MSK 3 Mod 1 Elbow & Forearm PDF

Mod 1: elbow and forearm Elbow/Forearm exam 1.​ History, common pain mechanisms 2.​ observation: carrying angle, swelling 3.​ Palpation ( bony and soft tissue) 4.​ upper quarter screen 5.​ range of motion and manual muscle testing 6.​ and feels and accessory motion 7.​ special t...

Mod 1: elbow and forearm Elbow/Forearm exam 1.​ History, common pain mechanisms 2.​ observation: carrying angle, swelling 3.​ Palpation ( bony and soft tissue) 4.​ upper quarter screen 5.​ range of motion and manual muscle testing 6.​ and feels and accessory motion 7.​ special tests 8.​ functional assessment 1. History, common pain mechanisms 1.​ History -​ precipitating incident or activity -​ traumatic versus atraumatic -​ date of onset -​ chronic versus acute -​ position of the elbow during loading and subsequent degree and direction of stress -​ location of symptoms, intensity, and duration -​ activities/ positions that aggravate or relieve symptoms -​ previous treatment and results -​ impact of condition on work and other ADL History: differential diagnoses development -​ Pain over lateral elbow with gripping -​ lateral epicondylalgia, Radial tunnel -​ pain in the medial elbow with wrist flexion and pronation -​ Medial epicondylalgia -​ Numbness and tingling in the medial forearm distal to the Elbow -​ cubital tunnel, ulnar nerve involvement -​ pain during movements with complaints of catching or instability -​ rotary instability Etiology and presentation of elbow pain most common causes: 1.​ Periarticular ( outside the joint) -​ Epicondylitis -​ Olecranon bursitis -​ nerve entrapment syndromes -​ referred pain 2.​ Intra-articular ( inside the joint) -​ Fracture  -​ cartilage disruption 3.​ pain patterns -​ typical complaints are pain, swelling, or loss of motion 2. Observation: carrying angle and swelling Key points: the key areas for anatomical review of the elbow joint 1.​ humeroulnar and humeroradial joint -​ Flexion - extension -​ powered by biceps and triceps -​ normal Arc of motion: full extension at 0° to 135° flexion 2.​ radioulnar joints -​ Supination and pronation occur -​ biceps brachii muscle supinates and the pronator teres muscle pronates the forearm -​ allows rotation from 0 to 180° 3.​ Bursae -​ Multiple located around the elbow -​ olecranon Bursa is the most superficial -​ swelling of this bursa is common 4.​ nerves -​ Ulnar nerve: courses through the elbow joint and the ulnar groove, posterior and medial to the Elbow -​ course is contiguous with the joint capsule -​ any disruption to the joint, tends to impinge the ulnar nerve -​ Median nerve: runs anterior to the Joint capsule -​ entrapment is typically due to Elbow trauma Physical examination: inspection 1.​ carrying angle -​ Best viewed elbow extended and forearm supinated -​ normal values ( goniometer: Stationary arm over mid humerus and moving arm over the mid forearm, Center dial over elbow joint) -​ men: 5 to 10° -​ Women: 10 to 15° -​ Cubitus valgus: increased carrying angle -​ Cubitus varus: decreased carrying angle  2.​ Swelling -​ Intra-articular effusion affects all three joints of the elbow complex -​ may result in the arm being held in a resting position (Approximately 70° of flexion) -​ olecranon bursitis presents with localized swelling over the posterior aspect of the elbow Without trauma: -​ Most often it is the result of olecranon bursitis -​ warmth and redness that accompany the swelling and Rapid presentation of symptoms are clues to distinguish the underlying cause -​ The ability of patients to flex and extend the elbow generally excludes any intro articular process with trauma: must consider fracture or anatomical disruption 3.​ bony and soft tissue contours -​ Muscular atrophy or hypertrophy -​ olecranon and medial and lateral condyles form a triangle with the elbow flexed to 90° -​ these landmarks are in a straight line when the elbow is extended 3. Upper quarter screen Neurological screening/ exam -​ a comprehensive neurological screening may involve the following: 1.​ upper quarter screen -​ dermatome/ sensory testing -​ deep tendon reflexes ( biceps brachii - C5, triceps brachii - C7) -​ myotome testing 2.