Chapter 23: The Elbow PDF

# Chapter 23: The Elbow ## Anatomy of the Elbow - The image depicts a labelled diagram of the elbow joint, showing the bones and ligaments involved. ### Bones - **Humerus** - **Ulna** - **Radius** ### Ligaments - **Joint capsule** - **Radial Collateral Ligament** - **Ulnar Collateral Ligament**...

# Chapter 23: The Elbow ## Anatomy of the Elbow - The image depicts a labelled diagram of the elbow joint, showing the bones and ligaments involved. ### Bones - **Humerus** - **Ulna** - **Radius** ### Ligaments - **Joint capsule** - **Radial Collateral Ligament** - **Ulnar Collateral Ligament** - **Annular Ligament** - **Interosseous membrane** ### Other Structures - **Olecranon fossa** - **Trochlear notch** - **Coronoid process** - **Radial notch** - **Capitulum** - **Trochlea** - **Medial epicondyle** - **Lateral epicondyle** - **Tuberosity of ulna** - **Tuberosity of radius** - **Head of radius** - **Neck of radius** ## Functional Anatomy - **Complex joint** that allows for flexion, extension, pronation and supination - **Range of motion**: - 145 degrees of flexion - 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 - **Carrying angle**: due to distal projection of humerus - Normal in females: 10-15 degrees - Normal in 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 & decrease pain - Pain: type, quality, duration - 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 & 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 & radial arteries - 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 sustains sensation along 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 muscles. - **Pronator Teres Syndrome Test** - Forearm pronation is resisted. - Increased pain proximally over pronator teres indicates a positive test. - **Functional Evaluation** - Pain & 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 - The elbow is subject to injury due to a broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage. - Many sports place excessive stress on the joint. - The locking motion of some activities, use of implements, and involvement in throwing motion make the elbow extremely susceptible to injury. ### Injuries - **Contusion** - Etiology - Vulnerable area due to lack of padding. - Result of direct blow or repetitive blows. - Signs & Symptoms - Swelling (rapidly after irritation of bursa or synovial membrane) - Management - Treat with 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 & Symptoms - Pain, swelling, and point tenderness. - Swelling will appear almost spontaneously and without 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 & 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 with 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 neve inflammation, or wrist flexor tendinitis; overuse flexor/pronator strain, ligamentous sprains; elbow flexion contractures or increased instability. - Signs & Symptoms - Pain along medial aspect of elbow; tenderness over MCL. - Associated paresthesia, positive Tinel's sign. - Pain with 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 with in MCL; loose bodies in posterior compartment. - Management - Conservative treatment begins with RICE and NSAID's. - With 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 & Symptoms - Aching pain in region of lateral epicondyle after activity. - Pain worsens and weakness in wrist and hand develop. - Elbow has decreased ROM; pain with resistive wrist extension. - 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. - **Medial Epicondylitis** - Etiology - Repeated forceful flexion of the wrist and extreme valgus torque of the elbow. - Signs & Symptoms - Pain produced with forceful flexion or extension. - Point tenderness and mild swelling. - Passive movement of the 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 and shearing of the radiocapitaular joint. - Seen in young athletes involved in throwing motion. - Panner's disease in incidents of children age <10 - Signs & Symptoms - Sudden pain, locking; range usually returns in a few days. - 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. - **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 & 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. - Management - RICE, NSAID's and analgesics. - Throwing stops until pain resolved and full ROM is regained. - Gentle stretching and triceps strengthening. - Throwing under supervision with good technique to prevent recurrence. - **Cubital Tunnel Syndrome** - Etiology - Pronounced cubital valgus may cause deep friction problem. - Ulnar neve dislocation. - Traction injury from valgus force, irregularities with tunnel, subluxation of ulnar nerve due to lax impingement, or progressive compression of ligament on the neve. - Signs & 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. - Management - Rest, immobilization for 2 weeks with NSAID's. - 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 with 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 with shaft of humerus. - Signs & Symptoms - Swelling, severe pain, disability. - Complications with median and radial nerves and blood vessels. - Often a radial head fracture is involved. - Management - Cold and pressure immediately with sling. - Refer for reduction. - Neurological and vascular function 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). - **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 & Symptoms - May not result in visual deformity. - Hemorrhaging, swelling, muscle spasm. - 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. - **Volkmann's Contracture** - Etiology - Associate with humeral supracondylar fractures, causing muscle spasm, swelling, or bone pressure on brachial artery, inhibiting circulation to forearm. - Can become permanent. - Signs & Symptoms - Pain in forearm - increased with passive extension of fingers - Pain is followed by cessation of brachial & 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 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. - **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 with 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 within normal limits, strength should be equal with 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 without encouraging post-injury aggravation.