Stanbridge - T4 - TE2 - W7 - The Elbow and Forearm

Therapeutic Exercise II - PTA 1010

• Course focuses on the elbow and forearm complex.
• Students will learn common surgical procedures for soft tissue and joint pathology at the elbow.
• Students will understand postoperative management of elbow dysfunction and the necessary interventions.
• Students will learn how to demonstrate exercise progressions to develop ROM, muscle performance, and functional use of the elbow and forearm complex.
• Students will learn effective implementation of therapeutic exercise programs to manage soft tissue and joint lesions in the elbow and forearm region. This includes stages of recovery and post-operative healing for common surgeries.

Outline

• Elbow Function & Anatomy Review
• Joint Hypomobility- conservative care and surgical options
• Fractures & ligamentous injuries
• Myositis Ossificans
• Overuse Syndromes

Bones and Joints of the Elbow and Forearm

• Diagrams of the elbow and forearm bones and ligaments are provided.
• Key structures like the humerus, radius, ulna, annular ligament, and various collateral ligaments are included.

Joints of the Elbow & Forearm Complex

• Humeroulnar joint: responsible for flexion and extension.
• Humeroradial joint: responsible for flexion and extension.
• Radiocapitellar joint: carries 60% of the load transfer and can withstand up to 90% of body weight (Rizzo et al. 2002).
• Proximal radioulnar joint: involved in pronation and supination.
• Distal radioulnar joint: involved in pronation and supination.

Review - Ligaments of the Elbow

• Medial (Ulnar) Collateral Ligament: Includes anterior medial, posterior medial collateral, and transverse ligaments. Resists valgus stress, limits end-range extension, and approximates joint surfaces. Throwing and golfing can increase stress on the MCL.
• Lateral (Radial) Collateral Ligament: Includes lateral (radial) collateral, lateral ulnar collateral, and annular ligaments. It resists varus stress, stabilizes against supination forces, stabilizes the humeroradial joint, resists longitudinal distraction, and prevents posterior translation of the radial head.

Elbow joint Arthrokinematics

• Humeroradial joint: concave radial head, convex distal humerus (capitellum).
• Humeroulnar joint: concave proximal ulna (trochlear notch), convex distal humerus (trochlea).
• Proximal Radioulnar Joint (PRUJ): concave radial notch of the ulna, convex radial head.

Referred Pain and Nerve Injury in the Elbow Region

• C5, C6, T1, T2 nerve roots refer symptoms that can cross the elbow region.
• Ulnar nerve: compression in cubital tunnel, entrapment of deep branch under ECRB with radial head fracture, direct trauma to superficial branch along lateral radius.
• Median nerve: Pronator teres vs anterior interosseous vs carpal tunnel syndrome.

Joint Hypomobility: Common Causes

• Rheumatoid arthritis (RA)
• Juvenile rheumatoid arthritis (JRA)
• Degenerative joint disease (DJD)
• Trauma
• Dislocation
• Fractures

Joint Hypomobility: Common Impairments

• Acute stage (0-4-6 days): pain (often at rest), swelling, muscle guarding, restricted elbow flexion/extension.
• Subacute/Chronic stage: capsular pattern of elbow (flexion > extension), humeroradial joint shows no pattern, examination shows abnormal capsular/firm or bony end feel, decreased joint play, chronic elbow arthritis (pron./sup restricted with abnormal firm end feel, decreased joint play at the proximal radioulnar joint, pain with over pressure at the distal radioulnar joint), common functional limitations (difficulty or pain with pushing/pulling, restricted hand-to-mouth activities, unable to carry objects with a straight arm, limited reaching capabilities, difficulty turning doorknobs/keys)
• Functional motion: motion between 30 and 130 degrees of elbow flexion, total of 100 degrees of radioulnar motion equally divided between pronation & supination.

Tx Guidelines - Non-operative Management (Acute Phase)

• Education on joint protection and daily activities modifications.
• Reduce inflammation and synovial effusion, protect the area.
• Maintain integrity and function of related areas.
• Maintain soft tissue and joint mobility.

