Chapter 23: The Elbow © 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 23: The Elbow

© 2011 McGraw-Hill Higher Education. All rights reserved.

Anatomy of the Elbow


Figure 23-1


Figure 23-2


Figure 23-3


Figure 23-4 A-C


Functional Anatomy• Complex that allows for flexion, extension,

pronation and supination– 145 degrees of flexion and 90 degrees of

supination and pronation• Bony limitations, ligamentous support and

muscular stability at the elbow help to protect it from overuse and traumatic injuries

• Elbow demonstrates a 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 and where does it hurt?– Motions that increase or decrease pain– Type of, quality of, duration of, pain?– Sounds or feelings?– How long were you disabled?– Swelling?– Previous treatments?


• Observations– Deformities and swelling?– Carrying angle

• Cubitus valgus versus cubitus varus

– Flexion and extension• Cubitus recurvatum

– Elbow at 45 degrees• Isosceles triangle

(olecranon and epicondyles)


Figure 23-5

Figure 23-7

Figure 23-8

•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 and

extensors


• Special Tests– Circulatory and Neurological Function

• Pulse should be taken at brachial artery and radial artery• Skin sensation should be checked - 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 is found when athlete complains of sensation

along the forearm and hand

– Test for Capsular Injury• Tested after hyperextension of elbow

– Elbow is flexed to 45 degrees, wrist is fully flexed and extended

– If joint pain is severe, moderate/severe sprain or fracture should be suspected (chronic injury may present same)


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

collateral ligaments, respectively• Looking for gapping or complaint of pain

Figure 23-10


– Medial and Lateral Epicondylitis Tests• Elbow flexed to 45 degrees and wrist extension

or flexion is resisted• Pain at lateral or medial epicondyle,

respectively indicates a positive test

– Pinch Grip Test• Pinch thumb and index finger together• Inability to touch fingers together indicates

entrapment of anterior interosseous nerve between heads of pronator muscle

– Pronator Teres Syndrome Test• Forearm pronation is resisted• Increased pain proximally over pronator teres

indicates a positive test


Figure 23-11 & 12


Functional Evaluation

• Pain and weakness are evaluated through AROM, PROM and RROM– Flexion, extension,

pronation and supination– ROM of pronation and

supination are particularly noted

Figure 23-13 & 14© 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Injuries to the Elbow

• Subject to injury due to broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage

• Many activities place excessive stress on joint

• Locking motion of some activities, use of implements, and involvement in throwing motion make elbow extremely susceptible


• Contusion– Etiology

• Vulnerable area due to lack of padding• Result of direct blow or repetitive blows

– Signs and Symptoms• Swelling (rapidly after irritation of bursa or

synovial membrane)

– Management• Treat w/ RICE immediately for at least 24 hours• If severe, refer for X-ray to determine presence

of fracture


• Olecranon Bursitis– Etiology

• Superficial location makes it extremely susceptible to injury (acute or chronic) --direct blow

– Signs and Symptoms

• Pain, swelling, and point tenderness

• Swelling will appear almost spontaneously and w/out usual pain and heat

Figure 23-17


– Management• In acute conditions, compression for at least 1

hour• Chronic cases require superficial therapy

primarily involving compression• If swelling fails to resolve, aspiration may be

necessary• Can be padded in order to return to competition


• Muscle Strains– Etiology

• MOI is excessive resistive motion (falling on outstretched arm), repeated microtears that cause chronic injury

• Rupture of distal biceps is most common muscle rupture of the upper extremity

– Signs and Symptoms• Active or resistive motion produces pain; point

tenderness in muscle, tendon, or lower part of muscle belly

– Management• RICE and sling in severe cases• Follow-up w/ cryotherapy, ultrasound and exercise• If severe loss of function encountered - should be

referred for X-ray (rule out avulsion or epiphyseal fx)


• Ulnar Collateral Ligament Injuries– Etiology

• Injured as the result of a valgus force from repetitive trauma

• Can also result in ulnar nerve inflammation, or wrist flexor tendinitis; overuse flexor/pronator strain, ligamentous sprains; elbow flexion contractures or increased instability

– Signs and Symptoms• Pain along medial aspect of elbow; tenderness over MCL• Associated paresthesia, positive Tinel’s sign• Pain w/ valgus stress test at 20 degrees; possible end-

point laxity• X-ray may show hypertrophy of humeral condyle,

posteromedial aspect of olecranon, marginal osteophytes; calcification w/in MCL; loose bodies in posterior compartment


