Elbow 3 - Common Conditions PDF

Orthopedic Treatment FT400 PT600 Elbow Module Section 3 - Common Conditions Tendons Tendonitis (Tendinopathy) Definition: This is an overuse injury that causes inflammation to the tendons involved in repetitive movements. In general, provoked by - Contraction against resista...

Orthopedic Treatment FT400 PT600 Elbow Module Section 3 - Common Conditions Tendons Tendonitis (Tendinopathy) Definition: This is an overuse injury that causes inflammation to the tendons involved in repetitive movements. In general, provoked by - Contraction against resistance (strengthen) (RROM/MMT of that muscle) - Stretch/elongation (lengthen) (AROM in opposite movement of that muscle) - Palpation (the site of tissue damage; the origin, the insertion) The above is true for all musculotendinous tissue damage Tendonitis Commonly - CET - CFT - Triceps MOI CET - repetitive forceful extension, radial deviation and supination CFT - repetitive wrist flexion & pronation. Sports & work Plumbing, carpentry, typists Golf, tennis, climbing Lateral Epicondylitis (aka Tennis Elbow) Tendinopathy of the CET Most commonly ECRB tendon The most Common Elbow Injury (7% of all sports injuries) Peak age at which it occurs is 40 – 50 years old. Primarily affects the Extensor Carpi Radialis Brevis muscle and occasionally the ECRL and more rarely the ECU. ECRB is susceptible to injury due to the tensile load imposed on the tendon when the muscle crosses the radial head during wrist FLX, elbow EXT and PRON. Lateral Epicondylitis (aka Tennis Elbow) Causes: Lateral tension overload → repeated microtrauma with extension-supination Any repeated movements that add tensile loads to CET. eg Poor backhand biomechanics in tennis Vibrations from Equipment (tennis racquets, drills etc) – vibrations travel up arm and terminate here Lateral Epicondylitis (aka Tennis Elbow) Signs and Symptoms Pain over the lateral epicondyle. Often refers into the C7 Dermatomal segment, down the posterior forearm into the dorsum of the hand and perhaps into the ring and long fingers. Lateral Epicondylitis (aka Tennis Elbow) It is important to palpate at 3 different locations to assess for Tendonitis 1. Supracondylar Ridge 2. Epicondyle 3. Directly over tendon Medial Epicondylitis (aka Golfer’s Elbow) Medial Epicondylitis 1˚ involves pronator teres and FCR Causes: faulty forehand/serve (tennis), golfing, carpentry (hammering) Repetitive medial tension overload Micro trauma to flexor/pronator Signs and Symptoms = pain, weak grip possible ulnar n.involvement Triceps Tendonitis Aka Posterior Tendon Injury, or Posterior Tennis Elbow Involves the Insertion of the Triceps Brachii at tendinous junction Causes: Overuse which typically follows sudden severe strain to the Triceps B tendon as the arm is fully extended. Too many bench days, bruh Triceps Tendonitis Signs and Symptoms: Pain is provoked on resisted elbow extension or end-range elbow flexion Perception of snapping over posteromedial aspect of the elbow may develop spontaneously (rare) Tendonitis - Grades Grade 1 = pain only after activity. Grade 2 = pain at the beginning of activity and after. Alleviates during activity. Grade 3 = pain at the beginning, during and after activity. Pain may restrict activity. Grade 4 = pain with ADL and continues to get worse Elbow Tendinopathy - Special Tests Cozen’s / Method 1 CET tendon Mill’s / Method 2 CET tendon Maudsley’s / Method 3 CET tendon Medial Epicondylitis Test CFT tendon Triceps MMT Triceps Tendon Tendinopathy - Treatment Acute = Rest and ice Chronic = Break & Build Decrease inflammation Decrease restrictions/adhesions Reduce HT in affected mm’s, TrPs Muscle tone, TrPs Maintain available ROM, Friction therapy if needed Decrease pain Mobilize hypomobile joints (check lig integrity first) Compensatory areas Stretch to maintain new length of functional scar Strengthen RROM to help realign fibres and return strength Bursae 15 Olecranon Bursitis This bursa is situated between the olecranon and the subcutaneous fascia and is quite swollen and obvious when inflamed. Irritated by repetitive weight bearing or trauma such as dragging the elbow on the ground when wrestling. Olecranon Bursitis The overuse of the structures surrounding the bursa = excessive friction upon bursa = inflammation of bursa. Trauma (blunt force or falling or