1. Chapter 23: The Elbow

2. Anatomy of the Elbow

7. Functional Anatomy
Complex that allows for flexion, extension, pronation and supination
145 degrees of flexion and 90 degrees of supination and pronation
Bony limitations, ligamentous support and muscular stability at the elbow help to protect it from overuse and traumatic injuries
Elbow demonstrates a carrying angle due to distal projection of humerus
Normal in females is degrees, males 5 degrees
Critical link in kinetic chain of upper extremity

8. Assessment of the Elbow
History
Past history
Mechanism of injury
When and where does it hurt?
Motions that increase or decrease pain
Type of, quality of, duration of, pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?

9. Observations Deformities and swelling? Carrying angle
Cubitus valgus versus cubitus varus
Flexion and extension
Cubitus recurvatum
Elbow at 45 degrees
Isosceles triangle (olecranon and epicondyles)

10. 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 and extensors

11. Special Tests Circulatory and Neurological Function
Pulse should be taken at brachial artery and radial artery
Skin sensation should be checked - 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 is found when athlete complains of sensation along the forearm and hand
Test for Capsular Injury
Tested after hyperextension of elbow
Elbow is flexed to 45 degrees, wrist is fully flexed and extended
If joint pain is severe, moderate/severe sprain or fracture should be suspected

12. Valgus/Varus Stress Test
Assess injury to the medial and lateral collateral ligaments, respectively
Looking for gapping or complaint of pain

13. Medial and Lateral Epicondylitis Tests
Elbow flexed to 45 degrees and wrist extension or flexion is resisted
Pain at lateral or medial epicondyle, respectively indicates a positive test
Pinch Grip Test
Pinch thumb and index finger together
Inability to touch fingers together indicates entrapment of anterior interosseous nerve between heads of pronator muscle
Pronator Teres Syndrome Test
Forearm pronation is resisted
Increased pain proximally over pronator teres indicates a positive test

14. Functional Evaluation
Pain and weakness are evaluated through AROM, PROM and RROM
Flexion, extension, pronation and supination
ROM of pronation and supination are particularly noted

15. Recognition and Management of Injuries to the Elbow
Subject to injury due to broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage
Many sports place excessive stress on joint
Locking motion of some activities, use of implements, and involvement in throwing motion make elbow extremely susceptible

16. Contusion Etiology Signs and Symptoms Management
Vulnerable area due to lack of padding
Result of direct blow or repetitive blows
Signs and Symptoms
Swelling (rapidly after irritation of bursa or synovial membrane)
Management
Treat w/ RICE immediately for at least 24 hours
If severe, refer for X-ray to determine presence of fracture

17. Olecranon Bursitis Etiology Signs and Symptoms Management
Superficial location makes it extremely susceptible to injury (acute or chronic) --direct blow
Signs and Symptoms
Pain, swelling, and point tenderness
Swelling will appear almost spontaneously and w/out usual pain and heat
Management
In acute conditions, compression for at least 1 hour
Chronic cases require superficial therapy primarily involving compression
If swelling fails to resolve, aspiration may be necessary
Can be padded in order to return to competition

18. Strains Etiology Signs and Symptoms Management
MOI is excessive resistive motion (falling on outstretched arm), repeated microtears that cause chronic injury
Rupture of distal biceps is most common muscle rupture of the upper extremity
Signs and Symptoms
Active or resistive motion produces pain; point tenderness in muscle, tendon, or lower part of muscle belly
Management
RICE and sling in severe cases
Follow-up w/ cryotherapy, ultrasound and exercise
If severe loss of function encountered - should be referred for X-ray (rule out avulsion or epiphyseal fx

