Elbow Flashcards
What type of joint is the elbow?
Trochoginglymoid (combo hinge and pivot)
What percentage of elbow stability comes from the bone structure?
50%
Anterior elbow symptoms suggest which conditions?
Ant capsule sprain, distal biceps tendon issues, dislocation, pronator syndrome (primarily throwers)
Medial elbow symptoms suggest which conditions?
MET (medial elbow tendinopathy), UCL sprain, ulnar nerve injury, flexor-pronator muscle injury, fx, Little League elbow (in young), valgus extension overload
Posteromedial elbow symptoms suggest which conditions?
Olecranon tip stress fx, posterior impingement (throwers), trochlea chondromalacia
Posterior elbow symptoms suggest which conditions?
Olecranon bursitis, olecranon process stress fx, triceps tendinopathy
Lateral elbow symptoms suggest which conditions?
Capitulum fx, LET, RCL sprain, osteochondral degenerative changes, osteochondritis dessecans (Panners disease), posterior interosseous nerve syndrome, radial head fx, radial tunnel syndrome, synovitis
Forearm symptoms suggest which conditions?
W/ gradual onset can include radius or ulna stress fx, radial tunnel syndrome, cubital tunnel syndrome, and brachialis tendinopathy
Pronator teres syndrome
Compression of median nerve by pronator teres
Symptoms: - Tenderness over PT muscle and pain with resisted pronation of the forearm
- Weakness could be present with abduction of the thumb as well as impairment to the pincer muscles
- Sensation changes may also be experienced in the first three fingers and the palm
Difference between Panners disease and OCD?
Panner disease occurs in school-age children (7-12 y.o.) as opposed to adolescents (10-20 y.o.) and does not produce a loose foreign body
Panner’s Disease
Young boys younger than 10 y/o
- Bone growth disorder (osteochondrosis) of the humeral capitellum
- Lateral elbow pain, stiffness, decreased ROM (especially EXTENSION)
Osteochondritis Dissecans (OCD)
Young throwers (ages 12-14 y.o.)
- Inflammatory pathology of bone and cartilage. This can result in localized necrosis and fragmentation of bone and cartilage
- Lateral elbow pain, stiffness, popping, giving way, locking, instability, swelling
Lower motor neuron lesion symptoms
- Muscle atrophy
- Fasciculations (muscle twitching)
- Diminished DTR
- Decreased tone
- Negative Babinski
- Flaccid paralysis
Pancoast syndrome
Malignant neuoplasm of the superior sulcus of the lung
- Ipsilat shoulder/arm/hand pain
- Weakness and atrophy of the thenar eminence
- Horners syndrome (partial ptosis (drooping or falling of upper eyelid), miosis (constricted pupil), and facial anhidrosis (loss of sweating
Normal carrying angle:
Men
Women
Men: 11-14°
Women: 13-16°
Colles vs smiths fx
Colles is wrist extended, smiths is with wrist flexed
POLICE meaning
Protection
Optimal Loading
Ice
Compression
Elevation
Used to initially manage acute conditions
Only highly recommended special tests for the elbow (2)
Tinel, Elbow flexion tests for cubital tunnel syndrome
Cubital tunnel is formed between the 2 heads of which muscle?
Flexor carpi ulnaris
Elbow flexion test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = for new or worsening paresthesias
Pressure provocation test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
Compresses ulnar nerve in elbow flexion test position for 30”
+ = N/T in 4-5th digits
Tinels sign:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = Tingling or electrical sensations to 4-5th digits
Scratch Collapse test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = Loss of ER tone on affected side after “scratching” the cubital tunnel
Crossed finger test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = inability to cross middle finger over index
Shoulder internal rotation test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = any symptoms attributable to cubital tunnel syndrome occurs within 10”
Chair sign:
- Tests for?
- + result
Posterolateral rotary instability of elbow (PLRI)
+ = apprehension to push up
Special tests for cubital tunnel syndrome (6)
1) Elbow flexion
2) Pressure Provocation
3) Tinel sign
4) Scratch collapse
5) Crossed finger
6) Shoulder IR
PLRI stands for?
Posterior lateral rotary instability of the elbow
Special tests for PLRI (3)
1) Chair sign
2) Push-up sign
3) Table-top relocation
Special tests for UCL injury (3)
1) Valgus stress test
2) Milking maneuver (anterior band of UCL aka AUCL)
3) Moving valgus stress (chronic)
Special tests for Medial elbow tendinopathy (MET) (2)
1) Passive medial elbow tendinopathy (pain w/ PROM supination and wrist extension)
2) Active wrist flexion against resistance (MMT wrist flex)
LET stands for?