banging elbow). Signs and symptoms: Acute: an obvious swelling of the bursa, burning pain, palpable heat and some redness Chronic: Swelling has decreased, still heat and some redness with localized pain over bursa Olecranon Bursitis Assessment: Observation and ROM of the Elbow Treatment planning: Treating bursitis is similar to tendonitis in the acute, subacute and chronic stages. Manage inflammation first then address the structures contributing to the bursitis i.e. - tendonitis. Mobilize to decrease compression - rolled up towel b/w elbow for self mobe Precautions and Contraindications: Avoid compressing an inflamed bursa; Techniques should work around the affected area until inflammation subsides. Only perform light onsite work with acute bursitis. If infected, refer to MD for medical attention. ## 19 Fractures Etiology: Usually from Direct or Indirect Trauma, can be from Pathological Changes or from Chronic Overuse Injuries. In the Elbow/Forearm fractures are often due to a FOOSH injury.  Fracture Types Simple – no external wound Epiphyseal – between shaft and epiphysis (children) Comminuted – bone splintered into pieces Colles – distal radius proximal to wrist (fragments Impacted - one section is wedged into interior of rotate and displace dorsally > “dinner fork another bone deformity”); usually from FOOSH Incomplete – does not include entire cross Galeazzi – Radius with dislocation of distal section of a bone radioulnar joint Greenstick – partially broken/bent (only in children – predominantly those with vit D deficiency) Olecranon Galleazi Radial Head # A radial head fracture is the most common broken elbow bone seen in adults. This type of injury is most commonly caused by a FOOSH. Radial head fractures cause pain and swelling around the elbow. Displaced Supracondylar Fracture Most common in children and elderly people. Unlike the other types of elbow fracture, this one is caused by a displaced humerus bone which affects the neighboring arteries and nerves causing severe pain. Most cases of displaced humerus need immediate surgery except for few cases wherein the humerus does not cause any injury to the arteries and nerves. Fracture Assessment ROM – Active, Passive and Resisted ROM POP is Contra-Indicated before consolidation has occurred. With PTs permission the therapist may contact the attending physician. Union = 3-6 weeks still visible fx line, tender ,weak fragile, calcified callus Consolidation = complete heal 6-12 weeks no pain or weakness with weight bearing Fractures - Special Tests Capillary Refill Test (aka Digit blood flow) Ensuring circulation has returned to distal area Girth Measurements Fracture - Signs & Symptoms During Immobilization The affected limb may be casted and an external fixation device or sling may be used. Antalgic posture may be present. For example, if a patient is using a sling with a casted Colles’ fracture, the limb may be held in a protective position with the shoulders elevated. Edema is present at the fracture site and distal edema may also occur. A cast will obscure local edema. Red, black or purple bruising may be visible at the fracture site or distal to it. A cast will obscure local bruising. A pained or medicated facial expression may be present. Fracture - Signs & Symptoms Post-Immobilization Habituated antalgic posture may be present. Chronic edema may remain at the fracture site and distal to it. When the cast is initially removed, the skin that was under the cast is likely dry, scaly or flaky. Disuse atrophy may be visible, especially if the limb was casted or the patient did not isometrically exercise the immobilized limb. Bruising should resolve to brown, yellow and green, and then disappear. If surgery was performed, scars will be present. Scars may range from half a centimeter long (following external fixation) to several centimeters in length (with open reductions). Stress # The site of the fracture is painful upon compression. Inflammation may or may not be palpable Fracture - Treatment During Immobilization Hydro – a cold application distal to the cast. Eg. fingers to help reduce edema Compensatory structures such as the trunk, contralateral limb, shoulders and neck Diaphragmatic breathing throughout to reduce SNS firing and pain perception Careful, mid-range pain-free PROM to proximal and distal joints to promote