W7 PPT- TE2- The Elbow and Forearm PDF

Therapeutic Exercise II PTA 1010 The Elbow and Forearm Complex © Stanbridge University 2023 1 Road Map By the end of this section the student will be able to: Describe common surgical procedures for soft tissue and joint pathology at the elbow Explain the goals and a...

Therapeutic Exercise II PTA 1010 The Elbow and Forearm Complex © Stanbridge University 2023 1 Road Map By the end of this section the student will be able to: Describe common surgical procedures for soft tissue and joint pathology at the elbow Explain the goals and appropriate interventions for postoperative management of elbow dysfunction Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the elbow and forearm complex Effectively implement a therapeutic exercise program to manage soft tissue and joint lesions in the elbow and forearm region related to stages of recovery and or post-operative healing for common surgeries © Stanbridge University 2023 2 OUTLINE Joint Hypomobility- Fractures & Elbow Function& conservative care ligamentous Anatomy Review and surgical injuries options Overuse Myositis Ossificans Syndromes © Stanbridge University 2023 3 Bones and Joints of the Elbow and Forearm Figure 18.1 Kisner & Colby Figure 18.2 Kisner & Colby © Stanbridge University 2023 4 Joints of the Elbow & Forearm Complex Humeroulnar joint: flexion, extension Humeroradial joint: flexion, extension Radiocapitellar joint accepts 60% of the load transfer across the elbow and can withstand up to 90% of a Anatomage table person’s body weight Rizzo et al. 2002 Figure 18.1 Kisner & Colby Proximal radioulnar joint: pronation, supination Distal radioulnar joint: pronation, supination © Stanbridge University 2023 5 Review- Ligaments of the Elbow A: Medial (Ulnar) Collateral Ligament Medial (Ulnar) Collateral Ligament: Anterior medial collateral ligament Posterior medial collateral ligament Transverse Ligament Lateral (Radial) Collateral Ligament: Lateral (radial) collateral ligament Lateral ulnar collateral ligament B: Lateral (Radial) Collateral Ligament Annular ligament Kinser & Colby Fig 18.2 © Stanbridge University 2023 6 Review- Ligaments of the Elbow Medial (Ulnar) Collateral Ligament: Lateral (Radial) Collateral Ligament: Resists valgus stress to the Resists varus stress elbow Stabilizes against supination Limits end range elbow forces extension Stabilizes the humeroradial joint Approximates joint surfaces Resists longitudinal distraction Throwing, golfing: increased Prevents posterior translation of stress to MCL the radial head © Stanbridge University 2023 7 Elbow joint Arthrokinematics Humeroradial Joint Concave radial head Convex distal humerus (capitellum) Humeroulnar joint: Concave proximal ulna (trochlear notch) Convex distal humerus (trochlea) Proximal Radioulnar Joint (PRUJ) Concave radial notch of the ulna Convex radial head www.sideplayer.com © Stanbridge University 2023 8 Referred Pain and Nerve Injury in the Elbow Region C5, C6, T1, T2 nerve roots refer symptoms that cross the elbow region, but are NOT usually isolated to the elbow Nerve Disorders in Elbow Region: Ulnar Nerve: compression in cubital tunnel Radial Nerve: entrapment of deep branch under the ECRB, with a radial head fracture, direct trauma to superficial branch along lateral radius Median Nerve: Pronator teres vs anterior interosseous vs carpal tunnel syndrome © Stanbridge University 2023 9 OUTLINE Joint Hypomobility- Fractures & Elbow Function& conservative care ligamentous Anatomy Review and surgical injuries options Overuse Myositis Ossificans Syndromes © Stanbridge University 2023 10 Joint Hypomobility: Common Causes RA JRA eorthropod.com DJD Trauma Dislocation Fractures *Review: Table 18.1 Severity of elbow joint disease* © Stanbridge University 2023 11 Joint Hypomobility: Common Impairments Acute stage (0 to 4-6 days): Pain (often at rest) Swelling Muscle guarding Restricted elbow flexion/extension © Stanbridge University 2023 12 Joint Hypomobility: Common