Chapter 23 - The Elbow

5/13/2014 Chapter 23: The Elbow
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Chapter 23: The Elbow

Anatomy of the Elbow

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 10-15 degrees, males 5 degrees
Critical link in kinetic chain of upper
extremity

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?

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)

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

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
Tinels 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

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

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

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

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

Contusion
Etiology
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

Olecranon Bursitis
Etiology
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

Strains
Etiology
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

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 Tinels 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

Ulnar Collateral Ligament Injuries (cont.)
Management
Conservative treatment begins w/ RICE and NSAIDs
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 22-26 weeks post
surgery

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

Lateral Epicondylitis (continued)
Management
RICE, NSAIDs 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

Medial Epicondylitis
Etiology
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

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
Panners disease in incidents of children age <10
Signs and Symptoms
Sudden pain, locking; range usually returns in a few days

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; NSAIDs
Splint and cast applied for cases of extensive deterioration
If repeated locking occurs, loose bodies are removed
surgically

Little League Elbow
Etiology
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

Little League Elbow (continued)
Management
RICE, NSAIDs 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

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

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

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

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

Elbow Dislocation

Fractures of the Elbow
Etiology
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

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

Volkmanns 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

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 dont 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

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

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

""
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

Chapter 23 - The Elbow

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