lymph drainage and reduce adhesions Vibrations over cast may help reduce pain and decrease SNS firing Any secondary injuries, such as strains or contusions are also treated Fracture - Treatment Post-immobilization Mild contrast hydro is initially used on tissues that were under the cast. Once muscle tone has returned – deep moist heat. Proximal limb is treated to reduce HT and TrPs. Gentle stimulating techniques are utilized on muscles suffering from disuse atrophy. Pain-Free mid-range PROM and AAROM are interspersed to improve tone. Joint play techniques on joints proximal and distal to area of fracture. Eg, SC & GH joints, and Scapulothoracic mobes after a wrist fracture. Fracture - Precautions & CI During Immobilization Post-immobilization (pre-consolidation) No Tractioning before union No POP Testing No Hot Hydro Distal to or immediately proximal to No Hydro extremes on tissues that were under a the cast (do not increase congestion) cast No AROM or RROM at Fx site of mm attachment No deep longitudinal Techniques on hypotoned or if laceration or severence of tendon crossing fx tissues site No stretch hypotoned/flaccid tissue No Heat or Ice if hardware has been used (internal fixation) No direct work with Open Wound No local massage for Stress Fx Radial Head Subluxation 35 Nursemaid’s Elbow Radial Head Subluxation Nursemaid's elbow, Babysitter's elbow or Pulled elbow Dislocation of the elbow joint caused by a sudden pull on the extended pronated arm, such as by an adult tugging on an uncooperative child, or swinging the child by the arms during play. Nursemaid’s Elbow Etiology: Occurs in young children before the age of 8, peak incidence at 2-3 yr old. The proximal end of the radius in young children is conical, with the wider end of the cone nearest the elbow. With time the shape of this bone changes, becoming more cylindrical but with the proximal end being widened. Due to the shape of the head of the radius, it is possible to traction or pull the head out of its normal position, damaging the annular ligament If a child’s arm is pulled by a parent of caregiver to keep them from falling down, going too slow, swinging a child for fun. The situation cannot arise in adults, or in older children, because the changing shape of the radius associated with growth prevents it. Nursemaid’s Elbow Signs and Symptoms: The child stops using the arm, which is held flexed and pronated. There may be an audible or palpable click in elbow Held in 90* of flexion and pronated forearm to reduce pain Minimal swelling. Assessment: All movements WNL, except supination. No Special Tests for this condition. Nursemaid’s Elbow Nursemaid’s Elbow Treatment planning: Reduction is usually accomplished by their MD or Chiropractor with elbow flexion and sudden and firm supination of the forearm. Decrease inflammation. Decrease pain. Increase ROM if there was a decrease post immobilization. Precautions and contraindications: Reduction by their MD or Chiro should not be delayed (should be within 12 hours). If after 12 hours – they may have to be immobilized by an above elbow cast with forearm in full supination and 90* of flexion. Peripheral Nerves 41 Peripheral Nerves Ulnar Nerve Median Nerve Radial Nerve Case Studies 43 Case Study I Ry is a 28 year old electrician apprentice and is coming in with uncomfortable pain at the elbow & wrist. MOI? Is it given in the case, what info do you need to figure it out? ROM affected? Does Patient list any ROM they feel pain or discomfort in? What conditions does your patient possibly present with? What assessment techniques qould be best or most indicated to use? Is your patient at risk of developing another condition relation to the elbow complex? What THEX would be best to perscribe the patient? Case Study II Baylor is a young gymnast and is coming in because they’re experiencing some discomfort post FX after their cast was removed 2 weeks ago and would like some rehab advice. MOI? Is it given in the case, what info do you need to figure it out? ROM affected? Does Patient list any ROM they feel pain or discomfort in? What conditions does your patient possibly present with? What assessment techniques would be best or most indicated to use? Is your patient at risk of developing another condition relation to the elbow complex? What THEX would be best to prescribe the patient?