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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.