Impairments Subacute or Chronic Stage : Capsular pattern of elbow: Humeroulnar joint: flexion > extension Humeroradial joint: No true pattern Examination: Abnormal capsular/firm or bony end feel Decreased joint play © Stanbridge University 2023 13  Joint Hypomobility: Common Impairments Chronic elbow arthritis: Pron./sup also become restricted with abnormal firm end feel Decreased joint play at the proximal radioulnar joint Pain with overpressure at the distal radioulnar joint www.orthobullets.com © Stanbridge University 2023 14  Joint Hypomobility: Common Functional Limitations Common Functional Limitations Difficulty or pain with pushing/pulling (open/close doors, getting up from chair) Restricted hand to mouth activities (eating, drinking, telephone use, grooming) Unable to carry objects with a straight arm Limited reaching capabilities Difficulty turning doorknobs, keys © Stanbridge University 2023 15 Joint Hypomobility: Functional Motion Functional arc for elbow/forearm necessary for ADLS: Motion between 30 and 130 degrees of elbow flexion (a 100-degree arc of motion) Total of 100 degrees of radioulnar motion equally divided between pronation & supination © Stanbridge University 2023 16 Joint Hypomobility: Non-operative Management- Acute Phase Tx Guidelines Education: joint protection and modification of daily activities Reduce effects of inflammation or synovial effusion and protect the area Maintain integrity & function of related areas Maintain soft tissue & joint mobility © Stanbridge University 2023 17 Joint Hypomobility: Non-operative Management- Subacute Phase Tx Guidelines for Subacute Phase of Joint hypomobility Increase soft tissue and joint mobility Improve joint tracking of the elbow (MWM joint mobilization) Improve muscle performance and functional abilities © Stanbridge University 2023 18 Surgical options for advanced OA Radial head excision Total Elbow Arthroplasty (TEA) © Stanbridge University 2023 19  Excision/Resection Radial head Arthroplasty Removal of periarticular bone (bone around the joint) from one or both articular surfaces Seen with: Late-stage arthritis of the humeroradial joint, severe comminuted fracture of the radial head, or pt. with a low activity level www.hindawi.com © Stanbridge University 2023 20 Post operative Management: Radial Head Excision Resection of the head and stability: Resection with intact UCL- very little affect on stability Resection with unstable UCL- very significant functional limitation Post-operative immobilization position: Posterior resting splint in 90 degrees of elbow flexion and neutral forearm position © Stanbridge University 2023 21 Radial Head Excision: 0-6 weeks Maximum Protection Phase Maintain mobility of elbow and forearm in and out of the hinged splint (PROM) Maintain mobility and function of un-operated joints Education on wound care, pain management and edema control Always check protocol for guidance/contraindications © Stanbridge University 2023 22 Post operative Management: Radial Head Excision Exercise: Moderate and Minimum Protection Phases Increase ROM: Gentle manual or dynamic stretching with self stretching HEP: Low load long duration (LLLD) stretch preferable Hold relax techniques Grade II joint mobilization techniques →grade III at about 6 weeks post op (joint capsule is healed) Functional strength and endurance: LOW LOAD RESISTANCE !!! 1-2 lb ONLY*** © Stanbridge University 2023 23  Post operative Management: Radial Head Excision Resumption of recreational and work-related activities: With or without prosthetic implant: Permanently refrain from high demand or high impact work related or recreational activities Avoid using UE to move or hold heavy objects Refrain from sports that stress the elbow (racquet sports) © Stanbridge University 2023 24 Total Elbow Arthroplasty (TEA) © Stanbridge University 2023 25 Total Elbow Arthroplasty Indications for surgery: Debilitating pain and loss of functional use of the UE due to moderate-severe arthritis of the HU