Chapter 23: The Elbow

Jennifer Doherty-Restrepo, MS, LAT, ATC

Academic Program Director, Entry-Level ATEP

Florida International University

Acute Care and Injury Prevention

Anatomy of the ElbowReview

Functional Anatomy Elbow ROM = flexion, extension, pronation and

supination 145 degrees of flexion 90 degrees of supination and pronation

Stable joint: protection from overuse and traumatic injuries Bony limitations, ligamentous support, and muscular

stability at the elbow help to Carrying angle due to distal projection of humerus

Normal in females is 10-15 degrees, males 5 degrees Critical link in kinetic chain of upper extremity

Assessment of the Elbow: History Past history Mechanism of injury When does it hurt? Where does it hurt? Motions that increase

pain? Motions that decrease

pain?

Type of, quality of, duration of, pain?

Sounds or feelings? How long were you

disabled? Swelling? Previous treatments?

Deformities and swelling? Carrying angle

Cubitus valgus vs. Cubitus varus Flexion and extension

Cubitus recurvatum Elbow at 45 degrees

Isosceles triangle formed by the olecranon and epicondyles

Observations

Palpation: Bony and Soft Tissue Humerus Medial and lateral epicondyles Olecranon process Radial head Radius Ulna Medial and lateral collateral

ligaments Annular ligament

Biceps brachii Brachialis Brachioradialis Pronator teres Triceps Supinator Wrist flexors Wrist extensors

Pulse Assessed at brachial artery and radial artery

Skin sensation Determine presence of nerve root compression or

irritation in cervical or shoulder region Tinel’s sign

Ulnar nerve test Tap on ulnar nerve in ulnar groove Positive test = numbness/tingling along the

forearm and hand

Special Tests: Circulatory and Neurological Function

Tested after hyperextension of elbow Athlete position

Elbow is flexed to 45 degrees Wrist is fully flexed and extended

Positive test = pain in elbow joint If joint pain is severe, sprain or fracture should be

suspected Joint pain may indicate chronic injury as well

Special Tests: Capsular Injury

Valgus/Varus Stress Test Assess injury to the medial and lateral collateral

ligaments, respectively Positive test = joint laxity or complaint of pain

Special Tests: Ligament Injury

Medial Epicondylitis Test Athlete position

Elbow flexed to 45 degrees Resist wrist flexion

Positive test = pain at medial epicondyle Lateral Epicondylitis Test

Athlete position Elbow flexed to 45 degrees Resist wrist extension

Positive test = pain at lateral epicondyle

Special Tests: Muscle Injury

Pinch Grip Test Pinch thumb and index finger together Positive test = inability to touch fingers together

Indicates entrapment of anterior interosseous nerve between the heads of pronator muscle

Pronator Teres Syndrome Test Resist forearm pronation Positive test = increased pain over pronator teres

Special Tests: Muscle Injury

Special Tests: Functional Evaluation

Evaluate AROM, PROM and RROM Flexion Extension Pronation Supination

Positive test = pain and weakness

Elbow Injuries Subject to injury due to…

Broad range of motion Weak lateral bone structure Exposure of soft tissue

Many sports place excessive stress on joint Locking motion of some activities Use of implements Throwing motion

MOI = direct blow or repetitive blows Vulnerable area due to lack of padding

Signs and Symptoms Rapid swelling due to irritation of bursa or

synovial membrane Management

PRICE immediately, for at least 24 hours If severe, refer for X-ray to rule out fracture

Elbow Injuries: Contusion

Elbow Injuries: Olecranon Bursitis MOI = direct blow

Superficial location makes it extremely susceptible to injury

Signs and Symptoms Pain, swelling, and point

tenderness Swelling will appear almost

spontaneously without the pain and heat

Management Acute: compression for at

least 1 hour Chronic: requires superficial

therapy primarily involving compression

If swelling fails to resolve, aspiration may be necessary

May be padded to return to competition

MOI = overstretching or too forceful a contraction Falling on outstretched arm Repeated microtears may cause chronic injury