​ additional neurological tests -​ Upper motor neuron signs: Hoffman's reflex, Babinski test, hyperreflexia (tonic DTRs, clonus) -​ Upper Limb tension testing -​ cranial nerve tests -​ other neurological tests as appropriate -​ A neurological screen is relevant to a comprehensive upper quarter screen due to the possibility of the nerve root and or spinal cord compression.  -​ note that dermatome testing should be done as one point and not sweeping so as not to activate other sensory pathways ( complete testing as it was taught in your neuro class) 4. Palpation ( bony and soft tissue) Anatomy review -​ distal humerus -​ supracondylar ridges -​ Epicondyles -​ Capitellum -​ Olecranon -​ Radial head -​ proximal radius and ulna Bony and muscle structures 1.​ extensor Mass: -​ Brachioradialis -​ lateral to medial in anatomical position -​ ECRL -​ ECRB -​ EDC -​ ECU 2.​ flexor Mass: -​ pronator teres -​ FCR -​ palmaris longus -​ FCU 5. Range of motion, manual muscle testing, end feels, and accessory motion Range of motion ​ passive motion testing -​ Capsular pattern for entire complex is flexion more limited than extension and equal restriction of pronation and supination normal end feels -​ Elbow function: soft tissue approximation end feel -​ elbow extension: bone to bone end feel -​ forearm supination: firm/ capsule end feel -​ forearm pronation: bone to bone end feel ​ additional motions to test -​ wrist flexion with elbow extended -​ wrist extension with elbow extended ​ Active motion testing ​ Goniometry ​ Humeroulnar joint  -​ Some key points to remember when performing an elbow exam: normal range of motion of the elbow effectively rules out involvement of the joint itself. this is especially important when you are trying to determine the source of swelling. likewise, epicondylitis and bursitis, rarely affect the elbow range of motion. therefore, any loss of extension and flexion suggest the involvement of the elbow joint. -​ full extension dramatically reduces the intra-articular volume of the joint. therefore the resting position is in some flexion that increases the volume of the joint and reduces pain. -​ loss of full extension with end point stiffness suggests the presence of a small effusion -​ loss of full extension and flexion suggests the presence of large effusion with moderate to severe joint involvement -​ OA of the joint is in common unless there is a history of fracture Loss of range of motion ​ Intra-articular process -​ Occurs almost exclusively in athletes -​ loss of smooth motion of the elbow without inflammation -​ synovitis: possible causes include reactive arthritis, psoriasis, gout, septic bacterial arthritis -​ in the presence of loss of elbow range of motion, consider the source to be intra articular in nature. the loss of motion may be accompanied by swelling and pain, and the biggest complaint is typically the inability to fully straighten the elbow. there may be a synovitis present, secondary to a reactive arthritis, psoariasis or some sort of systemic issue. if there is loss of smooth and comfortable motion without evidence of a acute inflammation. The issue is likely related to sports or recreational activities. often baseball players and gymnasts suffer injuries to the Joint surfaces such as Osteonecrosis or osteochondritis dissecans. Clinical feature/ key point -​ Normal range of motion of the elbow effectively rules out the involvement of the joint itself. particularly important when trying to determine the source of swelling is bursal or articular -​ Epicondylitis and olecranon bursitis rarely affect elbow range of motion. any loss of full extension or flexion reflects the involvement of the elbow joint Strength ​ Resisted muscle testing -​ Resisted test performed with elbow in resting position ( 70° flexion and slight supination) -​ elbow flexion -​ elbow extension -​ forearm supination -​ forearm pronation -​ wrist flexion with elbow extended  -​ wrist extension with elbow extended 6. Joint Mobility assessment -​ Humero ulnar joint -​ distraction -​ Humero radial joint -​ Distraction -​ Dorsal glide -​ Volar glide 7. Special tests 1.​ Pronator teres syndrome test 2.​ ligamentous stability: Valgus and Varus stress test 3.​ lateral epicondylitis 4.​ medial epicondylitis 5.​ cubital tunnel syndrome 6.​ distal biceps tendon rupture 7.​ Nursemaid’s elbow 8.​ ulnar collateral ligament disruption 9.