Lateral elbow tendinopathy
Special tests for lateral elbow tendinopathy LETS (3)
1) Cozen
2) Maudsley
3) Mill
Distal biceps tendon rupture is assessed with which special test
Biceps squeeze test (good - LR)
T/F: Inflammation is the cause of medial and lateral epicondylitis
False
They are often NOT inflammatory conditions and lack prostaglandin-mediated inflammation
Thought to be more degenerative conditions that likely involve both peripheral and CNS pathways
3 Etiologies of tendinopathy in the elbow
1) Vascular: focal areas of vascular compromise
2) Mechanical: Repetitive loading causes microscopic degeneration, fibroplasia, and eventually scar tissue
3) Neural modulation: Results from neurally-mediated mast cell degranulation and release of substance P
In terms of function, tendons can be classified as what 2 categories?
1) Positional (responsible for exact movements)
2) Energy-storing (locomotion and ballistic performance)
Progression of loading the tendons that are injured (resistance)
1) Isometrics (10” x 24 reps OR 40” x 6 reps)
2) Heavy, slow-motion resistance training
3) Endurance training to sustain compression loads (friction over the tendon and heavy stretching)
4) Introducing speed first and then energy-storying loads (plyometrics)
T/F: In LET conditions you don’t need to look at c-spine and shoulder
False
To rule out use isometric wrist ext
Self-reported outcome measure for LET
Patient-rated tennis elbow evaluation (PRTEE)
Valid/reliable/sensitive
What nerve is commonly compressed at the arcade of Frohse
Posterior interosseous nerve
Standard of care for LETs includes:
1) NSAIDs
2) Cross friction massage
3) Electrical and thermal modalities
4) Therapeutic exercise
5) Bracing
6) Rest
NOTE: most studies are inconclusive as to the effectiveness of PT using the above interventions
Evidence for use of joint mobilization in LET treatment
Convincing substantiation show mobs can decrease pain and increased functional grip scores
Evidence for use of TFM in LET treatment
No sufficient evidence
Low-level benefits in later stages
Evidence for use of eccentric exercise in LET treatment
Limited but does suggest it is effective (more vs concentric with reducing pain and increasing strength)
Dosing of eccentric exercise in LET treatment
3 x 15 reps, 30” rest between sets
Evidence for use of electrophysical agents (US, ionto, pulsed electromagnetic field) in LET treatment
Little to NO evidence
Evidence for use of shockwave therapy in LET treatment
Not effective, less vs corticosteroids
Evidence for use of low-level laser in LET treatment
May help with pain in short-term vs placebo
LET treatment: stretching progression (jts)
Wrist (flex/ext), elbow (flex/ext), forearm (sup/pro)
LET treatment: strengthening progression (jts)
Wrist (ext/flex), Forearm (pro/sup), elbow (flex/ext)
Evidence for use of corticosteroid injections in LET treatment
High success rates for 6-8wks BUT then high recurrent rates and protracted recovery for long term
aka NOT good for long-term
Evidence for surgical intervention in LET management
Reserved for those who fail conservative tx
Evidence is insufficient effectiveness of surgery
How long post-op lateral epicondylar release can you start AROM and strengthening?
AROM: 2 wks, prior to that PROM of elbow
Strengthening: 3 wks, start w/ isometrics
Upcoming tx for LET and MET
PRP, Bone marrow aspirate concentrate (BMAC), collagen-producing cell injection
Bicipital tendinopathy is common in what population and age?
Athletic individuals >35 y/o
d/t repetitive hyperext of the elbow w/ pronation OR repetitive flex combined w/ stressful sup/pro
Bicipital tendinopathy symptoms
Pain over radial tuberosity, pain w/ elbow flex and supination (MMT)
Rehab of Bicipital tendinopathy includes 4 phases:
1) Rest
2) Stretching (scap mms, RTC, post GH jt capsule)
3) Eccentric strengthening of elbow flex and sup
4) Progressive return to sport or work
When does a distal bicep tear become chronic?
After 4 wks
Is early detection and intervention of distal bicep tear important?
Yes, delayed diagnosis may preclude primary repair and lead to chronic weakness
Common demographics for distal bicep tear
Male, 5th decade of life
Higher moment arm in what positions: Short head of biceps vs long head of biceps
SH: neutral and pronated
LH: supinated
Tests for diagnosing distal biceps tear
1) Hook test
2) Biceps squeeze test
3) Biceps crease interval test
Hook test for distal bicep tear
- Evidence
100% SN/SP, GREAT
Better vs MRI
Biceps squeeze test
- Evidence
SN 96%
Biceps crease interval
- Evidence
- positive test
- SN 92%/ SP 100%
- > 6cm difference