The Elbow and Forearm Complex

Anatomy of the Elbow

Muscles of the Elbow

Nerves of the Upper Extremity

Joint Positions and Capsular Patterns Loose Packed Position/resting position Closed-Pack Position Capsular Pattern Ulnohumeral Joint (elbow) 70 degrees flexion, 10 degrees supination Extension Flexion, Extension Radiohumeral Joint Full Extension, Full Supination Elbow flexed 90 deg, forearm supinated 5 deg. Flexion, Extension, Supination, Pronation Proximal Radioulnar Joint 70 deg. flexion, 35 deg. supination 5 deg. supination Supination, Pronation Distal Radioulnar Joint 10 deg. supination Full ROM, pain at extremes of rotation

Total Elbow Arthroplasty This picture depicts the prosthesis for a total elbow arthroplasty (TEA) This is the most common surgery when there is joint destruction (such as with RA) This procedure includes a humeral and ulnar implant and the head of the radius may be replaced as well. Cement is used for placement (don’t do US over a TEA) Figure 18.5 Kisner & Colby page 568

Joint Surgery and Post-op Management Some specific motions of the joint may be limited after surgery to prevent stress on the capsule, ligaments, tendons, etc. Consult with the PT, KNOW THE LIMITATIONS!

Lateral Epicondylitis Lateral Epicondylitis (Tennis Elbow) -pain in the common wrist extensor tendons along the lateral humeral epicondyle -typically brought on by repetitive movements of the wrist or activities requiring stability of the wrist (tennis backhand) http://www.hss.edu/conditions_tennis-elbowoverview.asp

Medial Epicondylitis Medial Epicondylitis (Golfer’s Elbow) -pain at the common wrist flexor tendon along the medial humeral epicondyle -due to repetitive movements into wrist flexion (golf swing, gripping, throwing a ball, etc.) -ulnar neuropathy can also occur http://www.aidmyelbow.com/common-elbow-strains.php

General Considerations for Overuse Syndromes PROTECTION PHASE -Immobilize: rest the muscles, can use a splint -Avoid provoking activities: repetitive wrist motions, gripping -Cryotherapy: ice massage, cold pack -Multi-angle muscle setting (low-intensity isometrics) -Cross-fiber massage -Maintain mobility / strength in unaffected joints (shoulder, etc)

General Considerations for Overuse Syndromes CONTROLLED MOTION AND RETURN TO FUNCTION PHASE *Progress to this stage only when inflammation is controlled -Manual stretching -Self-stretching -Cross-fiber (friction) massage -Isometrics progressing to Theraband, free weights, etc. -Isolated motions progressing to functional patterns -General strengthening and conditioning -Simulation of work or recreational activities -Plyometrics (if returning to sports, etc) -Activity Modification / Patient Education

Self Stretching to Increase Elbow Extension and Flexion -the biceps crosses the elbow and the shoulder, therefore to stretch the biceps brachii the shoulder and elbow must be extended -3 muscles can produce elbow flexion: biceps brachii, brachioradialis, brachialis -Mechanical Stretch: patient supine with towel under distal humerus, cuff weight on distal forearm. Forearm can be in pronation to effect biceps, neutral, or supinated depending on the muscle you wish to stretch. Shoulder must be stabilized, but this is a good technique for a mild contracture as it can be held for prolonged periods of time -Mechanical Stretch- Dynamic Splinting: low-intensity prolonged stretch of a long term contracture is best managed with dynamic splinting which affects soft tissue creep and stress-relaxation -Manual Stretch- Biceps Brachii: prone, elbow extended, PTA stabilizes scapula and extends the shoulder -Self Stretch-Biceps Brachii patient is standing, grasps table, walks forward to stretch elbow and shoulder into extension (forearm however is not pronated) Figure 2: To Increase Elbow Flexion -Self Stretch (mild extension contracture): prone on elbows, patient lowers themselves closer to the mat and hold as long as is comfortable. -Can also: in sitting, flex the elbow as far as possible then with opposite hand apply stretch into further flexion -Self Stretch Long head of Triceps: sitting or standing, patient flexes elbow and shoulder as far as possible, the opposite hand can either flex the elbow further or the shoulder flexion further, hold the stretch as long as tolerated

Self Stretching- Muscles of the Lateral and Medial Epicondyles This figure demonstrates stretching of the wrist extensors (from the lateral epicondyle) Stretching the wrist flexors involves extension at the wrist with the elbow in full extension See HEP handouts as well for more pictures Figure 18.10 Kisner & Colby page 579 To Stretch the Wrist Extensor Muscles (from the lateral epicondyle) -sitting or standing, patient extends elbow and flexes wrist, they apply over-pressure to the dorsum of the hand to increase flexion of the wrist in an ulnar direction -similar concept, but back of hand is against a wall and they slide the hand up the wall To Stretch the Wrist Flexor Muscles (from the medial epicondyle) -elbow and wrist extended in supination, opposite hand applies stretch force at the involved palm, pressing wrist into extension and radial deviation -similar concept but patient places palm on a wall and slides arm up wall

