
  transposition of subluxating nerve may be
  necessary
• Athlete must avoid hyperflexion and valgus
  stresses

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• Dislocation of the Elbow
• Etiology
• High incidence in sports caused by fall on
  outstretched hand w/ elbow extended or severe
  twist while flexed
• Bones can be displaced backward, forward, or
  laterally
• Distinguishable from fracture because lateral and
  medial epicondyles are normally aligned w/ shaft
  of humerus
• Signs and Symptoms
• Swelling, severe pain, disability
• Complications w/ median and radial nerves and
  blood vessels
• Often a radial head fracture is involved

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• Management
• Cold and pressure immediately w/ sling
• Refer for reduction
• Neurological and vascular fxn must be assessed
  prior to and following reduction
• Physician should reduce - immediately
• Immobilization following reduction in flexion for
  3 weeks
• Hand grip and shoulder exercises should be used
  while immobilized
• Following initial healing, heat and passive
  exercise can be used to regain full ROM
• Massage and joint movement that are too strenuous
  should be avoided before complete healing due to
  high probability of myositis ossificans
• ROM and strengthening should be performed and
  initiated by athlete (forced stretching should be
  avoided

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Elbow Dislocation
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• Fractures of the Elbow
• Etiology
• Fall on flexed elbow or from a direct blow
• Fracture can occur in any one or more of the
  bones
• Fall on outstretched hand often fractures humerus
  above condyles or between condyles
• Condylar fracture may result in gunstock
  deformity
• Direct blow to ulna or radius may cause radial
  head fracture as well
• Signs and Symptoms
• May not result in visual deformity
• Hemorrhaging, swelling, muscle spasm

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• Elbow Fractures (continued)
• Management
• Decrease ROM, neurovascular status must be
  monitored
• Surgery is used to stabilize adult unstable
  fracture, followed by early ROM exercises
• Stable fractures do not require surgery
• Removable splints are used for 6-8 weeks

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• Volkmanns Contracture
• Etiology
• Associate w/ humeral supracondylar fractures,
  causing muscle spasm, swelling, or bone pressure
  on brachial artery, inhibiting circulation to
  forearm
• Can become permanent
• Signs and Symptoms
• Pain in forearm - increased w/ passive extension
  of fingers
• Pain is followed by cessation of brachial and
  radial pulses, coldness in arm
• Decreased motion
• Management
• Remove elastic wraps or casts
• Close monitoring must occur

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Rehabilitation of the Elbow

• General Body Conditioning
• Must maintain pre-injury fitness levels -
  cardiovascular and strength (lower body)
• Flexibility
• Restoring ROM is critical in elbow rehab
• Variety of approaches can be used as long as they
  dont force the joint
• Joint Mobilizations
• Loss of proper arthrokinematics following
  immobilization is expected
• Joint mobilization and traction can be very
  useful to increase mobility and decrease pain
  through restoration of accessory motions

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• Strengthening
• Achieved through low-resistance, high-repetition
  exercises - must be pain free
• Shoulder and grip exercises should also be
  performed
• Continuous passive motion units followed by
  dynamic splinting is ideal following surgery
• Isometrics can be used while elbow is immobilized
• PNF and isokinetics are useful in early and
  intermediate active stages of rehab
• A graded PRE program w/ tubing, weights or manual
  resistance should be included
• Closed kinetic chain activities should also be
  incorporated - assist in both static and dynamic
  stability to the elbow
• Proprioceptive training should also incorporated

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• Functional Progressions
• Will enhance healing and performance
• PNF, swimming, pulley machines and rubber tubing
• to simulate sports activities
• Should include steps
• Warm-up
• Gradual build up to activity, becoming
  increasingly more difficult
• Return to Activity
• Can re-engage in activity when criteria has
  successfully been completed
• ROM w/in normal limits, strength should be equal
  w/ no complaint of pain
• Return should progress with use of restrictions
  in an effort to objectively measure activity
  progression

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• Protective Taping and Bracing
• Should be continued until full strength and
  flexibility have been restored
• Chronic conditions usually cause gradual
  debilitation of surrounding soft tissue
• Must restore maximum state of conditioning w/out
  encouraging post-injury aggravation