Rupture of distal biceps is most common in UE Signs and Symptoms

Pain with AROM and RROM Point tenderness in muscle, tendon, or lower part

of muscle belly

Elbow Injuries: Muscle Strains

Management PRICE Sling in severe cases Follow-up treatment

Cryotherapy, ultrasound, ROM and PRE exercises If severe loss of function, refer for X-ray to rule

out avulsion or epiphyseal fracture

Elbow Injuries: Muscle Strains

MOI = valgus force from repetitive trauma Secondary injuries may include…

Ulnar nerve inflammation Wrist flexor tendinitis Overuse flexor/pronator strain Ligamentous sprains Elbow flexion contractures Joint instability

Elbow Injuries: Ulnar Collateral Ligament Injuries

Signs and Symptoms Pain along medial aspect of elbow Point tenderness over UCL Associated paresthesia

Positive Tinel’s sign Positive Valgus Stress Test

Possible end-point laxity X-ray may show evidence of…

Hypertrophy of humeral condyle and/or posteromedial aspect of olecranon; and osteophytes

Calcification within the UCL Loose bodies in posterior compartment

Management Conservative treatment

PRICE and NSAID’s

ROM and PRE exercises as pain decreases Analysis of the throwing motion (if applicable) Surgical intervention may be necessary

Tommy John Procedure Throwing athlete may be able to return to activity

approximately 22-26 weeks post surgery

MOI = repetitive microtrauma to insertion of wrist extensor muscles Tendinosis may result

Degeneration of tendon without inflammation

Signs and Symptoms Aching pain at lateral epicondyle after activity Decreased elbow ROM Pain with AOM and RROM wrist extension Pain and weakness in wrist and hand develop

Elbow Injuries: Lateral Epicondylitis (Tennis Elbow)

Management PRICE NSAID’s and analgesics Mobilization and stretching in pain free ranges

ROM and PRE exercises as pain decreases

Deep friction massage Hand grasping while in supination

Avoid pronation motions

Use of neoprene sleeve Mechanics and skills training in order to avoid recurrence of

injury

MOI = repeated forceful wrist flexion and extreme valgus torque on the elbow May involve pronator teres, flexor carpi radialis,

flexor carpi ulnaris, and palmaris longus tendons Can be associated with ulnar nerve neuropathy

Signs and Symptoms Pain with AOM and RROM wrist extension

Pain with wrist flexion as well in severe injuries

Point tenderness and mild swelling at medial epicondyle

Elbow Injuries: Medial Epicondylitis

Management PRICE NSAID's and analgesics Sling in severe cases

Severe cases may require splinting and complete rest for 7-10 days

Cryotherapy, Ultrasound Curvilinear brace

Below elbow to reduce stress at the elbow joint

MOI = Repetitive microtrauma Injurious movements include elbow rotation and

extension Excessive valgus stresses causes compression of the radial

head, which adds shearing forces at the radiocapitular joint Impairment of blood supply may result, which causes

degeneration of articular cartilage creating loose bodies

Panner’s disease Occurs in children (age <10) Osteochondrosis of capitellum due to localized avascular

necrosis

Elbow Injuries: Osteochondritis Dissecans

Signs and Symptoms Sudden pain at radiohumeral joint Swelling, creptitus Decreased ROM (full extension)

ROM usually returns in a few days Grating with pronation and supination

Locking of the joint X-ray

May show flattening and crater of capitulum May show loose bodies in joint

Management Activity restriction for 6-12 weeks NSAID’s Splint and cast applied in severe cases of

deterioration If repeated locking of the elbow joint occurs,

loose bodies are removed surgically

MOI = repetitive microtraumas that occur from throwing motion (Not due to the type of pitch)

Linked to: Accelerated apophyseal growth and delayed medial

epicondyle epiphysis growth Traction apophysitis with possible fragmentation of

medial epicondylar apophysis Avulsion fracture at medial epicondyle or radial head Osteochondrosis of humeral capitellum Non-union stress fracture of olecranon epiphysis

Elbow Injuries: Little League Elbow

Signs and Symptoms Onset is slow Slight flexion contracture Tight anterior joint capsule Weakness in triceps “Locking” or “Catching” sensation Decreased ROM

