Chapter 23: The Elbow

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Chapter 23 The Elbow

• Jennifer Doherty-Restrepo, MS, LAT, ATC
• Academic Program Director, Entry-Level ATEP
• Florida International University
• Acute Care and Injury Prevention

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Anatomy of the Elbow

• Review

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Functional Anatomy

• Elbow ROM flexion, extension, pronation and
  supination
• 145 degrees of flexion
• 90 degrees of supination and pronation
• Stable joint protection from overuse and
  traumatic injuries
• Bony limitations, ligamentous support, and
  muscular stability at the elbow help to
• 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 does it hurt?
• Where does it hurt?
• Motions that increase pain?
• Motions that 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 vs. Cubitus varus
• Flexion and extension
• Cubitus recurvatum
• Elbow at 45 degrees
• Isosceles triangle formed by the 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
• Wrist extensors

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Special Tests Circulatory and Neurological
Function

• Pulse
• Assessed at brachial artery and radial artery
• Skin sensation
• 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 numbness/tingling along the
  forearm and hand

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Special Tests Capsular Injury

• Tested after hyperextension of elbow
• Athlete position
• Elbow is flexed to 45 degrees
• Wrist is fully flexed and extended
• Positive test pain in elbow joint
• If joint pain is severe, sprain or fracture
  should be suspected
• Joint pain may indicate chronic injury as well

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Special Tests Ligament Injury

• Valgus/Varus Stress Test
• Assess injury to the medial and lateral
  collateral ligaments, respectively
• Positive test joint laxity or complaint of pain

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Special Tests Muscle Injury

• Medial Epicondylitis Test
• Athlete position
• Elbow flexed to 45 degrees
• Resist wrist flexion
• Positive test pain at medial epicondyle
• Lateral Epicondylitis Test
• Athlete position
• Elbow flexed to 45 degrees
• Resist wrist extension
• Positive test pain at lateral epicondyle

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Special Tests Muscle Injury

• Pinch Grip Test
• Pinch thumb and index finger together
• Positive test inability to touch fingers
  together
• Indicates entrapment of anterior interosseous
  nerve between the heads of pronator muscle
• Pronator Teres Syndrome Test
• Resist forearm pronation
• Positive test increased pain over pronator
  teres

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Special Tests Functional Evaluation

• Evaluate AROM, PROM and RROM
• Flexion
• Extension
• Pronation
• Supination
• Positive test pain and weakness

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Elbow Injuries

• Subject to injury due to
• Broad range of motion
• Weak lateral bone structure
• Exposure of soft tissue
• Many sports place excessive stress on joint
• Locking motion of some activities
• Use of implements
• Throwing motion

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Elbow Injuries Contusion

• MOI direct blow or repetitive blows
• Vulnerable area due to lack of padding
• Signs and Symptoms
• Rapid swelling due to irritation of bursa or
  synovial membrane
• Management
• PRICE immediately, for at least 24 hours
• If severe, refer for X-ray to rule out fracture

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Elbow Injuries Olecranon Bursitis

• MOI direct blow
• Superficial location makes it extremely
  susceptible to injury
• Signs and Symptoms
• Pain, swelling, and point tenderness
• Swelling will appear almost spontaneously without
  the pain and heat

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• Management
• Acute compression for at least 1 hour
• Chronic requires superficial therapy primarily
  involving compression
• If swelling fails to resolve, aspiration may be
  necessary
• May be padded to return to competition

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Elbow Injuries Muscle Strains

• MOI overstretching or too forceful a
  contraction
• Falling on outstretched arm
• Repeated microtears may cause chronic injury
• Rupture of distal biceps is most common in UE
• Signs and Symptoms
• Pain with AROM and RROM
• Point tenderness in muscle, tendon, or lower part
  of muscle belly

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Elbow Injuries Muscle Strains

• Management
• PRICE
• Sling in severe cases
• Follow-up treatment
• Cryotherapy, ultrasound, ROM and PRE exercises
• If severe loss of function, refer for X-ray to
  rule out avulsion or epiphyseal fracture

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Elbow Injuries Ulnar Collateral Ligament Injuries