​ Posterolateral rotary instability (PLRI) 10.​Others: tap test or tuning fork test for fracture Pronator teres syndrome test -​ Purpose: test for median nerve compression by the pronator teres -​ positioning: the patient stands with the elbow in 90° of flexion, the therapist stands by the patient -​ technique: 1.​ the therapist places one hand on the clients elbow for stabilization and the other hand grasps the patient's hand in a handshake position 2.​ the patient holds this position as the practitioner attempts to supinate the patient's forearm ( forcing the patient to contract the pronator muscles) 3.​ while holding the resistance against pronation, the therapist extends the patient's elbow 4.​ the patient should keep the elbow relaxed during the test because holding the elbow firmly inflection will not allow elbow extension -​ positive sign is numbness and tingling or reproduction of the patient's pain along the median nerve distribution Ligamentous stability 1.​ Valgus stress test: -​ Stress the medial collateral ligament, elbow flexed to 20 to 25°. -​ Positive: Pain, increased laxity 2.​ Varus stress test: -​ Stress the lateral collateral ligament, elbow flexed to 20 to 25°  -​ Positive: pain, increased laxity lateral epicondylitis ​ Cozen’s: -​ Cozen’s Test is the most common test for lateral epicondylitis -​ Resistance to evoke pain or test placing inflamed structures on stretch Resisted versus passive: -​ Resisted test: with fingers and wrist flexed and forearm pronated ( with slight older deviation, ask the patient to extend, and radially deviate wrist against resistance -​ passive test: passively pronate forearm and flex and ulnarly deviate the wrist with elbow extended. Medial epicondylitis -​ Caused by an overload of the FCU (flexor carpi ulnaris tendon). there is no specific special test but reverse Cozen’s is usually positive. -​ tension test: extend wrist and elbow to reproduce pain -​ resistive test: flex wrist, ulnar deviation, hold position. Symptoms in medial epicondyle? Cubital tunnel syndrome ​ Overview: -​ Most common side of neural entrapment at the elbow, usually between 30 to 60 years old -​ the nerve can be compressed by the proximal edge of the FCU for the overlying retinaculum -​ clinical presentation will include all ulnar nerve musculature (FCU is spared occasionally) and the sensory distribution as well Special tests: -​ Tinels sign: Tap four to six times -​ pressure provocation test: apply pressure for 60 seconds -​ Flexion test: arm placed in full flexion with full supination and the wrist in neutral hold position for 60 seconds Distal biceps tendon rupture  -​ Historical findings of trauma and observational findings of muscle disruption and ecchymosis. flexion/ supination weakness and or pain. referral to an MD is Paramount due to retraction of the biceps tendon. NurseMaids elbow -​ Common injury in early childhood. this occurs when a child's elbow is pulled and partially dislocates. in this injury, the radial head slips under the annular resulting in pain and inability to supinate the forearm Ulnar collateral ligament disruption -​ Mechanism is typically one with overhead repetitive motion or FOOSH -​ pain upon palpation -​ positive valgus and moving stress tests ​ Moving valgus stress test -​ Purpose: to assess the Integrity of the medial collateral ligament of the elbow -​ positioning: patient is standing and their shoulder is abducted to 90°. the therapist is standing by the patient's shoulder -​ Technique:  1.​ the therapist grasps the distal forearm with one hand and stabilizes the elbow with the other 2.​ the therapist then maximally flexes the elbow and places a valgus force to the Elbow while simultaneously externally rotating the shoulder 3.