Resistance Exercises for the Elbow, Forearm, and Wrist Elbow Flexion (biceps brachii, brachialis, and brachioradialis) -seated or standing bicep curls with forearm pronated, supinated, and neutral *supinated curl= biceps brachii *neutral forearm curl= brachioradialis *pronated curl= brachialis -can do supine or prone elbow flexion with humerus resting on the table -to focus on biceps, patient flexes elbow and extends shoulder simultaneously (fig. 18.11 page 581) Elbow Extension (triceps and anconeus) -prone with shoulder abducted to 90 degrees and supported, patient extends elbow with weight or against Tband -supine tricep extension: shoulder is at 90 deg flexion, start with elbow bent, then extend the weight up towards the ceiling, stabilize the humerus with opposite hand. -Long Head of Triceps with Elbow Extension= seated with shoulder and elbow flexed overhead, support the active humerus with the opposite hand, extend the elbow with a weight or Tband Forearm Pronation and Supination (pronator teres and quadratus = pronators, supinator and biceps brachii= supinators) Free Weights: -weight needs to be offset to properly effect the supinators/pronators Theraband: -secure opposite end, can tie to a short rod and have patient pronate/supinate rod Functional Activity -Turn door knob without substituting with shoulder motions Wrist Flexion and Extension (flexion uses muscles of the medial epicondyle and extension uses muscles of the lateral epicondyle) Free Weights/ TBand: -seated with forearm resting on the table, wrist and hand off the edge, with forearm pronated the extensors are being worked, with forearm supinated the flexors are being worked Wrist Roller -can be done seated or standing, with elbows flexed or extended, and with forearms supinated or pronated. Tie a 2-4ft. cord around a short dowel with a weight secured to the opposite end. Patient uses alternating wrist motion to wind the cord up and then down the rod

Functional Exercises for the UE Fig1 would be good with patient who has a trapeze in their bed for elbow flexion strengthening Combined Pulling Motions -combine use of many muscles and joints -bilateral pull-up against elastic resistance -closed-chain chin-ups or modified pull-ups on overhead trapeze -bilateral or unilateral rowing motion on machine or with Tband, etc - ‘pulling’ a variety of weighted objects with good body mechanics Combined Pushing Motions -triceps involved as well as shoulder flexion and scapular protraction/depression -Military Press, Bench Press, UBE (upper extremity ergometer), wall push-ups, semi-prone and prone push-ups, push ups from a chair or parallel bars, using arms on ‘stair stepping machine’, pushing different weighted objects

UE Theraband Exercises for Elbow Strengthening Fig. 3 demonstrates Tband for tennis swings Simulated Tasks and Activities -determine the smaller components of the patient’s desired motion needed for job or recreational activity. Perform the smaller components initially and work up to the full motion needed (tennis swing, lifting for work, pitching motions, etc)

Combined Pushing Motions -triceps involved as well as shoulder flexion and scapular protraction/depression -Military Press, Bench Press, UBE (upper extremity ergometer), wall push-ups, semi-prone and prone push-ups, push ups from a chair or parallel bars, using arms on ‘stair stepping machine’, pushing different weighted objects

Case Study John is a 45 y/o painter who comes to your clinic with a diagnosis of left ‘elbow pain’. During the PT evaluation the therapist palpates tenderness and inflammation at the lateral epicondyle of the humerus and testing reveals tight wrist extensors with 4/5 MMT. Pain is a 4/10 in the morning and an 8/10 after working all day (painting). The patient is left hand dominant. His grip strength is weaker in his left hand by 30% when compared to the right. What term (pathology) would best describe the patient’s condition? What mechanics (actions) likely initiated his symptoms? What patient education would you give John? Create a home management program for this patient. What are the key components to this patient’s treatment? (1) Lateral epicondyitis (2) repetitive wrist flexion/extension with painting (3) home stretches, home cross-friction massage, home ice massage or cold pack, immobilization and/or frequent rest breaks (4)see #3, give pictures and written instructions for ice/friction massage (5) decrease pain,inflammation (pulsed US, ionto, estim, ice, massage),protection (immobilize, use compression strap), stretch weak muscles, strengthen wrist extensors through appropriate progression (isometrics, AROM, resistance- gentle at first may progress to plyometrics)