and HR joints (RA, JRA, OA) Gross elbow instability Comminuted intra-articular fracture Nonunion fracture of the distal humerus Failed prior surgeries Marked (B) elbow mobility © Stanbridge University 2023 26  Total Elbow Arthroplasty (TEA) Immobilization Position of immobilization depends on type/approach of surgery; tissue affected Maximum protection phase Maintain mobility of the shoulder wrist and hand Regain motion of the elbow and forearm Minimize atrophy of the UE musculature © Stanbridge University 2023 27  Total Elbow Arthroplasty (TEA) Moderate and Minimum Protection Phase Increase ROM of the elbow Regain strength and muscular endurance of the operated extremity Multiple angle isometrics Light ADLs and OKC exercises < 1 lb Limited repetitive lifting for 6 months Low-load closed chain exercises (ie. wall push ups) © Stanbridge University 2023 28  Postoperative Management: Total Elbow Arthroplasty (TEA) Patient Education to Permanently Avoid the Following (even after rehab has been completed) High load PRE during home and work-related activities Recreational activities that place high loads or impact on the UE: racquet sports, throwing, golf Lifting repetitively: 5# maximum One time/single lift: 10-15# maximum Box 18.3 Contraindications to a TEA Box 18.5 Specific Precautions © Stanbridge University 2023 29 Post-Operative Management Checklist ✓Look at MD Referral for RESTRICTIONS ✓PROTOCOL by MD ✓What TISSUE was affected ✓What PROTECTION PHASE is the pt in ✓Follow Plan of Care from PT of Record © Stanbridge University 2023 30 Review What is the position of the UE to maximize the stretch for the biceps? Triceps? Where should the stretching pressure be placed for a pronation and supination stretch? What is the ROM required for elbow and forearm to perform ADLs. What is the capsular pattern of the elbow and forearm? What does capsular pattern mean? © Stanbridge University 2023 31 OUTLINE Joint Hypomobility- Fractures & Elbow Function& conservative care ligamentous Anatomy Review and surgical injuries options Overuse Myositis Ossificans Syndromes © Stanbridge University 2023 32  Joint Surgery and Postoperative Management Fractures and dislocations: often require ORIF or arthroscopic or open excision of bone fragments Fracture of the head & neck of the radius: Most common fracture in the elbow typically due to a FOOSH injury Most common: Posterior dislocation of the radial head coupled with ligament injury Additional fractures will be covered in orthopedic interventions Box 18.2- surgical options © Stanbridge University 2023 33  Fracture Indication If pronation/supination are suddenly restricted after acute injury consider fracture, subluxation or, dislocation Refer to MD for Exam and X-ray © Stanbridge University 2023 34 Fracture Reduction by ORIF Open reduction internal fixation of fracture www.forums.mtbr.com Usually performed via a mini open procedure © Stanbridge University 2023 35  ORIF: Post-op Management Check MD Referral for precautions/contraindications following the procedure Goal: Maintain stability of healing fracture Ther ex Tx and progression depends on type and severity of fracture, age, health status, type of stabilization & status of the associated injuries may have additional external stabilization: cast, external fixator, splint if no external stabilization present: AROM, AAROM, protected weight bearing © Stanbridge University 2023 36 “Terrible Triad” Elbow Fracture Fitzgibbons et al., Functional outcomes after fixation of “Terrible Triad” elbow fracture dislocations, helio.com/orthopedics search 20140401-59, 2014 1. Dislocation of elbow 2. radial head fracture 3. coronoid fracture Tx options: Closed reduction and immobilization ORIF (most common) www.elbowshoulder.org © Stanbridge University 2023 37  Directional Instabilities Sebelski, Current Concepts Varus Instability- Radial collateral ligament insufficiency Occurs from: –Simple or complex elbow dislocation –Varus elbow stress Pt presentation: Combined elbow