​ when end range ER is reached, the therapist quickly extends the elbow to approximately 30° -​ positive test = pain in medial elbow. maximal pain is between 120 - 70 degrees of elbow flexion Posterior lateral rotary instability (PLRI) -​ Classical description is “ injury to the lateral ulnar collateral that results in transient external rotary subluxation of the ulna on the humerus -​ Typically from a fall on the outstretched arm causing axial load, valgus force and ER -​ pain on lateral side of elbow -​ pain with LCL complex ( including radial collateral ligament) palpation -​ Positive PLRI -​ positive liftoff from chair (alternative test) -​ Positive IR push-up (alternative test) ​ Staging Stage degrees of capsuloligamentous disruption 1 subluxation of the elbow in a posterolateral direction 2 Subluxation of the elbow joints with the coronoid perched underneath the trochlea 3 completes this location with the coronoid resting behind the trochlea 3a includes the posterior band of the medial collateral ligament tear 3b includes the anterior and posterior bands of the medial collateral ligament tear ​ Demonstration -​ Purpose: to assess the Integrity of the lateral ulnar and lateral collateral ligament complex of the elbow -​ positioning: patient is lying Supine and the therapist is standing by the patient -​ technique: 1.​ therapist takes the patient's arm to 120 degrees of flexion with the shoulder and external rotation 2.​ Initially hold elbow in slight flexion with forearm in Max supination 3.​ the therapist will slowly flex and extend the elbow while applying supination and valgus stress and axial load -​ Positive: reduction and extension and subluxation at about 40° of flexion, apprehension -​ you may feel a clunk or observe a skin dimple ​ Alternative PLRI: IR push up/lift off -​ Apprehension or dislocation as terminal extension occurs ​ Other conditions -​ Pts may also be experiencing: 1.​ Elbow dislocation (2nd most dislocated joint in body) 2.​ Rheumatoid arthritis 3.​ fractures Tuning fork auscultation test for fractures -​ Supine position affected limb exposed -​ Stethoscope on bony prominence or swelling -​ Tuning fork distal to fracture -​ Listen 6-8 seconds -​ Compare with unaffected side -​ Positive: diminished or absent sound Knowledge check: 1.​ Which special test checks for stability of the lateral collateral ligament of the elbow? -​ Posterior lateral rotary instability test 8. Elbow Conditions Introduction: Problem diagnostic considerations treatment concepts, tests, exercises medial epicondylitis -​ tendonitis at the origin Test: of the forearm flexors -​ passive wrist extension -​ also known as golfer's with the elbow extended, elbow manual resist wrist flexion -​ occurs from repetitive and pronation, palpation forearm pronation and over medial epicondyle wrist flexion Treatment: -​ NSAIDS, elbow brace, flexor stretches, friction massage, /wrist hand PRE’s, equipment modification lateral epicondylitis -​ tendonitis at the origin Test of the forearm -​ passive wrist flexion, extensors, most manual resist wrist commonly ECRB extension, palpation -​ known as tennis elbow Treatment -​ occurs from repetitive -​ Mills manipulation supination and wrist extension  fractures -​ Supracondylar is Tests common in children -​ observation, carrying with Associated angle, posterior triangle, temporary nerve neuro: Sharp/dull, MMT injuries involving Treatment median, ulnar, and -​ conservative sling or splint radial nerves with immediate A/PROM -​ radial head fractures exercises, PRE’s at12 -​ coronoid fracture, weeks dislocation Surgical -​ ORIF treatment as above, total healing time 10 weeks little Leaguers elbow ulnar nerve injury -​ Rest NSAIDS -​ positive Froment’s sign -​ decrease pitch count -​ positive elbow flexion -​ RC/SCAP exercises test -​ protocol MCL tear/ strain -​ Positive valgus test 0 and 20° elbow flexion growth plate avulsion Other conditions to see -​ Patients may also be experiencing 1.​ distal biceps tendon rupture 2.​ nurseMaids elbow 3.​ Elbow dislocation 4.​ rheumatoid arthritis Common differential diagnoses of the elbow for adults ​ Epicondylitis ​ Overview -​ Generally, overuse related -​ represents chronic tendinosis ( not an acute inflammatory process) -​ vasculoneural growth in the common extensor origin is the likely source of pain in lateral epicondylitis -​ mechanism: repetitive movement involving eccentric motion ​ Initial management 1.​ activity modification -​ avoid exacerbating symptoms -​ correct faulty mechanics 2.​ counterforce bracing -​ May provide benefit during the first 6 weeks following injury  -​ place on the forearm approximately 6 to 10 cm distal to the elbow joint 3.​ NSAIDS ( if not contraindicated) 4.