Elbow Instability PDF

Elbow Instability Filippo Olivo PT, OMPT Davide Seri PT, Msc, OMPT «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Elbow’s stabilisers Ulnohumeral Joint...

Elbow Instability Filippo Olivo PT, OMPT Davide Seri PT, Msc, OMPT «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Elbow’s stabilisers Ulnohumeral Joint Radiohumeral Muscles crossing the elbow compose the Joint dynamic stabilizers Common Capsule Extensor Tendons Anconeus Triceps Brachialis Common Flexor/Pronator Tendons UCL LUCL Static stabilizers Primary stabilisers O'Driscoll, 2001 Secondary stabilisers «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Ulnar collateral ligament Medial ulnar collateral ligament (MUCL), Medial collateral ligament (MCL) Primary restraint to valgus stress Anterior bundle Anterior band (tension ↑ in EXT ) Posterior band (tension ↑ in FLEX) Posterior bundle Tension ↑ in FLEX Transverse ligament May support the AB and provide some resistance to valgus loading Labott, 2018; Camp, 2018; Downham, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Lateral collateral ligament complex Restraint to varus and posterolateral rotatory instability Lateral Ulnar Collateral Ligament (LUCL) Radial collateral ligament Anular ligament Accessory Collateral Ligament Safran, 2005 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Epidemiology Second most common large joint dislocation Annual incidence of 5.21 per 100,000 About a quarter are associated with elbow fractures Age elbow dislocation rates Kuhn, 2008; Stoneback, 2012; Layson, 2022 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Classification Dislocation Associated Articulations Timing Direction Grade fractures involved Subluxation Ulno-humeral Acute Posterior Anterior Medial Lateral Simple (perched) joint Radio-humeral Chronic Posterolateral Dislocation Complex joint Recurrent Posteromedial O'Driscoll, 2001 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Etiology Traumatic Overuse «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Mechanism of injury Fall on outstretched hand Axial load to the elbow through the forearm, which transmits a rotational force Which structures? In which order? Adams, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Posterolateral rotatory instability Axial load Elbow flexion External rotation Valgism Horii Circle O'Driscoll, 1991 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome It is time to switch to the other side? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  It is time to switch to the other side? In posterolateral dislocation the soft tissue disruption initiates and is more severe on the medial side! «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  It is time to switch to the other side? External rotation was generally subtle Severe valgus deformity immediately after loading regardless of forearm position Failure of the AMCL may be necessary before joint dislocation occurs in at least some dislocations Lack radiographic proof of dislocation or knowledge of associated fractures «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome It is time to switch to the other side? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Etiology Traumatic Overuse «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Valgus instability Pitching places a high stress on the medial elbow, with forces recorded up to 115 N m. Ulnar collateral ligament fails at 32.1 N m Activity of secondary stabilizers is required to maintain elbow stability! Dillman, 1991; Dove, 2021; Bullock, 2021; The most valgus stress is applied during the late cocking and acceleration phases of throwing «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Valgus instability Improve pitching motion Increase shoulder external rotation torque Decrease shoulder abduction at front foot contact Increase elbow flexion at front foot contact Bullock, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Valgus instability Repetitive stress from the serve and forehand motions can compromise the UCL ligament Valgus stress on the elbow can exceed 60 N m during a tennis serve Patel, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Complex dislocation the risk of recurrent instability and posttraumatic osteoarthritis Radial head fractures 5-10 % Coronoid fractures 10 % Avulsion fractures of the medial 12 % or the lateral epicondyles Brachial artery Neurovascular injuries (rare) Compartment syndrome Median nerve entrapment Kuhn, 2008 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Terrible triad Coronoid fracture (white arrow) Radial head/neck fracture (black arrow) Elbow dislocation Poor treatment outcomes (recurrent instability, stiffness, post-traumatic arthrosis, chronic pain) Hotchkiss, 1996; Chen, 2015 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome PLRI Symptoms Recurrent painful clicking, snapping, clunking, or locking Extension portion of the arc of motion, with the forearm in supination The elbow feels loose or slides out of joint when they perform activities Apprehension in performing activities that precipitate the instability Pushing on the armrests while rising from a chair Medial elbow pain PAIN Lateral elbow pain O'Driscoll, 2000; Mehta, 2004 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Valgus instability Symptoms “Pop” and medial elbow pain following throwing activities Classically during the late cocking to early acceleration phase of throwing Progressive loss of velocity, accuracy, and endurance Exacerbated by glenohumeral internal rotation deficits Medial elbow pain PAIN Lateral elbow pain Karbach, 2017; Willemot, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Evaluation HISTORY OBSERVATION Deformity Age Ecchymosis Sports/work practice Tumefaction Trauma and mechanism Protective attitudes Symptoms characteristics Active ROM PALPATION INSTABILITY