Non-operative Management (Subacute Phase)

• Increase soft tissue and joint mobility.
• Improve joint tracking of the elbow (MWM joint mobilization).
• Improve muscle performance and functional abilities.

Surgical Options for Advanced OA

• Radial head excision
• Total Elbow Arthroplasty (TEA)

Excision/Resection Radial head Arthroplasty

• Removal of periarticular bone from one or both articular surfaces.
• Seen in late-stage arthritis of the humeroradial joint, severe comminuted fracture of the radial head, and pt with low activity level.

Post Operative Management: Radial Head Excision

• Resection with intact UCL has minimal affect on stability.
• Resection with unstable UCL results in significant functional limitation.
• Post-operative immobilization: posterior resting splint in 90 degrees of elbow flexion and neutral forearm.

Radial Head Excision: 0-6 weeks Maximum Protection Phase

• Maintain elbow and forearm mobility in the hinged splint (PROM).
• Maintain mobility and function of un-operated joints.
• Educate on wound care, pain management, and edema control.

Post operative Management: Radial Head Excision Exercise: Moderate and Minimum Protection Phases

• Increase ROM: gentle manual or dynamic stretching, LLLD preferable, hold relax techniques.
• Grade II joint mobilization → grade III at 6 weeks post op (joint capsule healed).
• Functional strength and endurance: low load resistance (1-2 lb only).

Post operative Management: Radial Head Excision - Resumption of Activities

• Refrain from high-demand activities after prosthetic implant or rehab.
• Avoid using UE to move or hold heavy objects.
• Refrain from sports that stress the elbow (racquet sports).

Total Elbow Arthroplasty (TEA)

• Indications: Debilitating pain and loss of functional use of the arm due to moderate-severe arthritis of the HU and HR joints (RA, JRA, OA), gross elbow instability, comminuted intra-articular fracture, nonunion fracture of the distal humerus, failed prior surgeries, or marked (B) elbow mobility.
• Immobilization: position depends on type/approach of surgery; tissue affected.
• Maximum protection phase: Maintain shoulder, wrist, and hand mobility, regain elbow and forearm motion, and minimize UE muscle atrophy.

Total Elbow Arthroplasty (TEA) Moderate and Minimum Protection Phase

• Increase ROM of the elbow.
• Regain strength and muscular endurance of the operated extremity.
• Multiple angle isometrics.
• Light ADLs and OKC exercises (<1 lb).
• Limited repetitive lifting (6 months).
• Low-load closed chain exercises (e.g., wall push-ups).

Post operative Management: Total Elbow Arthroplasty (TEA) - Patient Education

• Avoid high load PRE during home and work-related activities after rehab.
• Avoid activities that apply high loads or impact on the UE (racquet sports, throwing, golf).
• Limit lifting repetitively (5# maximum), one time/single lift (10-15# maximum).

Post-Operative Management - Checklist

• Check MD referral for restrictions.
• Follow MD protocol.
• Determine what tissue was affected.
• Determine the protection phase.
• Follow the care plan from previous PT

Review

• Position of UE for maximum biceps stretch.
• Position for stretching pressure on biceps and triceps, pronation, and supination stretches.
• ROM required for elbow and forearm ADLs.
• Capsular pattern of the elbow and forearm.

Outline (Page 32)

• Elbow Function & Anatomy Review
• Joint Hypomobility
• Joint Surgery and Post-Op Management
• Myositis Ossificans
• Overuse Syndromes

Joint Surgery and Postoperative Management

• Fractures and dislocations often require ORIF or arthroscopic or open excision of bone fragments.
• Fracture of the head and neck of the radius is a common FOOSH injury.
• Common: posterior dislocation of the radial head coupled with ligament injury.
• Additional fractures are covered in orthopedic interventions. (Box 18.2 surgical options).

Fracture Indication

• If pronation/supination are suddenly restricted after acute injury, consider fracture, subluxation or dislocation.
• Refer to MD for exam and x-ray.

