Upper Arm, Elbow, and Forearm Conditions

Anatomy

Anatomy Cont’d… Carrying angle 3 articulations (single capsule) Humeroulnar (elbow joint) Humeroradial Proximal radioulnar Carrying angle Angle between humerus and ulna (arm in anatomic position) 10-15° angle Greater in females

Anatomy Cont’d… Ligaments Ulnar (medial) collateral Radial (lateral) collateral Annular

Anatomy Cont’d… Bursae Several small Olecranon bursa Superficial

Anatomy Cont’d…

Anatomy Cont’d…

Anatomy Cont’d… Nerves Musculocutaneous Median Ulnar Radial

Anatomy Cont’d… Muscles Flexors (at the humeroradial and humeroulnar joints) Brachialis; biceps; brachioradialis Effectiveness depends on supination/pronation position Extensors (at the humeroradial and humeroulnar joints) Triceps; anconeus Pronation and supination (at the proximal radioulnar joint) Pronator quadratus; pronator teres; supinator; biceps

Kinematics Non–weight bearing but still sustains significant loads Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises

Injury Prevention Protective equipment Physical conditioning Pads Braces Physical conditioning Flexibility and strength Focus on entire arm Proper skill technique Throwing Falling

Contusions Susceptible due to: S&S Chronic blows Lack of padding General vulnerability S&S Rapid swelling – can limit ROM Chronic blows Development of ectopic bone Tackler’s exostosis Painful periostitis and fibrositis may develop Management: standard acute; NSAIDs

Olecranon Bursitis Acute and chronic Mechanism S&S Fall on a flexed elbow Constantly leaning on elbow Repetitive pressure and friction S&S Tender, swollen, relatively painless Rupture – goose egg visible 50% history of abrupt onset; 50% insidious onset over a few weeks Motion limited at extreme of flexion – tension increases over bursa Management: standard acute; NSAIDs; possible aspiration

Sprain Mechanism Ulnar nerve may also be affected S&S FOOSH - Fall on outstretched hand (hyperextension injury) Valgus or varus force More common; repetitive forces irritate and tear ligaments, especially UCL Ulnar nerve may also be affected S&S Localized pain Point tenderness Instability with stress test Management: standard acute

Dislocation Proximal radial head Adolescents: often associated with immature annular ligament Due to: longitudinal traction of an extended and pronated upper extremity Inability to pronate and supinate pain free warrants immediate physician referral Immobilization for 3-6 weeks in flexion is usually necessary

Dislocation Ulnar dislocation Younger than 20 years old Mechanism: Hyperextension Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral Associated conditions fractures of the medial epicondyle, radial head, coronoid process, and olecranon process disruption of the anterior capsule tearing of the brachialis muscle injury to the ulnar collateral ligament

Dislocation Cont’d… S&S Snapping or cracking sensation Severe pain, rapid swelling Total loss of function Obvious deformity Arm held in flexion, with forearm appearing shortened Olecranon and radial head palpable posteriorly Slight indentation in triceps visible just proximal to olecranon Nerve palsy Management: immediate immobilization in vacuum splint; activation of EMS

Strains Flexors and pronator teres Extensor S&S Repetitive tensile stresses Extensor Decelerating type injury S&S Typical muscle strain S&S Self-limiting Management: standard acute

Triceps Brachii Rupture Mechanism: Direct blow to posterior elbow Uncoordinated triceps contraction during a fall 80% involve olecranon avulsion fracture S&S Pain and swelling in distal attachment Palpable defect in the triceps tendon or a step-off deformity of the olecranon Active extension weak – partial tear; nonexistent – total rupture Management: standard acute; immobilize in sling; immediate physician referral

Overuse Conditions Medial epicondylitis (aka – Little League Elbow) Due to repeated valgus forces during acceleration phase of throwing motion Commonly involved tendons: pronator teres and flexor carpi radialis S&S Swelling, ecchymosis, and point tenderness at humeroulnar joint or over the flexor/pronator origin Severe pain; aggravated by: Resisted wrist flexion and pronation Valgus stress applied at 15-20° of elbow flexion Ulnar nerve involved – tingling and numbness Management: ice; NSAIDs; sling immobilization for 2-3 weeks with wrist in slight flexion; therapeutic exercise