TESTS Bony findings Painful areas IMAGING Rezaie, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Instability tests Valgus Instability Valgus stress test Moving valgus stress test PLRI Varus stress test Lateral pivot-shift test Chair push-up test Prone push-up test Table-top relocation test «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Valgus instability Valgus stress test Moving Valgus stress test Callaway, 1997 O’Driscoll, 2005 SN 66% SN 100% SP 60% SP 75% «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome PLRI Varus stress test Lateral pivot shift test Morrey, 1996 O'Driscoll, 1991 SN 66% SN 100% (anaesthetised patient) SP 60% SN 38% «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome PLRI Chair push-up test Prone push-up test Regan, 2006 Regan, 2006 SN 87% SN 100% (if permormed in clusters) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome PLRI Table-top relocation test Arvind, 2006 SN% 100 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Imaging Plain anteroposterior, lateral and oblique Intra-articular fractures X-Rays Repeated at 1 week to ensure the reduction has been maintained Computed tomography (CT) Occult fractures and intra-articular fracture fragments MRI Chronic instabilities or simple dislocations in which instability persists. Dynamic fluoroscopy or Dynamic examination of the soft tissue structures ultrasonography Rezaie, 2020; Reichert, 2021; Marinelli, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Rehabilitation guidelines to optimize outcomes ✓ The mechanism of injury and the various structures involved, if known ✓ The status of the UCL and LCL and the safe arc of motion ✓ The status of the ligamentous and osseous injuries in operative cases ✓ The surgeon should advise the therapist if a radiographic “drop sign” is present Pipicelli, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Conservative Surgery Unreducible dislocation (1% or less) Simple dislocations Inability to maintain the elbow sufficiently reduced (10%) Low functional demands High functional demands Complex dislocations Unstable elbow dislocation Marinelli, 2021; Barco, 2023 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Conservative treatment The optimal rehabilitation remains unclear Immobilisation in an above-elbow plaster No longer than 2/3 weeks! (high risk of developing elbow stiffness) Manual therapy Gravity compress the ulnohumeral joint and Overhead exercises recommended thereby improve joint tracking and stability Isometric exercises Positive drop sign Schreiber, 2015; Pipicelli, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Conservative treatment Avoid varus or valgus forces! Protect the collateral ligaments Forearm rotation Affects joint stability MCL deficient Supination LCL deficient Pronation MCL and LCL deficient Neutral Pipicelli, 2020; Marinelli, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Strengthening and Functional Retraining Strengthening of the dynamic stabilizers of the ulnohumeral joint at 4 to 6 weeks post-reduction Gradual and graded to prevent an inflammatory reaction, which can contribute to further stiffness Isotonic strengthening of the elbow flexors/extensors and the shoulder girdle at 8 weeks Varus and valgus load at 12 weeks Job/sport-specific exercises Pipicelli, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Outcome measures Dysability of Arm, Shoulder and Hand (DASH) Mayo Elbow Performance Score Oxford Elbow Score NPRS «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Early or late mobilization? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Early or late mobilization? Almost half the costs per patient! «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Conservative Surgery «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  To repair, or not to repair, that is the question. «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Repair vs no repair Conservative treatment Coservative treatment/surgery Surgery Marinelli, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  To repair, or to reconstruct, that is the question. «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Repair vs Reconstruction Return to competition at 6.7 months Return to competition at 11.6 months Patient selection is crucial for success Proximal or distal tears with good quality tissue Mid-substance tears with poor quality Chronic UCL insufficiency or adaptive changes of the ligament «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Recurrent instability Elbow stiffness Heterotopic ossification Complications Nerve injury CRPS Infection Downham, 2020; Luchetti, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Take home messages The pattern of soft tissue injury depends on the position of the limb at the time of impact, direction of the force, and the variations in soft tissue laxity of the patient The decision-making process must be based on HISTORY, CLINICAL EXAMINATION AND IMAGING The first-choice treatment is conservative. Surgery is proposed in cases of Complex Dislocation or in case of failure of conservative treatment Early mobilization should be preferred over plaster immobilization «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Bibliography 1. O'Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect. 2001;50:89-102. PMID: 11372363. 2. Labott JR, Aibinder WR, Dines JS, Camp CL. Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function. World J Orthop. 2018 Jun 18;9(6):78-84. doi: 10.5312/wjo.v9.i6.78. PMID: 29984194; PMCID: PMC6033709. 3. Camp CL, Jahandar H, Sinatro AM, Imhauser CW, Altchek DW, Dines JS. Quantitative Anatomic Analysis of the Medial Ulnar Collateral Ligament Complex of the Elbow. Orthop J Sports Med. 2018 Mar 26;6(3):2325967118762751. doi: 10.1177/2325967118762751. PMID: 29637082; PMCID: PMC5888833. 4. 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