Fracture Reduction by ORIF

• Open reduction internal fixation of the fracture.
• Usually performed via mini open procedure.

ORIF: Post-op Management

• Check MD referral for precautions and contraindications following procedure.
• Goal: Maintain stability of healing fracture.
• Ther ex progression depends on type, severity, age, and associated health status.
• May have external stabilization (cast, external fixator, splint), or AROM, AAROM, protected weight bearing if no external stabilization.

"Terrible Triad" Elbow Fracture

• Dislocation of the elbow
• Radial head fracture
• Coronoid fracture
• Treatment options include closed reduction and immobilization or ORIF (most common).

Directional Instabilities (Varus)

• Radial collateral ligament insufficiency, occurs from simple/complex elbow dislocation or varus stress.
• Presentation: combined elbow extension with forearm supination is uncomfortable.
• Often treated with ORIF.

Directional Instabilities (Varus) Non-Operative Treatment

• Goal is protection and unloading of injured tissues.
• Hinged elbow brace with forearm in pronation (4-6 weeks).
• Avoid shoulder abduction and IR with flexion and extension-avoid varus force during rehab

Directional Instabilities (Valgus)

• Ulnar collateral ligament insufficiency, occurs from FOOSH or overuse (chronic attenuation), and often seen in overhead athletes.
• Presentation: tenderness approximately 2 cm distal from medial epicondyle.
• Non-operative management: Pt. education (activity restriction on throwing count), immobilization, strengthening of pronator flexor group and shoulder/trunk to generate force, surgery (Tommy John surgery).

Complex Elbow Instability

• Primary goals of surgery: anatomical osteosynthesis of all articular fractures, reconstruction of ligament injuries.
• Critical recovery period within 1st 6 months.
• 70% of patients recover functional ROM within first year.
• 80% recover functional ROM within one year.
• Protocol followed though phases of healing.

Review

• Why can AAROM and AROM be performed in the maximum protection phase after a radial excision?
• Why is performing gentle stretching important to the elbow?
• What are the weight restrictions for lifting after a radial head excision?
• What are the precautions and strengthening recommendations for varus vs. valgus instability?

Outline (Page 43)

• Elbow Function & Anatomy Review
• Joint Hypomobility
• Joint Surgery & Post-Op Management
• Myositis Ossificans
• Overuse Syndromes

Myositis Ossificans (MO), Heterotopic Ossificans (HO)

• Deposition of bone in muscle, tendon, etc.
• Causes: trauma, including fracture, dislocation, or injury to the brachialis muscle, commonly associated with aggressive stretching.
• Signs/Symptoms : Progressive loss of ROM, hyperemia, swelling, warmth, and pain with resisted flexion.

Myositis Ossificans Signs and Symptoms

• Progressive loss of ROM
• Signs: hyperemia, swelling, warmth
• Humeroulnar joint: passive extension more limited than flexion (noncapsular pattern)
• Pain with resisted flexion in mid range
• TTP over distal brachialis muscle
• Muscle is firm to the touch

Myositis Ossificans Management

• Contraindications: massage, stretching, resistive exercises.
• Rest: elbow kept in a splint until bony mass matures and reabsorbs.
• Active ROM, active pain-free exercises
• Possible surgical excision.

Myositis Ossificans: Prevention

• Avoid aggressive stretching during elbow pathology or post-op care while increasing range of motion.
• Use gentle low-load long-duration (LLLD) or proximal-pattern stretching (PPS) stretches.
• Educate patients on specific stretch application during lab.

Review

• Definition of myositis ossificans (MO).
• Signs and symptoms of MO.
• Lifting weight restriction after Total Elbow Arthroplasty (TEA).
• Possible complications of TEA.