Overuse Conditions Cont’d… Lateral epicondylitis (aka – Tennis Elbow) Due to eccentric loading of extensor muscles (especially extensor carpi radialis brevis) during deceleration phase of throwing motion or tennis stroke Contributing factors S&S Pain anterior or just distal to lateral epicondyle; may radiate into forearm extensors during and after activity Repetition produces pain that becomes more severe and ↑ with resisted wrist extension Management: ice; NSAIDs; rest; support

Overuse Conditions Cont’d… Ulnar nerve Entrapment Vulnerable to compression and tension S&S Shocking sensation (medial elbow), radiating as if “hitting their funny bone.” + Tinel sign – ulnar groove (tingling and numbness of medial forearm into ring and little finger) Pain not present, ROM is not limited Grip strength may be weak

Fractures Ulna (forearm fracture) Olecranon Direct blow Triceps tension pulls bone fragment superiorly Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention Ulna (forearm fracture) Also known as “nightstick” fracture

Assessment History Observation/inspection Palpation Carrying angle Position of function Palpation Physical examination tests

Assessment Cont’d… AROM AAROM PROM RROM Elbow flexion Elbow extension Supination Pronation Wrist flexion Wrist extension AAROM PROM RROM

ROM (cont.) 30

Special Tests Ligamentous instability Valgus stress Varus stress **Test at multiple angles

Special Tests Common extensor tendinitis (lateral epicondylitis) Resisted extension and radial deviation of wrist Passive stretching of wrist extensors Resisted extension of extensor digitorum communis in middle finger with wrist extended Common flexor tendinitis (medial epicondylitis) Epicondylitis Lateral (tennis elbow or lateral epicondylitis) Pt is seated or standing; elbow flexed ~90°, forearm pronated Examiner uses one hand to grasp forearm at elbow, palpating lateral epicondyle with thumb (fingers grasp around posterior elbow); other hand grasps pt’s hand/fist Pt is instructed make a fist and pronate the forearm Pt is instructed to radially deviate and extend wrist against examiner resistance Test is + if: pain over lateral epicondyle is present = lateral epicondylitis 32

Special Tests (cont.) Tinel’s sign for ulnar neuritis Medial (golfer’s elbow or medial epicondylitis) Pt is seated or standing; elbow flexed; forearm pronated/neutral Examiner uses one hand to palpate medial epicondyle and support elbow; other hand grasps hand/wrist Examiner extends wrist and elbow; pt is instructed to resist this movement Test is + if: pain over medial epicondyle is present = medial epicondylitis Tinel’s sign for ulnar neuritis Pt is seated or standing; elbow flexed 90°; forearm neutral/supinate Examiner stands to side/behind pt; uses one hand to support forearm and the other hand to palpate ulnar nerve in groove at elbow (between olecranon process and medial epicondyle) Examiner taps nerve in/over groove Test is + if: tingling sensation into ulnar distribution of forearm/hand = nerve compression Elbow flexion test for ulnar neuritis Pt is seated or standing; instructed to completely flex the elbow and hold that position for 5 minutes Test is + if: tingling or numbness in ulnar distribution of forearm/hand = ulnar neuropathy Pronator teres syndrome test (test for median nerve compression) Pt is seated or standing; elbow flexed 90° Examiner resists forearm pronation while elbow is extended Test is + if: tingling or paresthesia in median distribution of forearm/hand = median nerve compression 33

Rehabilitation (cont.) Restoration of motion Use of opposite hand to supply load UBE 34

Rehabilitation (cont.) Restoration of proprioception and balance Closed-chain exercises Muscular strength, endurance, and power Open-chain exercises PNF-resisted exercises Cardiovascular fitness 35