Elbow - Notes PDF

Elbow – Notes 2025-01-17 8:35 PM Section 1: Anatomy Elbow Function The elbow functions to serve hand movements Elbow flexion & extension adjusts for the appropriate height and distance...

Elbow – Notes 2025-01-17 8:35 PM Section 1: Anatomy Elbow Function The elbow functions to serve hand movements Elbow flexion & extension adjusts for the appropriate height and distance Forearm supination and pronation allow for complex movements and mobility The elbow allows for a wide range of complex and skilful, or strong and forceful hand movements needed for daily function, leisure, or work Muscles: Brachium Biceps Brachialis Coracobrachialis Brachioradialis Triceps Anconeous Superficial Extensors Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Deep Distal Four Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor insidious Superficial Flexors Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis Deep Flexors Flexor digitorum profundus Flexor pollicis longus Bursae: Olecranon Bursa Found between the olecranon and the subcutaneous fascia and becomes quite swollen and obvious when inflamed It is irritated by weight bearing or trauma such as dragging the elbow on the group when wrestling Mixed martial arts, or jujitzu Called "students elbow" Blood Vessels: Brachial artery is closely related to the median nerve in proximal regions, the median nerve is immediately lateral to the brachial artery Distally, the median nerve crosses the medial side of the brachial artery and lies anterior to the elbow jt Ulnar and radial arteries branch off of the brachial artery just distal to the elbow jt Interosseous Membrane: It is a fibrous sheet that connects radius and ulna It is the main part of the radioulnar syndesmosis, a fibrous joint between the two bones The interosseous membrane Divides the forearm into anterior and posterior compartments Serves as a site of attachment for muscles of the forearm Transfers forces from the radius, to the ulna, then to the humerus – it absorbs force Checks proximal displacement of the radius on the ulna Tissue is LAX when the forearm is PRONATED Oblique Cord: Checks distal displacement of the radius on the ulna Arcuate Ligament of Osborne: Can compress the ulnar nerve becomes taut at 90 degrees of elbow flexion and can potentially compress the ulnar nerve HumeroUlnar Joint: Joint Type Synovial, Hinge Articulating Surfaces Trochlea of the humerus w/ trochlear notch of the ulna Capsular Strength/Coaptation Weak – moderate coaptation Ligaments Ulnar Collateral Ligament Triangular shape – 3 bands: 1. Anterior = medial epicondyle ---> medial edge of coronoid process 2. Posterior = holds medial epicondyle and olecranon process together 3. Transverse = stabilizes the distal attachments of anterior & posterior Resists VALGUS stress or checks medial inferior displacement HumeroRadial Joint: Joint Type Synovial, Atypical ball and socket Articulating Surfaces Capitulum of the humerus w/ head of the radius Capsular Strength/Coaptation Weak – Moderate coaptation Ligaments Radial Collateral Ligament V – shaped Underside of lateral epicondyle ---> annular ligament and radial notch Resists VARUS stress or checks lateral inferior displacement Proximal RadioUlnar Joint: Joint Type Synovial, pivot Articulating Surfaces Head of the radius w/ radial notch of ulna Capsular Strength/Coaptation Weak Ligaments Annular Ligament Major joint stabilizer Anchors the head of the radius to the radial notch Prevents INFERIOR distraction of radius Children get 'pulled-elbow' via sudden jerking movements Quadrate Ligament Inferior thickening Posterior fibers become taught w/ pronation Anterior fibers become taught on supination Extras: Interosseous Membrane Dissipates force Stabilizes both radioulnar joints Prevents proximal displacement of radius on ulna from pushing movement Oblique Cord Originates at radial notch (ulna) obliquely to insert at medial surface of the neck of the radius Prevents distal displacement of radius on ulna especially w/ pulling movements Ligament of Struthers Originates at supracondylar process to insert at medial epicondyle Can impinge the median nerve HumeroUlnar Joint: Osteokinematics 1 degree of freedom: Flexion – Extension There is some Abd/Add - oblique axis – is NOT considered a degree of freedom Arthrokinematics Trochlea of HUMERUS Ant/post = convex Med/lat = concave Trochlear notch of ULNA Ant/post = concave Med/lat = convex Resting Position 70˚ FLX w/ 10˚ supination Closed Pack Position* Full extension & supination CPR Flexion > extension, supination/pronation limited only if severe ROM & End Feel Flexion 0 - 150˚; Soft Extension 0 – 5˚; Hard HumeroRadial Joint: Osteokinematics 2 degrees of freedom: Flexion – extension Pronation – supination There is some Abd/Add - oblique axis – is NOT considered a degree of freedom Arthrokinematics Capitulum of the humerus – convex Radial head – concave Resting Position Full extension and supination Closed Pack Position* 90˚ FLX & 5˚ Suination CPR Flexion > extension, supination/pronation limited only if severe ROM & End Feel Flexion 0 - 150˚; Soft Extension 0 – 5˚; Hard Supination 0 – 90˚; Firm Pronation 0 – 70/90˚; Firm/Hard Proximal RadioUlnar Joint: Osteokinematics 1 degree of freedom: Supination – Pronation Arthrokinematics Head of the radius – convex Radial notch of ulna – concave Resting Position 70˚ flexion w/ 35˚ supination Closed Pack Position* 5˚ supination and full extension CPR Supination = Pronation ROM & End Feel Supination 0 – 90˚; Firm Lever system: 1˚ 2˚ , 3˚ Pronation 0 – 70/90˚; Firm/Hard Effort – muscle Fulcrum – axis Load – weight Section 2 – Biomechanics: 1˚ lever system = eg. C-spine 1. Carrying Angle Effort – Fulcrum – Load The trochlea of the humerus is asymmetrical 2˚ order lever system = eg. Calf or wheelbarrow This gives the elbow the CARRYING ANGLE Fulcrum – load – effort High mechanical advantage Men: 10 – 15˚ , Women: 20 - 25˚ (H&K) **don’t need to know numbers** 3˚order lever system = elbow flexors (elbow jt) opposite as wheelbarrow Men: 5 – 10˚, Women: 10 – 15˚ (Magee) Fulcrum (elbow jt) – effort – load (hand) Mechanical disadvantage This asymmetry allows for joint play needed for full ROM Axis of motion (follows the trochlear groove) is oblique: the Trochlea is oblique SUPERIOR – LATERAL to INFERIOR – MEDIAL A little gap on the medial surface of the joint when in extension – medial gap joint mob A little gap on the lateral surface of the joint when in flexion – lateral gap joint mob Carrying Angle & Accessory Movements The carrying angle produces the following accessory movements: 1. A slight screw action – supination w/ flexion, pronation w/ extension 2. ABD, ADD & gliding of the radial head on both the humerus and ulna On full EXTENSION the MEDIAL part of olecranon is not in contact with the trochlea - MEDIAL GAP On full FLEXION the LATERAL part of the olecranon is not in contact w/ the trochlea – LATERAL GAP This allows for side-to-side joint play needed for supination and pronation Joint Mobilizations Full extension On full EXTENSION the MEDIAL part of the olecranon is not in contact with the trochlea (medial gap) Hence, a medial gap joint mob can assist in achieving full EXTENSION Full flexion On full FLEXION the LATERAL part of the olecranon is not in contact with the trochlea (lateral gap) Hence, a lateral gap joint mob can assist in achieving full FLEXION 2. Mid Radioulnar Joint Not a true joint Between the radius, ulna, and interosseous membrane The interosseous membrane is TAUT midway b/w supination and pronation (neutral position) Helps to dissipate forces from the hand so they are less at the elbow This 'joint' is affected by injury to the elbow joints and can affect the mechanics of the elbow articulations Interosseous Membrane Prevents proximal displacement of radius on ulna Engaged by pushing movements Oblique Cord Prevents distal displacement of radius on ulna Engaged by pulling movements 3. Third Order Lever The lever structure means 1. Load in the hand is 10x more at the elbow joint 2. The joint therefore has poor mechanical advantage 3. However, it is a good speed multiplier (eg. Throwing) What is slowing this down? Biceps brachii – could develop bicipital tendonitis Elbow Observation: MOI Traumatic/Sudden vs. Insidious/Gradual FOOSH, traumatic, repetitive strain etc. What activities do you engage in that requires repetitive, vigorous action of the arm and elbow? Most elbow pain is either traumatic OR progressive that becomes active w/ certain activities – tennis elbow Does pulling (traction), twisting (torque), or pushing (compression) alter the pain? 1. Holding Pattern Posture in which the elbow is held 2. Functionally Use during gait, ability to undress, willingness to use the arm 3. Structure Place guest in anatomical position to assess the carrying angle Normal = slight valgus More than normal is cubitus valgus – most evident on full extension Less than normal is cubitus varus – decreases as elbow flexes If there was a fracture or epiphyseal injury to the distal humeral, a cubitus varus may result and a gun-stock deformity may be seen on full extension Soft Tissue Look for Atrophy Swelling – most evident in the triangular space between the radial head, tip of the olecranon and lateral epicondyle Bursitis = demarcated 'goose egg' over olecranon process If inflammation/joint effusion All 3 joints affected b/c they share the same joint capsule Palpation Look for Skin – temperature, moisture, mobility, tenderness, texture