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Chapter 23: The Elbow

Chapter 23: The Elbow

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Chapter 23: The Elbow

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  1. Chapter 23: The Elbow Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International University Acute Care and Injury Prevention

  2. Anatomy of the Elbow Review

  3. 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

  4. 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? Assessment of the Elbow: History

  5. 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

  6. Biceps brachii Brachialis Brachioradialis Pronator teres Triceps Supinator Wrist flexors Wrist extensors Palpation: Bony and Soft Tissue • Humerus • Medial and lateral epicondyles • Olecranon process • Radial head • Radius • Ulna • Medial and lateral collateral ligaments • Annular ligament

  7. 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 • Tinel’s sign • Ulnar nerve test • Tap on ulnar nerve in ulnar groove • Positive test = numbness/tingling along the forearm and hand

  8. 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

  9. 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

  10. 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

  11. 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

  12. Special Tests: Functional Evaluation • Evaluate AROM, PROM and RROM • Flexion • Extension • Pronation • Supination • Positive test = pain and weakness

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Signs and Symptoms • Pain along medial aspect of elbow • Point tenderness over UCL • Associated paresthesia • Positive Tinel’s 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

  21. Management • Conservative treatment • PRICE and NSAID’s • 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

  22. 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

  23. Management • PRICE • NSAID’s 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

  24. 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

  25. 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

  26. 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 • Panner’s disease • Occurs in children (age <10) • Osteochondrosis of capitellum due to localized avascular necrosis

  27. 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

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

  29. 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

  30. 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

  31. Management • PRICE • NSAID’s and analgesics • Stop throwing until… • Pain resolved • Full ROM is regained • Gentle ROM exercises • Gently triceps strengthening exercises • Analysis of throwing motion

  32. 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

  33. 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

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

  35. 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

  36. 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

  37. 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

  38. 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

  39. Elbow Injuries: Volkmann’s 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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