​ physical therapy -​ Include Progressive eccentric and isometric strengthening -​ Flexibility -​ modalities as needed ​ Anti-inflammatory agents management -​ have been consistently utilized in treatment for many years ( only anecdotal evidence and a few limited studies) -​ controversy over use has grown as understanding of tendinopathy has improved ( examples: ice, NSAIDs, iontophoresis, Glucocorticoid injection) -​ NSAIDs: evidence is limited, May reduce pain and improve function in the initial 6 weeks ​ Lateral epicondylitis ​ Causes -​ caused by micro-tearing/Microavulsion of the extensor carpi radialis brevis and longus tendons ​ ​ Signs and symptoms -​ Local tenderness over lateral epicondyle -​ pain with resisted wrist extension and Radial deviation -​ pain with strong gripping or decreased grip strength -​ normal elbow range of motion ​ differential diagnosis -​ Loose bodies -​ osteochondral defect ( radiocapitellar joint) -​ Arthritis ( posterior osteophytes) -​ Valgus extension overload  -​ radial tunnel syndrome -​ inflammatory arthritis -​ lateral synovial plica -​ cervical radiculopathy -​ thoracic outlet syndrome -​ myofascial pain ​ Medial epicondylitis ​ Causes -​ micro tearing/ micro avulsion of the flexor carpi radialis tendon ​ ​ Signs and symptoms -​ local tenderness over medial epicondyle -​ pain would resisted wrist flexion and ulnar deviation -​ pain with strong gripping or decreased grip strength -​ normal elbow range of motion ​ differential diagnosis -​ Cubital tunnel syndrome -​ ulnar neuritis -​ UCL insufficiency -​ Little League elbow -​ inflammatory arthritis -​ cervical radiculopathy -​ thoracic outlet syndrome -​ myofascial pain ​ Olecranon bursitis ​ Causes -​ Trauma: leaning on Elbow or using elbow to rise from bed, etc -​ infection following an abrasion ​ diagnosis -​ Made by noting the cystic swelling over the posterior olecranon process  -​ swelling does not involve the joint, therefore it does not prevent full extension ​ Nerve entrapment ​ Ulnar neuropathy -​ Most common compression neuropathy affecting the elbow -​ sensory loss and paresthesia over the ring and small fingers -​ in most severe cases, weakness of the interossei becomes apparent, weakened grip, and clumsiness ​ Anterior interosseous nerve -​ Elbow joint inflammation -​ pure motor branch of the median nerve -​ leads to motor dysfunction of the flexor pollicis longus end of the flexor digitorum profundus of the index and middle fingers ( no sensory loss) -​ weakness of grip and pinch ( thumb and index fingers) -​ unable to make OK sign ​ Osteoarthritis ​ Overview -​ degenerative processes are rare -​ when present usually related to previous episodes of osteonecrosis ​ ligamentous injury ​ Overview -​ Primarily in throwing athletes -​ primarily the ulnar collateral (medial) ligament -​ due to the tremendous Force generated during the late caulking phase and early acceleration phase of throwing or serving -​ leads to valgus stress on the elbow -​ repetitive throwing can create cumulative microtrauma to the UCL -​ leads to medial pain and possible laxity ​ distal biceps tendon rupture ​ Overview -​ Distal biceps attaches to the radial tubercle just distal to the radial head -​ major function is to supinate the forearm ( 2 degrees elbow flexion) ​ Cause -​ Forceful lifting or supination leads to sudden pain ( he described in quality and location) ​ signs and symptoms -​ Swelling and ecchymosis in antecubital fossa -​ tenderness over radial tubercle -​ pain with resisted flexion or supination -​ optimal results require surgical fixation Common differential diagnosis of the elbow for adolescents -​ Injuries to the elbow, forearm, and wrist account for more than 25% of all sports related injuries. acute injuries are related to falls. Chronic injuries are related to repetitive motion ​ acute injury ​ Overview -​ Children and young adolescents with elbow pain after an acute injury have a high likelihood of fracture or dislocation ​ fracture -​ Up to 60% with decreased range of motion or bony tenderness after elbow injury have a fracture -​ furthermore, there are a number of patients with elbow pain, but normal exam with fracture -​ should receive radiographs according to findings ​ Supracondylar fracture ​ Overview -​ up to 60% of pediatric elbow fractures -​ most frequently in kids age 5 to 10 ​ Cause -​ Fall on outstretched arm 70% of the time ​ signs and symptoms -​ Pain, swelling, limited to no range of motion -​ be aware that vascular compromise or open fracture is an emergency ​ lateral condyle fracture ​ Overview -​ 15% of elbow fractures in children ​ ​ cause -​ Fall on outstretched hand, with a varus Force to the Elbow -​ causes avulsion fracture ​ medial elbow pain ​ Overview -​ Related to the stress of throwing in children and young adolescents -​ risk factors are related to the amount of throwing ​ Variations -​ Variations of pathology depending on age and skeletal maturity -​ Related to the stress of throwing in children and young adolescents -​ risk factors are related to the amount of throwing -​ medial epicondylar apophysitis -​ ulnar collateral ligament injury -​ medial epicondylar Evolution fractures (Little League elbow) ​ ​ most common -​ Most common medial elbow throwing injury by skeletal level  Maturity level skeletal maturity most common injury childhood from birth to the appearance medial epicondyle of all secondary ossification apophysitis centers adolescence from the appearance of all to medial epicondyle avulsion the fusion of all the secondary fracture ossification centers young adulthood from the end of adolescence ulnar collateral ligament tear to the attainment of all bone growth and muscular form ​ medial epicondyle apophysitis ​ Symptoms -​ Medial elbow pain ( initially after throwing, progresses to persistent pain) -​ TTP medial epicondyle, made worse by Elbow flexion -​ valgus testing of the elbow will be painful ​ Diagnosis -​ Radiographs demonstrate an open ossification Center without separation ​ treatments -​ No throwing for 4 to 6 weeks -​ pain control -​ correct throwing mechanics and a progressive throwing program over the following 6 to 8 weeks ​ medial epicondyle avulsion fracture ​ Overview -​ Most common elbow injury related to throwing and skeletally immature adolescence ​ ​ Symptoms -​ May report a sudden pop during throw -​ onset of acute pain  -​ finding similar in medial epicondyle apophysitis ​ treatments -​ Minimally displaced (2mm, referred to orthopedic surgeon ​ UCL sprain ​ Overview -​ Occurs in skeletally mature throwers, wrestlers, gymnast, or other athletes who sustained traumatic valgus injury from a fall on an outstretched arm -​ anterior bundle of UCL is the primary restraint to valgus force at the elbow during the throwing lotion ​ radial head or neck fracture ​ Cause -​ Fall on an outstretched hand with elbow extended -​ transmits of valgus force to the neck of the radius, pushing the radial head into capitellum ​ Symptoms -​ Tenderness over the radial head -​ supination or pronation of the forearm produces pain on the lateral side of the elbow ​ additional injuries -​ Approximately 50% of kids with proximal radial fracture, will have a secondary injury such as a ligament rupture, a medial epicondyle fracture, or an ulnar fracture ​ posterior elbow dislocation ​ Overview -​ 5% of elbow injuries in children ( 64% have Associated fractures) ​ ​ Causes -​ Fall or twisting injury to the Elbow ​ signs and symptoms -​ Pain and obvious deformity -​ olecranon is prominent posteriorly -​ normal triangular relationship between olecranon and medial and lateral epicondyles is lost -​ neurovascular complications are relatively uncommon ​ olecranon apophysitis/ stress fracture ​ Overview -​ During throwing or gymnastic movements, the triceps applies significant forces to the apophysitis ​ Symptoms -​ Pain during weight-bearing activities or with follow through phases of throwing -​ posterior elbow swelling -​ TTP of posterior and medial portion of olecranon -​ Decreased range of motion -​ pain reproduced with resisted elbow extension ​ Diagnosis -​ Typically done with plain radiographs ​ treatment -​ Relative rest for 4 to 6 weeks, pain control, PT with attention to Eccentric tricep work ​ valgus extension overload ​ Cause -​ Forceful repeated hyperextension ( throwers and boxers) -​ repetitive valgus stress: -​ can stretch the UCL ( leads to medial elbow instability) -​ causes medial olecranon to rotate internally and rub against the medial olecranon fossa and or stretch the ulnar nerve ​ Symptoms -​ TTP along medial border of the olecranon fossa -​ pain with valgus testing of the elbow in extension -​ possible flexion contracture -​ symptoms worsened by