Soft tissues – tone consistency, mobility, swelling, pulse, tenderness Bones & soft-tissue attachments – joint lines, bony contours, tenderness Movement Functional ROM Full range of elbow movements is not necessary to perform most ADLs Most ADLs are performed (as combined movements) requiring - 30 – 130 degrees FLEX – EXT and 50 degrees SUPINATION – PRONATION Some commonly affected ADLS: a. Eating – picking up something and bringing it to your mouth or vice versa b. Screw driver – tightening or loosening (add extension or flexion) c. Opening a bottle of wine Keys to look for in ROM: Musculotendinous – painful resistance to stretch, pain or weakness Joint capsule – early end feel, and multiple ranges affected (decreased in all ranges) Contracture – restriction of movement Neurological Nerve roots Myotomes Dermatomes C5 – T1 Reflex Testing 1. C5 – biceps 2. C6 – brachioradialis 3. C7 – triceps Special Tests Valgus more commonly used cause is it more commonly injured Section 3: Common Conditions Tendons Tendonitis (Tendinopathy): An overuse injury that causes inflammation to the tendons involved in repetitive movements In general, provoked by 1. Contraction against resistance (strength) - RROM/MMT of that muscle 2. Stretch/elongation (length) - AROM in opposite movement of that muscle 3. Palpation – the site of tissue damage; the origin & insertion The above is true for all musculotendinous tissue damage Things to do for Tendonitis 1. Offload Tendon Massage to the muscle belly 2. Strengthening – eccentric load (helps to remodel tendons) - mainly through homecare Get a baseline Learn movement – rate, amplitude, sensory feedback, accurate prescription 3. Inflammation NSAIDS Stop/modify activities Onset + severity 4. MFR – Adhesions 5. TrP Intention is to modify collagen fibers Commonly Affected Areas Common extensor tendon – CET Common flexor tendon – CFT Triceps MOI CET – repetitive forceful extension, radial deviation and supination CFT – repetitive wrist flexion and pronation Sports & Work – plumbing, carpentry, typists, golf, tennis, climbing Lateral Epicondylitis – aka Tennis Elbow: Most commonly ECRB tendon – extensor carpi radialis brevis The most common elbow injury (7% of all sports injuries) Peak age at while it occurs is 40 – 50 years old Primarily affects the extensor carpi radialis brevis mm and occasionally the extensor carpi radialis longus (ECRL) and more rarely the extensor carpi ulnaris (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 Causes Lateral tension overload –> repeated microtrauma w/ 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 Signs & 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 TrP's of extensor digitorum give off a similar pattern of pain for lateral epicondylitis Palpation 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 Golfers Elbow: 1˚ involves pronator teres and FCR Causes Faulty forehand/serve (tennis), golfing, carpentry (hammering) Repetitive medial tension overload Microtrauma to flexor/pronator Signs & Symptoms Pain, weak grip Possible ulnar nerve involvement Ulnar nerve travels through Flexor digitorum profundus and flexor capri ulnaris Triceps Tendonitis: Aka Posterior Tendon Injury, or Posterior Tennis Elbow Involves the Insertion of the Triceps Brachii at tendinous junction Causes Overuse with typically follows sudden severe strain to the triceps brachii tendon as the arm is fully extended To many bench days Signs & 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 w/ 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 / Reverse Mills CFT tendon Triceps MMT Triceps Tendon Tendinopathy – Treatment: Acute Rest and ice Decrease inflammation Reduce HT in affected mm's, TrPs Maintain available ROM Decrease pain Compensatory areas Strengthen Chronic Break & Build Decrease restrictions/adhesions Muscle tone, TrPs Friction therapy if needed Mobilize hypomobile joints – check lig integrity first Stretch to maintain new length of functional scar RROM to help realign fibers and return strength Common Conditions: Bursae Olecranon Bursitis: This bursa is situated b/w 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 wresting Causes The overuse of the structures surround the bursa = excessive friction upon bursa = inflammation of bursa Trauma – blunt force or falling or banging elbow, wrestling, or mixed martial arts Signs & Symptoms Acute An obvious swelling of the bursa, burning pain, palpable heat and some redness Chronic Swelling has decreased, still heat and some redness w/ localized pain over bursa 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 mobilize to decrease compression – rolled up towel b/w elbow for self-mob Precautions & CI's Avoid compressing an inflamed bursa Techniques