extension with forearm supination is uncomfortable Often treated with ORIF © Stanbridge University 2023 38 Directional Instabilities Sebelski, Current Concepts Varus instability nonoperative treatment: Goal is protection and unloading of injured structures – Hinged elbow brace with forearm in pronation (4-6 weeks) – Avoidance of shoulder abduction and IR with flexion and extension elbow exercises to avoid varus force Example: Example: Deceleration of throwing Early cocking phase of throwing www.beyondthebox.com www.drchrismckenzie.com © Stanbridge University 2023 39 Directional Instabilities Sebelski, Current Concepts Valgus Instability- Ulnar collateral ligament insufficiency Occurs from: – FOOSH – Overuse or chronic attenuation (overhead athlete) Examination: Pt is TTP 2 cm distal from medial epicondyle Non-operative management: Pt education : Activity restriction; on throwing/pitch count Immobilization Strengthening of pronator flexor group (helps with dynamic valgus support) Strengthening of shoulder and trunk for generating force with overhead activity Operative tx: Tommy John surgery- Follow protocol through healing phases (9-12 months of rehab) © Stanbridge University 2023 40 Complex Elbow Instability (CEI) Giannicola et al., Critical time period for recovery of functional ROM after surgical treatment of complex elbow stability: Prospective study on 76 patients, Injury Int. Care Injured, 2014 Primary Goals of Surgery Anatomical and osteosynthesis of all articular fractures Reconstruction of ligament injuries The critical period of recovery is within the 1st 6 months 70% of patients recovered functional ROM ≤ 1 year 80% of patients recovered functional ROM ***Follow protocol through phases of healing © Stanbridge University 2023 41  Review Why can AAROM and AROM be performed in the maximum protection phase after a radial head excision? Why is it important to perform gentle stretching to the elbow? What is the weight restriction for lifting after a radial head excision? What are the precautions and strengthening recommendations for varus vs valgus instability? © Stanbridge University 2023 42 OUTLINE Elbow Joint Surgery Joint Function& and Post Op Hypomobility Anatomy Review Management Myositis Overuse Ossificans Syndromes © Stanbridge University 2023 43 Myositis Ossificans (MO) Heterotopic Ossificans (HO) www.theboneschool.org www.shoulderelbow.blogspot.com © Stanbridge University 2023 44 Myositis Ossificans “Ossification of muscle” Heterotopic ossificans: bone formation in muscle-tendon unit, capsule, ligament *text uses terms synonymously Most often develops in brachialis muscle or the joint capsule Result of trauma: fracture, fracture dislocation, trauma to brachialis; includes aggressive stretching © Stanbridge University 2023 45 Myositis Ossificans After acute inflammatory period, bone is laid down between individual muscle fibers or around joint capsule within a 2–4-week period Imaging diagnosis: Plain radiographs do not show HO until 5th week Bone scan can show changes as early as 2 weeks Can permanently restrict motion of the joint, but is often reabsorbed over several months; motion returns to a large extent © Stanbridge University 2023 46 Myositis Ossificans Pt population prone to developing MO: TBI or SCI Extremity burns Result of aggressive stretching of elbow flexors after injury and a period of immobilization © Stanbridge University 2023 47 Myositis Ossificans Signs and Symptoms Pt presentation: Primary sign: Progressive loss of ROM Secondary sign: Hyperemia, swelling, warmth Humeroulnar joint: passive extension more limited than flexion (noncapsular pattern) Pain with resisted flexion in mid range Flexion limited & painful when muscle pinched b/w ulna & humerus TTP over distal brachialis Muscle firm to the touch © Stanbridge University 2023 48 Myositis Ossificans Management Contraindications for the Involved Muscle (Brachialis): -Massage -Stretching -Resistive exercise Elbow kept at rest in splint until bony mass