• Ulnar Collateral Ligament Injuries (cont.)– Management

• Conservative treatment begins w/ RICE and NSAID’s

• W/ resolution, strengthening should be performed; analysis of the throwing motion (if applicable)

• Surgical intervention may be necessary (Tommy John procedure)

– Involves reconstruction using palmaris longus autograft and occasionally transposition of the ulnar nerve

– Throwing athlete can return to activity 22-26 weeks post surgery with full-recovery taking 18-24 months


• Lateral Epicondylitis (Tennis Elbow)– Etiology

• Repetitive microtrauma to insertion of extensor muscles of lateral epicondyle

• Tendinosis with degeneration of tendon without inflammation

– Signs and Symptoms• Aching pain in region of lateral epicondyle after

activity• Pain worsens and weakness in wrist and hand

develop• Elbow has decreased ROM; pain w/ resistive

wrist extension


• Lateral Epicondylitis (continued)– Management

• RICE, NSAID’s and analgesics• ROM exercises and PRE, deep

friction massage, hand grasping while in supination, avoidance of pronation motions

• Mobilization and stretching in pain free ranges

• Use of a counter force or neoprene sleeve

• Mechanics and skills training in order to avoid recurrence

Figure 23-19


• Medial Epicondylitis– Etiology

• Repeated forceful flexion of wrist and extreme valgus torque of elbow

• May involve pronator teres, flexor carpi radialis and ulnaris, and palmaris longus tendons

• Can be associated with ulnar nerve neuropathy

– Signs and Symptoms• Pain produced w/ forceful flexion or extension• Point tenderness and mild swelling• Passive movement of wrist seldom elicits pain,

but active movement does


– Management• Sling, rest, cryotherapy or heat through

ultrasound• Analgesic and NSAID's• Curvilinear brace below elbow to reduce elbow

stressing• Severe cases may require splinting and

complete rest for 7-10 days


• Elbow Osteochondritis Dissecans– Etiology

• Impairment of blood supply to anterior surface resulting in degeneration of articular cartilage, creating loose bodies

• Repetitive microtrauma in movements of elbow rotation, extension, valgus stress causing compression of the radial head and shearing of the radiocapitellar joint

• Seen in young athletes involved in throwing motion• Panner’s disease in incidents of children age <10

– Osteochondrosis of capitellum due to localized avascular necrosis

– Signs and Symptoms• Sudden pain, locking; range usually returns in a few

days


– Signs and Symptoms (continued)• Swelling, pain at radiohumeral joint, crepitus,

decreased ROM (full extension); grating w/ pronation and supination

• X-ray may show flattening and crater of capitulum w/ loose bodies

– Management• Activity restriction for 6-12 weeks; NSAID’s• Splint and cast applied for cases of extensive

deterioration• If repeated locking occurs, loose bodies are

removed surgically


• Little League Elbow– Etiology

• Caused by repetitive microtraumas that occur from throwing (not type of pitch)

• May result in numerous disorders of growth in the pitching elbow

• Linked to:– Accelerated apophyseal growth region and delay in

medial epicondyle growth plate– Traction apophysitis with possible fragmentation of

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


• Little League Elbow (continued)– Signs and Symptoms

• Onset is slow; slight flexion contracture, including tight anterior joint capsule and weakness in triceps

• Patient may complain of locking or catching sensation

• Decreased ROM of forearm pronation and supination

– Management• RICE, NSAID’s and analgesics• Throwing stops until pain resolved and full

ROM is regained• Gentle stretching and triceps strengthening• Throwing under supervision w/ good technique

to prevent recurrence© 2011 McGraw-Hill Higher Education. All rights reserved.

• Cubital Tunnel Syndrome– Etiology

• Pronounced cubital valgus may cause deep friction problem

• Ulnar nerve dislocation• Traction injury from valgus force, irregularities

w/ tunnel, subluxation of ulnar nerve due to lax impingement, or progressive compression of ligament on the nerve

– Signs and Symptoms• Pain medially which may be referred proximally

or distally• Tenderness in cubital tunnel on palpation and

hyperflexion• Intermittent paresthesia in 4th and 5th fingers


• Cubital Tunnel Syndrome (continued)– Management

• Rest, immobilization for 2 weeks w/ NSAID’s• Splinting or surgical decompression or

transposition of subluxating nerve may be necessary

• Patient must avoid hyperflexion and valgus stresses


• Dislocation of the Elbow– Etiology

• Caused by fall on outstretched hand w/ elbow extended or severe twist while flexed