should work around the affected area until inflammation subsides Only perform light onsite work w/ acute bursitis If infected, refer to MD for medical attention Common Conditions: Fractures 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 Wont be asked these questions in this course Simple No external wound Comminuted Bone splintered into pieces Impacted One section is wedged into interior of another bone Incomplete Does not include entire cross section of a bone Stress Fracture The site of the fracture is painful upon compression Inflammation may or may not be palpable Greenstick Partially broken/bent - only in children Predominantly those w/ Vitamin D deficiency Epiphyseal Between shaft and epiphysis – children Colles Distal radius proximal to wrist – fragments rotate and displace dorsally Dinner fork deformity Usually from FOOSH Galeazzi Radius w/ dislocation of distal radioulnar joint Radial Head Fracture The most common broken elbow bone seen in adults Most commonly caused by a FOOSH 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 neighbouring 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 CI'd 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 – this is key Radiographic healing Fractures – Special Tests Capillary Refill Test Aka digit blood flow Ensuring circulation has returned to distal area Girth Measurement Checks for atrophy/amount of atrophy Checks for residual swelling 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 Eg. If a patient is using a sling w/ a casted colles fracture, the limb may be help 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 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 ½ a cm long (following external fixation) to several cm in length (with open reductions) Fracture – Treatment During Immobilization Hydro – a cold application distal to the cast 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 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 and interspersed to improve tone Joint play techniques on joints proximal and distal to area of fracture Eg. SC & GH joints, and scapulothoracic mobs after a wrist fracture Fracture – Precautions & CI's During Immobilization No tractioning before union No hot hydro distal to or immediately proximal to the cast – do not increase congestion No AROM or RROM at fracture site of mm attachment or if laceration or severence of tendon crossing fracture site No heat or ice if hardware has been used (internal fixation) No direct work with open wound No local massage for stress fracture Post – Immobilization PRE-CONSOLIDATION No POP testing No hydro extremes on tissues that were under a cast No deep longitudinal techniques on hypotoned tissues No stretch on hypotoned/flaccid tissue Common Conditions: Radial Head Subluxation Nursemaid's Elbow: Radial head subluxation – aka nursemaid's elbow, babysitter's elbow or pulled elbow Dislocation of the elbow jt caused by a sudden pull on the extended pronated arm, such as an adult tugging on an uncooperative child, or swinging the child by the arms during play Etiology Occurs in young children before the age of 8, peak incidence at 2 - 3 years 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 or caregiver to keep them from falling down, going too slow, or 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 Signs & 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 Treatment Planning Reduction is usually accomplished by their MD or chiropractor with elbow flexion and sudden and firm supination of the forearm Decrease inflammation and pain Increase ROM if there was a decrease post immobilization Precautions and CI's 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 and above elbow cast with forearm in supination and 90˚ of flexion Section 4: Home Care Joint Lesions & Overuse Syndromes Acute – PROTECTION Control pain, effusion, mm guarding; immobilize in sling Controlled pain-free AROM elbow & wrist – flex, extend, pronate, supinate Multiple angle muscle setting in pain-free positions Ice, rest; avoid strong, repetitive gripping actions PRICE – protection, rest, ice, compression, elevate Sub-acute/Chronic Self-mob's to elbow – grades 1 & 2 Controlled pain-free AROM & RROM elbow & wrist – flex, extend, pronate, supinate Self-massage (Frictions) to muscle belly, CET/CFT - duration 1-5 minutes Stretch tight muscles – triceps, biceps, forearm flexors, extensors etc. Strengthening – elbow & wrist flexors, extensors, pronators, supinators; include eccentric and concentric strengthening; open & closed chain Peripheral joints love compression Stretching Flexors Extensors Pronators Supinators Strengthening Flexors Extensors Pronators Supinators Elbow Self-Mobilization Tractioning at the elbow – relief for bursitis