matures and reabsorbs- removed for active pain free ROM POC: CPM, AAROM, pain-free activities Surgical excision © Stanbridge University 2023 49 Myositis Ossificans: Prevention When treating an elbow pathology or post-operative care with the goal of increasing motion= avoid aggressive stretching into extension Choose to perform and teach pt. a HEP for LLLD or PPS Lab will focus on specifics of the LLLD stretch application © Stanbridge University 2023 50 Review What is myositis ossificans (MO)? What are the signs and symptoms of MO? What is the lifting weight restriction after a total elbow arthroplasty (TEA)? What are the possible complications of TEA? © Stanbridge University 2023 51 OUTLINE Elbow Joint Surgery Joint Function& and Post Op Hypomobility Anatomy Review Management Myositis Overuse Ossificans Syndromes © Stanbridge University 2023 52 Overuse Syndromes: Repetitive Trauma Syndromes Osteochondral Defects Medial & Lateral Epicondylitis Biceps Tendonitis Triceps Tendonitis Olecranon Bursitis © Stanbridge University 2023 53 Osteochondral Defects (OCD) defect within the bone and cartilage Occur is skeletally mature and immature individuals Result of repetitive trauma, vascular susceptibility and genetic disposition Can occur on one or more articular surfaces of the elbow complex Most common bone in elbow affected: capitellum Can cause a loose body or piece of bone to break off into the joint © Stanbridge University 2023 54 Osteochondritis dissecans (OCD) Frequently seen in adolescence (12-17) with repetitive weightbearing and overhead activities Two primary groups: 1) Young male baseball pitchers – 90% insidious onset of vague lateral elbow pain – ROM loss in dominant arm of extension (less flexion, pronation, and supination) 2) Young female gymnasts © Stanbridge University 2023 55  Osteochondritis dissecans (OCD) www.researchgate.com Sxs of clicking, popping, and locking occur later in the disease process and indicate separation of the bone fragments Crepitus with pronation/supination © Stanbridge University 2023 56 Osteochondritis dissecans (OCD) Management Cartilage intact over fragment- nonoperative tx Pt education: Rest, bracing, and break from aggravating activities ROM and strengthening of shoulder and scapular stabilizers while resting elbow Return to full function 3-6 months Surgery may be chosen with persistent or worsening of symptoms, symptomatic loose bodies, fx. of articular cartilage and/or displacement of capitellar lesion Post operative protocol followed based on surgical procedure © Stanbridge University 2023 57 Overuse Syndromes: Repetitive Trauma Syndromes Tendonitis: Overuse causing microscopic tears and inflammation (medial and lateral elbow= epicondylitis) Tendinosis: overuse causing degenerative changes (microscopic tears) in the collagen tissue without signs of inflammation -immature fibroblastic and vascular elements -weakening of the tendinous structure © Stanbridge University 2023 58 Lateral Elbow Tendinopathy www.orthobullets.com © Stanbridge University 2023 59 Tennis: Stress to the Lateral Elbow www.bouncetennis.worldpress.com © Stanbridge University 2023 60 Lateral Elbow Tendinopathy (Tennis Elbow) Also termed Lateral Epicondylitis, Epicondylalgia or Epicondylosis, lateral elbow tendinopathy 1-3% of population Hoogvliet et al, 2013 7-10x more common than medial epicondylitis TTP: Common wrist extensor tendons at lateral epicondyle and Humeroradial joint Tendons most affected: ECRB, extensor digitorum communis muscles Pain may also occur w/ stress to annular ligament © Stanbridge University 2023 61 Lateral Elbow Tendinopathy (Tennis Elbow) Etiology van Rijn et al 2009 Activities that require repetitive movements of the hands and wrists (wrist ext) Repetitive work tasks that require handling loads > 20 kg 10 times/day; tools >1kg (2.2lbs) Repetitive movements >2hr/day Low job control and social support © Stanbridge University 2023 62 Lateral Elbow Tendinopathy (Tennis Elbow) Positive tests of provocation: TTP on or near lateral epicondyle Pain with resisted wrist extension with elbow extended Pain with resisted middle finger extension, performed with elbow extended Pain with passive wrist flexion with elbow extended and forearm pronated © Stanbridge University 2023 63 Medial Elbow Tendinopathy www.drgordongroh.com © Stanbridge University 2023 64 Medial Elbow Tendinopathy (Golfer’s Elbow) Involves the common flexor/pronator tendon near the medial epicondyle Associated with: Repetitive movements into wrist flexion: Swinging golf club Pitching a ball Work related- grasping shuffling papers Lifting heavy objects Ulnar neuropathy is often an associated finding © Stanbridge University 2023 65 Medial Elbow Tendinopathy (Golfer’s Elbow) Etiology van Rijn et al 2009 Handling loads >5kg (2x/min at min 2 hrs/day) (1kg = 2.2 lbs; 5kg x 2.2= 11lbs) Handling loads > 20 kg at least 10x/day High hand grip forces >1hr/day Repetitive movements >2 hr/day Working with vibrating tools > 2 hrs/day © Stanbridge University 2023 66  Golfer’s Elbow Excessive strain to the medial elbow with impact with the ball www.howardsgolf.com © Stanbridge University 2023 67  Pitching Excessive Stress to the Medial Elbow www.bostonglobe.com © Stanbridge University 2023 68 Tennis: Stress to the Medial Elbow www.improve-your-tennis.com www.woman.thenest.com © Stanbridge University 2023 69 Medial Elbow Tendinopathy (Golfer’s Elbow) Positive Tests of Provocation: TTP on or near medial epicondyle Pain with resisted wrist flexion performed with the elbow extended Pain with passive wrist extension performed with elbow extended © Stanbridge University 2023 70 Overuse Syndromes: Repetitive Trauma Syndromes Etiology of symptoms: Excessive repetitive use or eccentric strain of the wrist or forearm muscles (lateral or medial) Microdamage and partial tears near the MT junction where strain exceeds the strength of the tissues (OR) when demand exceeds the repair process © Stanbridge University 2023 71 Overuse Syndromes: Repetitive Trauma Syndromes Etiology of symptoms: Initially: inflammation followed by formation of granulation tissue and adhesions With continued trauma: fibroblastic activity and collagen weakening Recurring problems: immature scar is re-damaged due to too-early return to activity/insufficient healing © Stanbridge University 2023 72 Overuse Syndromes: Common Impairments Gradually increasing pain in the elbow after excessive activity of the wrist and hand Pain when the involved muscle is stretched or contracts against resistance Decreased muscle strength & endurance for the demand Decreased grip strength, limited by pain TTP at site of inflammation: lateral or medial epicondyle, head of radius, muscle belly, etc. © Stanbridge University 2023 73 Overuse Syndromes: Common Functional Limitations & Disabilities Inability to participate in provoking activities: racket sports, throwing, or golf Difficulty with repetitive forearm/wrist tasks: -sorting or assembling small pars -typing, use of computer mouse -gripping activities -using hammer, screwdriver -shuffling papers -playing an instrument © Stanbridge University 2023 74  Non-operative Management of Overuse Syndromes Acute Phase Decrease Pain, Inflammation, Edema, Spasm Immobilize: cock up splint- fingers & elbow free to move (if lateral tendinopathy) Corticosteroid injection Develop Soft Tissue & Joint Mobility Wrist isometrics starting in a shortened position, neuro-mobilization, cross friction massage Maintain Upper Extremity Function Resistive exercises: shoulder and scapula ROM and stabilization exercises with resistance applied proximal to the elbow © Stanbridge University 2023 75 Non-operative Management: Overuse Syndromes Subacute and Chronic Phases Increase Muscle Flexibility & Scar Mobility Restore Joint Tracking at the RU joint Improve Muscle Performance and Function Counterforce elbow sleeve or strap: for lateral epicondylitis Eccentric training Olaussen et al, 2013, Cullinane et al, 2013 Plyometrics Patient