hyperextension of the elbow ​ diagnosis -​ radiographs are indicated ​ panner disease ​ Overview -​ Osteochondritis of the capitellum -​ degenerative disorder of the growing epiphysis and its secondary ossification centers -​ occurs most frequently in boys between 7 to 12 years old ​ ​ Symptoms -​ Sudden onset of lateral elbow pain -​ decreases loss of range of motion in extension -​ swelling/effusion may occur over time ​ Diagnosis -​ Plain radiographs show irregularity of the capitellum ​ treatments -​ Self-limiting, pain control, possible immobilization. Elbow/ forearm osteoarthritis ​ Anatomy ​ Overview -​ three joints within the same articular capsule: -​ Radiohumeral -​ Radioulnar -​ Humeroulnar (elbow) ​ Conservative care for elbow osteoarthritis  1.​ lifestyle modifications 2.​ physical therapy ( modalities, joint mobilization, range of motion, strengthening) 3.​ intra-articular injections ( typically corticosteroids) 4.​ Medication (NSAIDs, aspirin, acetaminophen) ​ Surgical intervention for a elbow OA ​ Procedure -​ less common than me, hip and shoulder but just as effective at relieving pain -​ typically replaces just the humero ulnar but may involve humero radial based on the extent of OA -​ most patients have a history of injury to the Elbow or the surrounding ligaments -​ risk increases when surgical reconstruction is needed ​ post-surgical rehab ​ Overview -​ little evidence-based literature available -​ precautions are specific to each surgeon but generally involved: -​ no lifting greater than 3 to 5 lb for 4 weeks -​ HEP / physical therapy to start immediately -​ protect the incision and watch for signs of infection physical therapy -​ initiated within the first week -​ joint is usually stiff and range of motion is encouraged -​ no evidence for Rehab before but many surgeons are of the opinion that those with more range of motion before surgery ultimately have better outcomes ​ return to activity -​ once the incision has healed and prosthesis is stable return to moderate level activity recommended Knowledge check 1.​ Radial tunnel syndrome should be differentiated with which elbow epicondylitis? -​ Lateral 2.​ which condylar fracture happens more often in pediatric patients? -​ Supracondylar fractures Referral to Radiology -​ Should be suggested/ Obtained in children who present with localized tenderness or swelling of the elbow with known or suspected trauma -​ Anterior: posterior in extension -​ lateral View at 90 degrees of flexion -​ the radial head should Point towards the capitellum on all views  -​ suspect elbow dislocation, lateral condyle fracture, or monteggia fracture Knowledge check 1.​ Radiograph should be considered in children who present with localized tenderness or swelling of the elbow with known or suspected trauma -​ true Treatment -​ NSAIDS,Elbow brace, stretches, friction massage, shoulder/ wrist hand PREs, equipment modification ​ Interventions ​ Non-operative ​ Acute phase ( Week 1) -​ goals: improve motion, diminished pain and inflammation, retard muscle atrophy -​ exercises 1.​ stretching for wrist and elbow joint, stretches for shoulder joint 2.​ strengthening exercises: isometrics for wrist, elbow, and shoulder musculature 3.​ pain and inflammation control cryotherapy, high voltage galvanic stimulation, ultrasound, and whirlpool ​ Subacute phase (week 2) -​ goals: normalize motion, improve muscle strength, power, endurance ​ week 2: 1.​ Initiate isotonic strengthening for wrist and elbow muscles 2.​ initiate exercise tubing exercises for shoulder 3.​ continue use of cryotherapy ​ Week 3 1.​ Initiate rhythmic stabilization drills for elbow and shoulder joint 2.​ progress isotonic strengthening for entire upper extremity 3.​ initiate isokinetic strengthening exercises for elbow flexion/ extension Week 4 1.​ Initiate throwers ten program 2.​ emphasize eccentric bicep work, concentric tricep work, and wrist flexor work 3.​ program endurance training 4.​ initiate light plyometric drills 5.​ initiate swinging drills ​ Intermediate phase ( weeks 4-6) ​ Criteria to progress to Advanced phase 1.​ Full non painful range of motion 2.​ no pain or tenderness 3.​ satisfactory isokinetic test 4.​ satisfactory clinical examination ​ Weeks 4-5  1.​ Continue strengthening exercises, endurance drills, and flexibility exercises daily 2.