• MOI valgus force from repetitive trauma
• Secondary injuries may include
• Ulnar nerve inflammation
• Wrist flexor tendinitis
• Overuse flexor/pronator strain
• Ligamentous sprains
• Elbow flexion contractures
• Joint instability

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• Signs and Symptoms
• Pain along medial aspect of elbow
• Point tenderness over UCL
• Associated paresthesia
• Positive Tinels sign
• Positive Valgus Stress Test
• Possible end-point laxity
• X-ray may show evidence of
• Hypertrophy of humeral condyle and/or
  posteromedial aspect of olecranon and
  osteophytes
• Calcification within the UCL
• Loose bodies in posterior compartment

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• Management
• Conservative treatment
• PRICE and NSAIDs
• ROM and PRE exercises as pain decreases
• Analysis of the throwing motion (if applicable)
• Surgical intervention may be necessary
• Tommy John Procedure
• Throwing athlete may be able to return to
  activity approximately 22-26 weeks post surgery

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Elbow Injuries Lateral Epicondylitis (Tennis
Elbow)

• MOI repetitive microtrauma to insertion of
  wrist extensor muscles
• Tendinosis may result
• Degeneration of tendon without inflammation
• Signs and Symptoms
• Aching pain at lateral epicondyle after activity
• Decreased elbow ROM
• Pain with AOM and RROM wrist extension
• Pain and weakness in wrist and hand develop

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• Management
• PRICE
• NSAIDs and analgesics
• Mobilization and stretching in pain free ranges
• ROM and PRE exercises as pain decreases
• Deep friction massage
• Hand grasping while in supination
• Avoid pronation motions
• Use of neoprene sleeve
• Mechanics and skills training in order to avoid
  recurrence of injury

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Elbow Injuries Medial Epicondylitis

• MOI repeated forceful wrist flexion and extreme
  valgus torque on the elbow
• May involve pronator teres, flexor carpi
  radialis, flexor carpi ulnaris, and palmaris
  longus tendons
• Can be associated with ulnar nerve neuropathy
• Signs and Symptoms
• Pain with AOM and RROM wrist extension
• Pain with wrist flexion as well in severe
  injuries
• Point tenderness and mild swelling at medial
  epicondyle

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• Management
• PRICE
• NSAID's and analgesics
• Sling in severe cases
• Severe cases may require splinting and complete
  rest for 7-10 days
• Cryotherapy, Ultrasound
• Curvilinear brace
• Below elbow to reduce stress at the elbow joint

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Elbow Injuries Osteochondritis Dissecans

• MOI Repetitive microtrauma
• Injurious movements include elbow rotation and
  extension
• Excessive valgus stresses causes compression of
  the radial head, which adds shearing forces at
  the radiocapitular joint
• Impairment of blood supply may result, which
  causes degeneration of articular cartilage
  creating loose bodies
• Panners disease
• Occurs in children (age lt10)
• Osteochondrosis of capitellum due to localized
  avascular necrosis

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• Signs and Symptoms
• Sudden pain at radiohumeral joint
• Swelling, creptitus
• Decreased ROM (full extension)
• ROM usually returns in a few days
• Grating with pronation and supination
• Locking of the joint
• X-ray
• May show flattening and crater of capitulum
• May show loose bodies in joint

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• Management
• Activity restriction for 6-12 weeks
• NSAIDs
• Splint and cast applied in severe cases of
  deterioration
• If repeated locking of the elbow joint occurs,
  loose bodies are removed surgically

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Elbow Injuries Little League Elbow

• MOI repetitive microtraumas that occur from
  throwing motion (Not due to the type of pitch)
• Linked to
• Accelerated apophyseal growth and delayed medial
  epicondyle epiphysis growth
• Traction apophysitis with possible fragmentation
  of medial epicondylar apophysis
• Avulsion fracture at medial epicondyle or radial
  head
• Osteochondrosis of humeral capitellum
• Non-union stress fracture of olecranon epiphysis

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• Signs and Symptoms
• Onset is slow
• Slight flexion contracture
• Tight anterior joint capsule
• Weakness in triceps
• Locking or Catching sensation
• Decreased ROM
• Especially forearm pronation and supination