19. Ulnar Collateral Ligament Injuries
Etiology
Injured as the result of a valgus force from repetitive trauma
Can also result in ulnar nerve inflammation, or wrist flexor tendinitis; overuse flexor/pronator strain, ligamentous sprains; elbow flexion contractures or increased instability
Signs and Symptoms
Pain along medial aspect of elbow; tenderness over MCL
Associated paresthesia, positive Tinel’s sign
Pain w/ valgus stress test at 20 degrees; possible end-point laxity
X-ray may show hypertrophy of humeral condyle, posteromedial aspect of olecranon, marginal osteophytes; calcification w/in MCL; loose bodies in posterior compartment

20. Ulnar Collateral Ligament Injuries (cont.)
Management
Conservative treatment begins w/ RICE and NSAID’s
W/ resolution, strengthening should be performed; analysis of the throwing motion (if applicable)
Surgical intervention may be necessary (Tommy John procedure)
Throwing athlete can return to activity weeks post surgery

21. Lateral Epicondylitis (Tennis Elbow)
Etiology
Repetitive microtrauma to insertion of extensor muscles of lateral epicondyle
Signs and Symptoms
Aching pain in region of lateral epicondyle after activity
Pain worsens and weakness in wrist and hand develop
Elbow has decreased ROM; pain w/ resistive wrist extension

22. Lateral Epicondylitis (continued)
Management
RICE, NSAID’s and analgesics
ROM exercises and PRE, deep friction massage, hand grasping while in supination, avoidance of pronation motions
Mobilization and stretching in pain free ranges
Use of a counter force or neoprene sleeve
Mechanics training

23. Medial Epicondylitis Etiology Signs and Symptoms Management
Repeated forceful flexion of wrist and extreme valgus torque of elbow
Signs and Symptoms
Pain produced w/ forceful flexion or extension
Point tenderness and mild swelling
Passive movement of wrist seldom elicits pain, but active movement does
Management
Sling, rest, cryotherapy or heat through ultrasound
Analgesic and NSAID's
Curvilinear brace below elbow to reduce elbow stressing
Severe cases may require splinting and complete rest for 7-10 days

24. Elbow Osteochondritis Dissecans
Etiology
Impairment of blood supply to anterior surface resulting in degeneration of articular cartilage, creating loose bodies
Repetitive microtrauma in movements of elbow rotation, extension, valgus stress causing compression of the radial head ad shearing of the radiocapitular joint
Seen in young athletes involved in throwing motion
Panner’s disease in incidents of children age <10
Signs and Symptoms
Sudden pain, locking; range usually returns in a few days

25. Signs and Symptoms (continued)
Swelling, pain at radiohumeral joint, creptitus, decreased ROM (full extension); grating w/ pronation and supination
X-ray may show flattening and crater of capitulum w/ loose bodies
Management
Activity restriction for 6-12 weeks; NSAID’s
Splint and cast applied for cases of extensive deterioration
If repeated locking occurs, loose bodies are removed surgically

26. Little League Elbow Etiology Signs and Symptoms
Caused by repetitive microtraumas that occur from throwing (not type of pitch)
May result in numerous disorders of growth in the pitching elbow
Signs and Symptoms
Onset is slow; slight flexion contracture, including tight anterior joint capsule and weakness in triceps
Athlete may complain of locking or catching sensation
Decreased ROM or forearm pronation and supination

27. Little League Elbow (continued)
Management
RICE, NSAID’s and analgesics
Throwing stops until pain resolved and full ROM is regained
Gentle stretching and triceps strengthening
Throwing under supervision w/ good technique to prevent recurrence

28. Cubital Tunnel Syndrome
Etiology
Pronounced cubital valgus may cause deep friction problem
Ulnar nerve dislocation
Traction injury from valgus force, irregularities w/ tunnel, subluxation of ulnar nerve due to lax impingement, or progressive compression of ligament on the nerve
Signs and Symptoms
Pain medially which may be referred proximally or distally
Tenderness in cubital tunnel on palpation and hyperflexion
Intermittent paresthesia in 4th and 5th fingers