​ throwers 10 program 3.​ progress plyometric drills 4.​ emphasize maintenance program based on pathology 5.​ progress swinging drills (hitting) ​ Weeks 6-8 1.​ Initiate interval sport program wants determined by physician ​ Phase I throwing program ​ Return to activity phase (weeks 6-9) -​ Return to play depends on thrower's condition and progress, physician will determine when it is safe 1.​ continue strengthening program throwers 10 program 2.​ continue flexibility program 3.​ progress functional drills to unrestricted play ​ Post-operative Initial Phase (Week 1) -​ Goals: full wrist and elbow ROM; decrease swelling; decrease pain, retardation, or muscle atrophy Day of Surgery 1.​ Begin gently moving elbow in bulky dressing Postoperative Days 1 and 2 1.​ Remove bulky dressing and replaced with elastic bandages 2.​ Immediate post operative hand, wrist, and elbow exercises -​ Putty slash grip strengthening -​ Wrist flexor stretching -​ Wrist extensor stretching -​ Wrist curls -​ Reverse wrist curls 3.​ Neutral wrist curls 4.​ Pronation/supination 5.​ AIAAROM elbow extension/flexion Postoperative Days 3-7 1.​ Passive range of motion (PROM) elbow extension/flexion (motion to tolerance) 2.​ Begin progressive resistive exercises (PRE) exercises with one pound weight 3.​ Reverse wrist curls 4.​ Neutral wrist curls 5.​ Pronation/supination 6.​ Broomstick roll-up Intermediate Phase (Weeks 2-4) -​ Goals: improve muscular strength and endurance, normalized joint arthrokinematics Week 2: ROM exercises (overpressure into extension) 1.​ Addition of biceps cud and triceps extension 2.​ Continue to progress PRE weight and repetitions as tolerable Week 3 1.​ Initiate biceps and biceps eccentric exercise program 2.​ Initiate rotator cuff exercises program -​ External rotators -​ Internal rotators -​ Deltoid -​ Supraspinatus -​ Scapulothoracic strengthening Advanced Phase (Weeks 4-8) -​ Goal: preparation of athlete for return to functional activities Criteria to progress to the advanced phase: 1.​ Full nonpainful ROM 2.​ No pain or tenderness 3.​ Isokinetic tests that fulfills criteria to throw 4.​ Satisfactory clinical examination Weeks 4-6 1.​ Continue maintenance program, emphasizing muscular strength, endurance, and flexibility 2.​ Initiate interval throwing program phase Weeks 7-8 1.​ Continue program 2.​ Progress throwing program as tolerated ​ Manual therapy 1.​ Humeroradial anterior glide ​ Purpose: to increase elbow joint flexion range of motion ​ Positioning: patient is prone and therapist is standing or seated ​ technique: -​ passively extend the elbow and fully supinate the forearm -​ stabilize the humerus against the table with one hand -​ locate the radial head just distal to the lateral epicondyle and apply repetitions of anterior Glides to the radial head 2.​ Humeroradial posterior glide ​ Purpose: To increase elbow joint extension range of motion ​ Positioning: patient is Supine and therapist is standing or seated ​ technique -​ passively extend the elbow and fully supinate the forearm -​ at the edge of the table, stabilize the humerus with one hand -​ palpate the radial head just distal to the lateral epicondyle and apply repetitions of posterior glides of the radial head 3.​ Humeroradial traction  ​ Purpose: to increase elbow joint flexion and/or extension ROM ​ Positioning: Patient is supine or seated and therapist is standing or seated ​ technique -​ Stabilize the humerus against the table with your proximal hand -​ with the other hand, grasp the radial head and apply a distraction Force -​ repeat for multiple repetitions of the distraction Force 4.​ Humeroulnar distraction ​ Purpose: to increase elbow joint flexion and extension ROM ​ Positioning: Patience is supine or seated and therapist is standing or seated ​ technique: this can be used as an assessment and treatment -​ position the elbow into 70° of flexion and 10 degrees of supination -​ block the distal humerus with your hand and place the patients forearm on your shoulder to stabilize -​ using your fingers, grasp the proximal ulna and apply a distraction Force ​ Knowledge check: 1.​ List the three joint mobilization techniques used to increase elbow extension? -​ humeroradial posterior glide, humeroulnar distraction, humeroradial traction.