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• Management
• PRICE
• NSAIDs and analgesics
• Stop throwing until
• Pain resolved
• Full ROM is regained
• Gentle ROM exercises
• Gently triceps strengthening exercises
• Analysis of throwing motion

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Elbow Injuries Cubital Tunnel Syndrome

• MOI narrowing of cubital canal or irregularity
  of cubital tunnel
• Pronounced cubital valgus may cause deep friction
  contributing to injury
• Ulnar nerve injury may result
• Ulnar nerve subluxation or dislocation
• Traction of ulnar nerve from valgus force
• Ulnar nerve compression from ligaments

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• Signs and Symptoms
• Pain on medial aspect of elbow
• Pain may be referred proximally or distally
• Point tenderness in cubital tunnel
• Pain with hyperflexion
• Intermittent paresthesia in 4th and 5th fingers

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• Management
• Rest, immobilization for 2 weeks
• NSAIDs
• Splinting, surgical decompression or
  transposition of subluxating nerve may be
  necessary
• Avoid hyperflexion and valgus stresses

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Elbow Injuries Dislocation

• MOI fall on outstretched hand with elbow
  extended or severe twist while elbow flexed
• High incidence in sports
• Dislocation may be posterior, anterior, or
  lateral
• Signs and Symptoms
• Swelling, severe pain, disability
• Median and radial nerves may be compromised
• Blood vessels may be compromised
• Often a radial head fracture is involved

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• Management
• Pack with ice and apply sling immediately
• Refer for reduction immediately
• Following reduction
• Immobilize in elbow flexion for 3 weeks
• PRE exercises for grip and shoulder strenthening
• Following immobilization
• Heat and PROM exercises to regain full ROM
• ROM and PRE exercises should be initiated by
  athlete
• Exercises that are too strenuous should be
  avoided before complete healing due to high
  probability of developing myositis ossificans
• Forced stretching should be avoided

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Elbow Injuries Fractures

• MOI fall on flexed elbow or direct blow
• May occur in one or more of bones in elbow joint
• Fall on outstretched hand may fracture the
  humerus above condyles or between condyles
• Condylar fracture may result in gunstock
  deformity
• Direct blow may fracture olecranon or radial head
  
• Signs and Symptoms
• May not result in visual deformity
• Hemorrhaging, swelling, muscle spasm

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• Management
• Monitor neurovascular status
• Non-surgical treatment
• Appropriate for stable fractures
• Immobilize with cast or removable splint for 6-8
  weeks
• Surgical treatment
• Used to stabilize unstable fractures in adults
• ROM exercises initiated early to prevent frozen
  elbow

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Elbow Injuries Volkmanns Contracture

• MOI impaired circulation or ischemia
• Associate with humeral supracondylar fractures,
  which compromises the brachial artery and
  inhibits circulation to forearm
• May be loss of motor and sensory function
• Classic case involves median nerve
• Edema further impairs circulation via condition
  called compartment syndrome
• Muscle necrosis may occur with irreversible
  muscle damage after 4-6 hours, which may lead to
  secondary fibrosis and calcification

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• Signs and Symptoms
• Pain in forearm which increases with PROM finger
  extension
• Cessation of brachial and radial pulses
• Coldness in arm
• Decreased ROM
• Management
• Monitor neurovascular integrity

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Rehabilitation of the Elbow

• General Body Conditioning
• Must maintain pre-injury CV and LE strength
  fitness levels
• Flexibility
• Restoring ROM is critical in elbow rehab
• Variety of approaches can be used as long as they
  do not force the joint

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• Joint Mobilizations
• Loss of proper arthrokinematics following
  immobilization is expected
• Joint mobilization and traction
• Very useful to increase mobility
• Useful to decrease pain
• Restores accessory motions

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• Strengthening
• Achieved through low-resistance, high-repetition
  exercises
• Must be pain free
• Shoulder and hand grip exercises
• Isometrics can be used while immobilized
• PNF and isokinetics are useful in early and
  intermediate stages of rehabilitation
• PRE exercises with tubing, weights, or manual
  resistance
• Closed kinetic chain activities
• 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
• Simulate sports activities
• Should include steps
• Warm-up
• Gradual build up to activity, becoming
  increasingly more difficult
• Return to Activity
• ROM must be WNL
• Strength should be restored without pain