Outline (Page 52)

• Elbow Function & Anatomy Review
• Joint Hypomobility
• Joint Surgery & Post-Op Management
• Myositis Ossificans
• Overuse Syndromes

Overuse Syndromes: Repetitive Trauma Syndromes

• Osteochondral defects
• Medial & lateral epicondylitis
• Biceps tendonitis
• Triceps tendonitis
• Olecranon bursitis

Osteochondral Defects (OCD)

• Defect of the bone and cartilage.
• Occurs in skeletally mature and immature individuals.
• Result of repetitive trauma and vascular susceptibility.
• Occurs on one or more articular surfaces of the elbow complex.
• Most common site: capitellum.
• Can cause loose bodies or bone fragments to break off into the joint. Osteochondritis dissecans.

Osteochondritis dissecans (OCD)

• Common in adolescents (12-17) with repetitive weightbearing and overhead activities.
• Two main groups: young male baseball pitchers and young female gymnasts
• Frequent symptoms: clicking, popping, and locking (later in the disease process).

Osteochondritis dissecans (OCD) Management

• Cartilage intact over fragment—non-operative treatment.
• Patient education: rest, bracing, break from aggravating activities.
• ROM and strengthening of the shoulder and scapular stabilizers while resting the elbow.
• Return to full function within 3-6 months.
• Surgery may be necessary due to continued symptoms, loose bodies, or displacement of capitellar lesions.
• Post-operative protocol follows the surgical procedure.

Overuse Syndromes: Tendinopathy

• Tendonitis: overuse causing microscopic tears and inflammations (in medial and lateral elbow=epicondylitis)
• Tendinosis: overuse causing degenerative changes (micro tears), lacking inflammation.

Lateral Elbow Tendinopathy (Tennis Elbow)

• Also termed Lateral Epicondylitis (or Epicondylalgia, Epicondylosis); 1–3% of population; 7–10x more common than medial epicondylitis; common wrist extensor tendons at the lateral epicondyle and humeroradial joint; affected tendons: ECRB, extensor digitorum communis, pain may also occur with stress to the annular ligament.

Lateral Elbow Tendinopathy (Tennis Elbow) - Etiology

• Activities requiring repetitive movements of the hands and wrists (wrist extension).
• Repetitive work tasks requiring handling loads >20 kg (10 times/day; tools>1kg).
• Repetitive movements >2 hrs/day.
• Low job control, and social support.

Lateral Elbow Tendinopathy (Tennis Elbow) - Positive Tests of Provocation

• Tenderness on or near lateral epicondyle.
• Pain with resisted wrist extension with elbow extended.
• Pain with resisted middle finger extension (elbow extended).
• Pain with passive wrist flexion (elbow extended, and forearm pronated).

Medial Elbow Tendinopathy (Golfer's Elbow)

• Involves the common flexor/pronator tendon near the medial epicondyle.
• Associated with repetitive movements into wrist flexion (e.g., swinging a golf club, pitching, work-related activities, heavy lifting.)
• Ulnar neuropathy is a possible finding.

Medial Elbow Tendinopathy (Golfer's Elbow) - Etiology

• Handling loads >5 kg (2x/min at 2 hrs/day) or >20kg (at least 10x/day).
• High hand grip forces (≥ 1 hr/day).
• Repetitive movements (≥2 hr/day).
• Working with vibrating tools (≥2 hrs/day).

Non-operative Management of Overuse Syndromes - Acute Phase

• Decrease pain, inflammation, edema, and spasm.
• Immobilize (cock-up splint, fingers and elbow free to move if lateral tendinopathy).
• Corticosteroid injections.
• Develop soft tissue and joint mobility (wrist isometrics, neuro-mobilization, cross-friction massage).

Non-operative Management of Overuse Syndromes - Subacute and Chronic Phases

• Increase muscle flexibility and scar mobility
• Restore joint tracking at the RU joint
• Improve muscle performance and function.
• Counterforce elbow sleeve or strap (lateral epicondylitis).
• Eccentric training
• Plyometrics
• Patient education (reducing overload forces and recognizing provoking factors).

Example of Activities in the Subacute Phase(Page 79)

• Provide images of activities in the subacute phase (Page 79)

Olecranon Bursitis

• Hard blow to the tip of the elbow or repeated leaning on hard surfaces
• Treatment: RICE, cortisone, draining the bursa, potential resection.