Evaluation, Recognition and Treatment of the Elbow and Forearm SEATA-Student Symposium Competencies Workshop Dr. Ben Velasquez, D.A. ATC, LAT Associate Professor, Program Director Athletic Training Education Program School Human Performance and Recreation University of Southern Mississippi Hattiesburg, Mississippi

Introduction to this lecture Before beginning: Ask yourself “what” does this topic have to do with “me” getting certified??????

Where does this “fit in?” The NATABOC Role Delineation Study 4 th ed. NATA Athletic Training Educational Competencies

The Role Delineation Study- Under the domain of “Prevention” “Educate the appropriate individual(s) about risks associated with participation using effective communication techniques to minimize risk of injury” Knowledge of: Mechanisms of injury

The Role Delineation Study- Under the domain of “Prevention” “Review preparticipation screening information by applying accepted guidelines to minimize the risk of injury and illness.” Skill in: Identifying conditions that may limit or compromise participation

The Role Delineation Study- Under the domain of “Immediate Care” “Initiate and/or execute techniques to mitigate life-threatening and other emergency conditions through the use of standard emergency care procedures” Knowledge of: Immobilization techniques and equipment

The Elbow & Forearm: The elbow is a hinge joint, important to the kinetic chain by adjusting the length of the arm and allowing positioning of the forehand, wrist and hand for effectiveness during daily living and sport activities.

The Elbow & Forearm: The elbow is vital for positioning the hand for all functional activities. The elbow is also vital for providing a “link” between the powerful movements of the shoulder and the fine motor control of the hand and fingers.

Anatomy: Review Bones: Humerus, Radius, Ulna Articulations: Humeroulnar, Radiohumeral, and Radioulna articulations. Ligamentous: Ulnar Collateral Ligament - (UCL) Anterior Oblique Ligament- (AOL) Lateral Collateral Ligament- (LCL) Radial Collateral Ligament- (RCL) Accessory Collateral Lig - (ACL) Lateral Ulnar Collateral Lig- (LUCL)

Anatomy:Review Nerves: Ulnar Nerve Radial Nerve Median Nerve Musculocutaneous Nerve

Elbow Anatomy:Review Muscles and Movements: 1. Flexion: Biceps, Brachialis, Brachioradialis 2. Extension: Triceps, Anconeus 3. Supination: Supinator, Biceps, Brachioradialis 4. Pronation: Pronator Teres, Pronator Quadratus

Forearm Anatomy-Review Muscles: Extensors and Flexors of the wrist Supinator and Pronator of the wrist

Elbow Review- Range of Motion Flexion: 135+ degrees Extension:0/-5 degrees Supination:90 degrees Pronation:90 degrees (see Hoppenfeld-Physical Examination of the Elbow)

Prevention of Elbow Injuries The keys to preventing injuries to the elbow are: 1. Strength of all muscles surrounding the joint. 2. Flexibility and proper Range of Motion 3. Use of proper throwing techniques and biomechanics.

Elbow Injury Evaluation Sequence History: Acute injury: -What, where, when, how -Type of pain (radiating, sharp, referred, dull, aching, intermittent) -Previous injury -Sounds: (popping, crepitus) -Sensations: (numbness or tingling)

Elbow Injury Evaluation Sequence History: Chronic Injury 1. All the previous questions of an acute injury plus: -conditioning program -throwing mechanism -biomechanics -pain (type and source during activity)

Elbow Injury Evaluation Sequence -swelling -deformity -discoloration -signs of trauma or injury -skin color -carrying angle -muscle guarding/spasm Observation and Inspection Bilaterally For Comparison of:

Elbow Injury Evaluation Sequence Palpation: Palpate underlying anatomy (bilaterally) -swelling -deformity -skin temperature -crepitation -muscle spasms and sensations

Elbow Injury Evaluation Sequence Range of Motion Evaluation: Perform bilateral range of motion tests (observe for pain and limitations of motion) -passive ROM -active and resistive ROM -flexion and extension -pronation and supination

Evaluation and Recognition of Elbow Injuries-Review: Check the Bony Anatomy Check the Joints that compose the elbow: 1. Humeroulnar (Trochlea & Trochlea Notch of the Ulna) 2. Humeroradial (Capitulum & Radial Head) 3. Superior Radioulna (Radial Head & Radial notch of the Ulna)