29. Cubital Tunnel Syndrome (continued)
Management
Rest, immobilization for 2 weeks w/ NSAID’s
Splinting or surgical decompression or transposition of subluxating nerve may be necessary
Athlete must avoid hyperflexion and valgus stresses

30. Dislocation of the Elbow
Etiology
High incidence in sports caused by fall on outstretched hand w/ elbow extended or severe twist while flexed
Bones can be displaced backward, forward, or laterally
Distinguishable from fracture because lateral and medial epicondyles are normally aligned w/ shaft of humerus
Signs and Symptoms
Swelling, severe pain, disability
Complications w/ median and radial nerves and blood vessels
Often a radial head fracture is involved

31. Management Cold and pressure immediately w/ sling Refer for reduction
Neurological and vascular fxn must be assessed prior to and following reduction
Physician should reduce - immediately
Immobilization following reduction in flexion for 3 weeks
Hand grip and shoulder exercises should be used while immobilized
Following initial healing, heat and passive exercise can be used to regain full ROM
Massage and joint movement that are too strenuous should be avoided before complete healing due to high probability of myositis ossificans
ROM and strengthening should be performed and initiated by athlete (forced stretching should be avoided

32. Elbow Dislocation

33. Fractures of the Elbow Etiology Signs and Symptoms
Fall on flexed elbow or from a direct blow
Fracture can occur in any one or more of the bones
Fall on outstretched hand often fractures humerus above condyles or between condyles
Condylar fracture may result in gunstock deformity
Direct blow to ulna or radius may cause radial head fracture as well
Signs and Symptoms
May not result in visual deformity
Hemorrhaging, swelling, muscle spasm

34. Elbow Fractures (continued)
Management
Decrease ROM, neurovascular status must be monitored
Surgery is used to stabilize adult unstable fracture, followed by early ROM exercises
Stable fractures do not require surgery
Removable splints are used for 6-8 weeks

35. Volkmann’s Contracture
Etiology
Associate w/ humeral supracondylar fractures, causing muscle spasm, swelling, or bone pressure on brachial artery, inhibiting circulation to forearm
Can become permanent
Signs and Symptoms
Pain in forearm - increased w/ passive extension of fingers
Pain is followed by cessation of brachial and radial pulses, coldness in arm
Decreased motion
Management
Remove elastic wraps or casts
Close monitoring must occur

36. Rehabilitation of the Elbow
General Body Conditioning
Must maintain pre-injury fitness levels - cardiovascular and strength (lower body)
Flexibility
Restoring ROM is critical in elbow rehab
Variety of approaches can be used as long as they don’t force the joint
Joint Mobilizations
Loss of proper arthrokinematics following immobilization is expected
Joint mobilization and traction can be very useful to increase mobility and decrease pain through restoration of accessory motions

37. Strengthening
Achieved through low-resistance, high-repetition exercises - must be pain free
Shoulder and grip exercises should also be performed
Continuous passive motion units followed by dynamic splinting is ideal following surgery
Isometrics can be used while elbow is immobilized
PNF and isokinetics are useful in early and intermediate active stages of rehab
A graded PRE program w/ tubing, weights or manual resistance should be included
Closed kinetic chain activities should also be incorporated - assist in both static and dynamic stability to the elbow
Proprioceptive training should also incorporated

38. Functional Progressions
Will enhance healing and performance
PNF, swimming, pulley machines and rubber tubing
to simulate sports activities
Should include steps
Warm-up
Gradual build up to activity, becoming increasingly more difficult
Return to Activity
Can re-engage in activity when criteria has successfully been completed
ROM w/in normal limits, strength should be equal w/ no complaint of pain
Return should progress with use of restrictions in an effort to objectively measure activity progression

39. Protective Taping and Bracing
Should be continued until full strength and flexibility have been restored
Chronic conditions usually cause gradual debilitation of surrounding soft tissue
Must restore maximum state of conditioning w/out encouraging post-injury aggravation