• Bones can be displaced backward, forward, or laterally

• Distinguishable from fracture because lateral and medial epicondyles are normally aligned w/ shaft of humerus

– Signs and Symptoms• Swelling, severe pain, disability• Complications w/ median and radial nerves and

blood vessels• Often a radial head fracture is involved


Elbow Dislocation


– Management• Cold and pressure immediately w/ sling• Refer for reduction• Neurological and vascular fxn must be assessed prior

to and following reduction• Physician should reduce - immediately• Immobilization following reduction in flexion for 3

weeks• Hand grip and shoulder exercises should be used

while immobilized• Following initial healing, heat and passive exercise

can be used to regain full ROM• Massage and joint movement that are too strenuous

should be avoided before complete healing due to high probability of myositis ossificans

• ROM and strengthening should be performed and initiated by patient (forced stretching should be avoided)


• Fractures of the Elbow– Etiology

• Fall on flexed elbow or from a direct blow• Fracture can occur in any one or more of the

bones• Fall on outstretched hand often fractures

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

• Direct blow to olecranon or radial head may result in fracture

– Signs and Symptoms• May not result in visual deformity• Hemorrhaging, swelling, muscle spasm


• Elbow Fractures (continued)– Management

• Decrease ROM, neurovascular status must be monitored

• Surgery is used to stabilize adult unstable fracture, followed by early ROM exercises

• Stable fractures do not require surgery

– Removable splints are used for 6-8 weeks

Figure 23-22


• Volkmann’s Contracture– Etiology

• Associate w/ humeral supracondylar fractures, causing muscle spasm, swelling, or bone pressure on brachial artery, inhibiting circulation to forearm

• Can become permanent• There may be loss of motor and sensory function

– Classic case involves median nerve

• Results from insufficient arterial perfusion and venous stasis followed by ischemic degeneration

• Irreversible muscle damage occurs after 4-6 hours• Edema further impairs circulation propagating

muscle necrosis• Necrosis may lead to secondary fibrosis and

calcification


– Signs and Symptoms• Pain in forearm -

increased w/ passive extension of fingers

• Pain is followed by cessation of brachial and radial pulses, coldness in arm

• Decreased motion

– Management• Remove elastic wraps

or casts • Close monitoring must

occur

Figure 23-23


• Pronator Teres Syndrome– Etiology

• Entrapment of median nerve– Proximal to the elbow joint

– In the pronator teres muscle as the nerve passes between the superficial and deep heads of the muscle

• May become trapped due to edema or muscle hypertrophy– Signs & Symptoms

• Sensory deficits – numbness, tingling, pins & needles (digits 1-4)

• Motor deficits – loss of flexion and opposition, weakness with pronation

• Symptoms reproduced with tightly gripping and resisted pronation

– Management• Rest, NSAID’s, TENS for pain, modified activity

• Decompression surgery if treatment is unsuccessful


Rehabilitation of the Elbow• General Body

Conditioning– Must maintain pre-

injury fitness levels - cardiovascular and strength (lower body)

• Flexibility– Restoring ROM is

critical in elbow rehab– Variety of approaches

can be used as long as they don’t force the joint

Figure 23-24


• Joint Mobilizations– Loss of proper arthrokinematics following

immobilization is expected– Joint mobilization and traction can be very

useful to increase mobility and decrease pain through restoration of accessory motions

Figure 23-25 A & B© 2011 McGraw-Hill Higher Education. All rights reserved.

• Strengthening– Achieved through low-resistance, high-repetition

exercises - must be pain free

– Shoulder and grip exercises should also be performed

– Continuous passive motion units followed by dynamic splinting is ideal following surgery

– Isometrics can be used while elbow is immobilized

– PNF and isokinetics are useful in early and intermediate active stages of rehab

– A graded PRE program w/ tubing, weights or manual resistance should be included


Figure 23-27 Figure 23-26


Strengthening Exercises

Plyometric Exercises

Figure 23-28


Closed Kinetic Chain Exercises

– Closed kinetic chain activities should also be incorporated

• 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– Can re-engage in activity

when criteria has successfully been completed

– ROM w/in normal limits, strength should be equal w/ no complaint of pain

– Return should progress with use of restrictions in an effort to objectively measure activity progression


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