Evaluation and Recognition of Elbow Injuries Review: Check the Ligmentous Structures: 1. Ulnar Collateral (Medial) 3 sections: Ant./Transverse/Posterior Obilque 2. Radial Collateral (Lateral) 3. Lateral Ulnar Collateral 4. Annular 5. Interosseous Membrane

Evaluation and Recognition of Elbow Injuries Review: Evaluate Muscle Structure, Range of Motion, Strength and Power. 1. Flexion: Biceps Brachii, Brachialis, Brachioradialis 2. Extension: Triceps Brachii, Anconeus 3. Supination: Supinator, Biceps Brachii, Brachioradialis 4. Pronation: Pronator Teres, Pronator Quadratus

Emergency Care of an Acute Elbow Injury: Careful evaluation: - Check the Distal Radial Pulse - Check Fingernail Bed Compression - Immobilize in the position in which the body part is found using proper types of splints - Ice, Compression and Elevation as indicated by the position of the injury.

Common Mechanisms of Injury Falling on the outstretched arm Direct contact from blows Overuse syndromes

Common Mechanisms of Injury (young athletes) Falling on the outstretched arm Direct contact from blows Overuse syndromes strength imbalances during periods of growth Bone length imbalances during periods of growth. Decreased flexibility Impaired coordination Biomechanical stress on the epiphysis

Injuries to the Elbow Osseous and Articular Ligamentous Soft Tissue/Joint Tendon Alterations Muscle Alterations Nerve Alterations

Elbow Injuries: Osseous and Articular Bony hypertrophy Traction spur formation Osteochondral defects Loose bodies Joint degeneration -Chondromalacia -Osteophyte formation Problems of bone immaturity: Epiphyseal -Apophyseal -Hypertrophy -Fragments and avulsion Effects of fracture and dislocation

Elbow Injuries: Ligamentous Stretching/Tears of Ligaments Contractures Calcium Deposits

Elbow Injuries: Soft Tissue/Joint /Tendon Injuries Synovitis Adhesive Capsulitis (inflammation of the joint capsule) Tendinosis Tendinitis Tenosynovitis

Elbow Injuries: Muscle Alterations Myositis Fibrosis Myositis Ossificans

Elbow Injuries: Nerve Alteration Ulnar nerve entrapment in the cubital tunnel Ulnar nerve stretching and dislocation Median nerve entrapment (Pronator syndrome) Radial nerve entrapment Lateral antebrachial cutaneous nerve entrapment

Injury Evaluation Key Points: Deformity or crepitation may indicate fracture. Suspect avulsion fracture with pre- adolescents and adolescents rather than ligamentous or muscular injury Throwing mechanisms produce great force at the elbow joint.

Injury Evaluation Key Points: Elbow injuries may refer pain into the forearm, wrist and fingers. Nerves of the brachial plexus innervate the elbow and forearm. Major blood supply to the elbow and forearm is the brachial artery which branches into the radial and ulna artery.

When To Refer The Athlete To A Physician: Joint instability, or suspected fracture. Gross deformity, or swelling around the joint and loss of sensation below the elbow. Significant loss of ROM. Considerable PAIN (on finger extension). Audible “click” or “pop” a time of injury. If you have any doubt regarding severity.

Review of Special Tests for Elbow Evaluation: Valgus and Varus Stress Test Wrist Extension Test (Lateral Epicondylitis) Hand Shaking Test (Lateral Epicondylitis Medial Epicondylitis Test Ulnar, Median and Radial Nerve Distribution Test

Review of Special Tests for Elbow Evaluation: Allen Test Pinch Grip Test Phalen’s Test Tinel’s Sign

Management and Treatment of Elbow Injuries: Use of Cryotherapy / Thermotherapy/ Hydrotherapy that is appropriate to the healing process Local compression Use of nonsteroidal anti- inflammatory medications (NSAIDs) Rehabilitation protocols

Goals of Elbow Rehabilitation Reduce pain and local inflammation Regain normal joint movement and artho- kinematics Regain strength, power, and endurance of the entire elbow region (forearm and upper arm) Elbow must perform functionally and handle stresses from sports specific activities Minimize the risk of re injury.

Preventing Recurrence of Injuries to the Elbow Education of the athlete in maintaining 1. proper conditioning 2. proper biomechanics 3. functional strength

Hands On Practice: Break up in to groups of eight or nine. Use your practice sheets. Evaluate your partner for an elbow injury. HAVE FUN!!!!!!!