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Rehabilitation of the Elbow

Melanie StevensHonsBKin, MSc(PT), FCAMT, MCPA

Registered Physiotherapist, David Braley Sport Medicine andRehabilitation Centre at McMaster University

Professional Associate to the School of Rehabilitation Scienceat McMaster University

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Overview

Common Musculoskeletal and Sport Injuries atthe Elbow

Components of Effective PhysiotherapyIntervention

Elbow and Sport Specific Treatments

Evidence and Current LiteratureBottom Line

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The Elbow

Tri-joint complex witharticular connections to the

wrist and shoulder

Ulnohumeral joint Radiohumeral joint Radioulnar joint

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The Elbow

UlnohumeralJoint

RadiohumeralJoint

RadioulnarJoint

Close Pack

Position

Extension / Supination 90 degrees flexion /mid-supination

Full pronation orsupination

Rest Position 70 degrees flexion, 10degrees supination

70 degrees flexion orextension in supination

Depends onphysiologist

Capsular Pattern Flexion > extension Flexion > extension Equal limitation ofpronation andsupination

End Feel Soft tissue (flexion)Bony (extension)

Soft tissue (flexion)Bony (extension)

Capsular (supination)Capsular or bony(pronation)

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The Elbow

Superficial and integratedneural structure Musculocutaneous nerve

Ulnar nerve (pitchers wind up) Median Nerve (straight arm) Radial Nerve (throw follow

through)

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The Elbow

Site of multiple muscleattachments Biceps Triceps Supinator Wrist extensors Wrist flexors

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Sport Injuries

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Commonly Seen Sport Injuries

at the Elbow

Posterior dislocation ofthe ulnohumeral joint

Distal biceps rupture Radial head fracture

Rupture or sprain ofthe ulnar or radial

collateral ligaments

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Commonly Seen Sport Injuries

at the Elbow Tendonopathy of the

wrist extensors or

flexors Malalignment of theulnohumeral joint

Neurodynamic

entrapment or stasis Bursitis

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Implications of Structure on

Treatment

Affected bybiomechanics of distal

and proximal joints Frequent site of neuro-dynamic stasis orentrapment and

referred pain Highly susceptible torepetitive strain

injuries

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Rehabilitation of Elbow

Injuries

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Components of Effective

Physiotherapy Interventions Must address all the

joints of the elbow aswell as distal and

proximal joints Needs to take

biomechanics intoaccount

Neural, muscular andarticular mobility must

be comprehensivelyassessed

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Reduction of Joint Effusion

Active range of motionwithin pain-free range

Appropriate homemodalities (i.e. ice,elevation)

Effleurage and

drainage whenappropriate

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Range of Motion

Type of movement must

be appropriate for injuredstructure

Incorporate conjunctmovements and quadrant

positions as well as planar

movements

Provide appropriateenvironment to assistrange

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Strengthening

Match type of

strengthening to stage ofhealing

Strengthen through rangeand in weight bearing

positions Correct imbalance through

the entire upper extremity Avoid overloadingrepetitive strain injuries

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Manual Therapy

Correct joint adhesionsand fixations

Restore end of rangequadrant positions

Address biomechanicalissues with matched

strengthening

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Neural Mobility

Reduce biomechanicbarriers and muscle

impingement Restore mobility withflossing as opposed tostretching

Follow neural chainfrom the cervical spineto the peripheral

nerves

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Massage

Decrease muscle tonepotentially altering the

alignment of the joint Correct muscleadhesions

Increase blood flow

Encourage normalhealing of muscletissue

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Sport Specific Rehab

Load the injured joint

when appropriate withequipment and gear

Complete sport specificmaneuvers and

incorporate into off season

training regimen Address modifications as

needed prior to return tosport

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Supporting Evidence

Bi t L P li A Vi i B B ll E A t ti

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Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic

review of clinical trials on physical interventions for lateral

epicondylagia.Br J Sport Med2005;39:411-422.

Bracing andTaping

Ultrasound

Laser Extracorporeal

Shock Wave

Therapy Electromagneti

c Field

Exercise Manipulation Acupuncture

CombinedMultimodal

treatment

Insufficient

Evidence

No Effect on

Lateral

Epicondylagia

Positive Effect on

Lateral

Epicondylagia

W dl BL N h W RJ B GD

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Woodley BL, Newsham-West RJ, Baxter GD.

Chronic tendinopathy: effectiveness of eccentric

exercise.Br J Sport Med2007;41:188-199.

Meta-analysis of 20 high quality RCTs Limited evidence to support positive effect

of eccentric exercise on pain, function andpatient satisfaction in chronic tendinopathywhen compared to concentric exercise,

stretching, splinting, frictions and ultrasound

C i EL D JR W lf RS A d JR Elb

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Cain EL, Dugas JR, Wolf RS, Andrews JR. Elbow

injuries in throwing athletes: A current concepts

review. Am J Sports Med2003;31:621-635.

Ulnar collateral ligament is primary stabilizingforce of the elbow in the throwing athlete andfrequent underlying cause of injury and instability

Positive prognosis for return to competitive sportin highly motivated population post ligamentreconstruction

Return to repetitive exposure to high valgus stressoften results in return of symptoms andconservative treatment is frequently maintenance

based

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Bottom Line

Treatment should be

multimodal with emphasison exercise

Alignment of the wholeupper kinetic chain is

necessary to prevent

recurrence of symptoms All systems must be

addressed includingmuscular, articular and

neural as opposed to justthe injured tissue

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Questions

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References

Ahrens PM, Boileau P. The long head of biceps and associated tendonopathy.J Bone JointSurg (Br) 2007;89-B:1001-1009.

Bisset L, Paungmali A, Nicenzino B, Beller E. A systematic review and meta analysis of

clinical trials on physical interventions for lateral epicondylalgia.Br J Sports Med2005;39:411-422.

Cain EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current

concepts review.Am J Sports Med2003;31:621-635.

De Smelt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis intennis: update on aetiology, biomechanics and treatment.Br J Sports Med2007;41:816-819.

Dodson CC, Altchek DW. Management of medial collateral ligament tears in the athlete.Oper Tech in Sports Med2006;14:75-80.

Eygendaal D, Safran MR. Postero-medial elbow problems in the adult athlete.Br J Sports

Med2006;40:430-434.

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References

Grimshaw P, Giles A, Tong R, Grimmer K. Lower back and elbow injuries in golf. Sports Med2002;32:655-666.

Hennrikus WL. Elbow disorders in the young athlete. Oper Tech in Sports Med2006;14:165-172.

Jaworski CA. Current understanding of tendinopathies and treatment options.American Family

Physician 2007;76;773-776.

Langer P, Fadale P, Hulstyn M. Evolution of the treatment options of ulnar collateral ligament

injuries of the elbow.Br J Sports Med2006;40:499-506.

Paoloni JA, Murrell GAC. Identification of prognostic factors for patient outcomes in extensor

tendinopathy at the elbow. Scand J Med Sci Sports 2004;14;163-167.

Stasinopoulos D, Stasinopoulos K, Johnson MI. An exercise program for the management oflateral elbow tendinopathy.Br J Sports Med2005;39:944-947.

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendonopathy: effectiveness of eccentric

exercise. Br J Sports Med 2007;41:188-199.