Especially forearm pronation and supination

Management PRICE NSAID’s and analgesics Stop throwing until…

Pain resolved Full ROM is regained

Gentle ROM exercises Gently triceps strengthening exercises Analysis of throwing motion

MOI = narrowing of cubital canal or irregularity of cubital tunnel Pronounced cubital valgus may cause deep

friction contributing to injury Ulnar nerve injury may result

Ulnar nerve subluxation or dislocation Traction of ulnar nerve from valgus force Ulnar nerve compression from ligaments

Elbow Injuries: Cubital Tunnel Syndrome

Signs and Symptoms Pain on medial aspect of elbow

Pain may be referred proximally or distally

Point tenderness in cubital tunnel Pain with hyperflexion Intermittent paresthesia in 4th and 5th fingers

Management Rest, immobilization for 2 weeks NSAID’s Splinting, surgical decompression or

transposition of subluxating nerve may be necessary

Avoid hyperflexion and valgus stresses

Elbow Injuries: Dislocation MOI = fall on outstretched hand with elbow

extended or severe twist while elbow flexed High incidence in sports Dislocation may be posterior, anterior, or lateral

Signs and Symptoms Swelling, severe pain, disability Median and radial nerves may be compromised Blood vessels may be compromised Often a radial head fracture is involved

Management Pack with ice and apply sling immediately Refer for reduction immediately Following reduction…

Immobilize in elbow flexion for 3 weeks PRE exercises for grip and shoulder strenthening

Following immobilization… Heat and PROM exercises to regain full ROM ROM and PRE exercises should be initiated by athlete

Exercises that are too strenuous should be avoided before complete healing due to high probability of developing myositis ossificans

Forced stretching should be avoided

MOI = fall on flexed elbow or direct blow May occur in one or more of bones in elbow joint Fall on outstretched hand may fracture the humerus

above condyles or between condyles Condylar fracture may result in gunstock deformity

Direct blow may fracture olecranon or radial head Signs and Symptoms

May not result in visual deformity Hemorrhaging, swelling, muscle spasm

Elbow Injuries: Fractures

Management Monitor neurovascular status Non-surgical treatment

Appropriate for stable fractures Immobilize with cast or removable splint for 6-8

weeks Surgical treatment

Used to stabilize unstable fractures in adults ROM exercises initiated early to prevent frozen elbow

MOI = impaired circulation or ischemia Associate with humeral supracondylar fractures, which

compromises the brachial artery and inhibits circulation to forearm

May be loss of motor and sensory function Classic case involves median nerve

Edema further impairs circulation via condition called compartment syndrome Muscle necrosis may occur with irreversible muscle damage

after 4-6 hours, which may lead to secondary fibrosis and calcification

Elbow Injuries: Volkmann’s Contracture

Signs and Symptoms Pain in forearm which increases with PROM

finger extension Cessation of brachial and radial pulses Coldness in arm Decreased ROM

Management Monitor neurovascular integrity

Rehabilitation of the Elbow General Body Conditioning

Must maintain pre-injury CV and LE strength fitness levels

Flexibility Restoring ROM is critical in elbow rehab Variety of approaches can be used as long as they

do not “force” the joint

Joint Mobilizations Loss of proper arthrokinematics following

immobilization is expected Joint mobilization and traction

Very useful to increase mobility Useful to decrease pain Restores accessory motions

Strengthening Achieved through low-resistance, high-repetition exercises

Must be pain free Shoulder and hand grip exercises Isometrics can be used while immobilized PNF and isokinetics are useful in early and intermediate

stages of rehabilitation PRE exercises with tubing, weights, or manual resistance Closed kinetic chain activities

Assist in both static and dynamic stability to the elbow Proprioceptive training should also incorporated

Functional Progressions Will enhance healing and performance

PNF, swimming, pulley machines, and rubber tubing Simulate sports activities

Should include steps Warm-up Gradual build up to activity, becoming increasingly

more difficult Return to Activity

ROM must be WNL Strength should be restored without pain