Education Reduction of overload forces and prevention/recognition of provoking factors © Stanbridge University 2023 76 Overuse Syndrome: Example of how to reload the muscle for lateral epicondylitis Initiate with Gentle Isometrics Start with muscle in shortened position: wrist in extension Progress into neutral and into further tension (flexion) Active ROM: full ROM Add weight slowly, isolated movement Progress into eccentric loads Progress into functional loads/patters © Stanbridge University 2023 77  Olecranon Bursitis “Liquid Elbow “; "elbow bump“; "student's elbow“; "Popeye elbow", or "baker's elbow Causes: Hard blow to tip of the elbow repeated leaning on the point of the elbow on a hard surface www.sciencedirect.com Treatment: ✓ RICE ✓ Cortisone ✓ Draining bursa ✓ Possible resection www.handandwristinstitute.com © Stanbridge University 2023 78 Example of Activities in the Subacute Phase © Stanbridge University 2023 79 Kisner & Colby Figure 18.7 A: Stretch to increase extension B: Self Stretch of biceps to increase elbow extension Forearm pronation is necessary to stretch the bicep © Stanbridge University 2023 80  Triceps Stretch to increase elbow flexion Two joint muscle, move one joint at the time: 1) Bring shoulder into end range flexion. 2) Next bring elbow into end range flexion to obtain a full stretch position © Stanbridge University 2023 81  Self Stretch: To Increase supination pressure must be on distal radius NOT hand Consider modification to include self distal RU joint mobilization © Stanbridge University 2023 82 Bicep Curl 2 joint muscles are strong in mid range Concurrent shoulder extension with elbow flexion improves optimal length tension throughout a greater ROM Consider needs of patient ▪ Do you want one end to remain stationary? ▪ What position of the forearm is important? © Stanbridge University 2023 83  Supination/Pronation Watch for shoulder IR/ER; wrist flexion/extension compensation Kisner & Colby Figure 18.13 © Stanbridge University 2023 84  Bar Roll Ups/Downs Wrist Flexion/Extension Consider compensation with upper traps Stabilize forearm with other hand © Stanbridge University 2023 85 Joint Hypomobility Non-operative Management: Chronic Phase Improve muscle performance Restore functional mobility of joints and soft tissues Promote joint protection Return to function- work, sport, etc. © Stanbridge University 2023 86 Closed Chain and Functional Strengthening Exercises © Stanbridge University 2023 87 Tennis Swing Simulation: Forehand and Backhand Swings © Stanbridge University 2023 88 Review What are the different overuse elbow and forearm pathologies? What is the difference between tendonosis and tendonitis? What are the common impairments associated with overuse pathologies of the elbow and forearm? What is the non operative management for each phase of tendinosis? © Stanbridge University 2023 89 References Current Concepts of Orthopedic Physical Therapy, The elbow: Physical therapy patient management using current evidence, Chris Sebelski PT, DPT, PhD, OCS, CSCS, APTA Independent study course, 2016 Peter Fitzgibbons MD, Dexter Louie MD, George Sinclair Mitchell Dyer MD, Phillip Blazar MD, Brandon Earp MD; Functional outcomes after fixation of “Terrible Triad” elbow fracture dislocations, Rheumatology, 2009; 48: 528-536helio.com/orthopedics search 20140401-59, 2014 Peter Hoogvliet, Manon S Randsdorp, Rudi Dingemanse, Bart W Koes, Bionka MA Huisstede, Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review; British Journal of Sports Medicine 2013, 47: 1112-1119 Marco Rizzo, MD, James Nunley MD, Fractures of the elbow’s lateral column radial head and capitellum, Hand Clinics 2002; 18 (1): 21-42 Giuseppe Giannicola, David Poliumanti, Gianluca Bullitta, Frederico M. Sacchettii, Critical time period for recovery of functional ROM after surgical treatment of complex elbow stability: Prospective study on 76 patients, Injury International Journal Care Injured, 2014; 45:540- 545 © Stanbridge University 2023 90