Elbow Flashcards
What is the functional range of the elbow?
30-130 degrees
What is convex and what is concave in the Humeroulnar Joint?
Convex trochlea of the humerus
Concave trochlear notch on ulna
How does the ulna move during extension? Why?
Laterally
Due to the articular groove and the distal medial aspect
What is a normal carrying angle?
5-15 degrees
In closed chain exercise, does the radius or the ulna get the most WB? How much? Why?
Radius
60-70%
Has the most congruency at the wrist region
What provides stability for the humeroulnar joint?
Medial (ulnar) collateral ligament
-Anterior band: biggest stabilizer against valgus force
-Posterior band: stabilizer against valgus force past 90 degrees of flexion
-Oblique Band
Capsule
Resting Position of the Humeroulnar Joint
70 degrees flexion
10 degrees supination
Close Packed Position of the Humeroulnar Joint
Full extension
Full supination
Capsular Pattern of the Humeroulnar Joint
More limitation in flexion than extension
What is convex and concave in the humeroradial joint?
Convex: capitulum of the humerus
Concave: head of the radius
What provides the stability for the humeroradial joint?
Lateral collateral ligament
What are the three parts of the lateral collateral ligament of the humeroradial joint?
Radial collateral ligament
Lateral ulnar collateral ligament (humerus to ulna)
Annular ligament (around radial head to ulna)
Resting Position of the Humeroradial Joint
Full extension
Forearm supination
Closed Packed Position of the Humeroradial Joint
90 degrees elbow flexion
5 degrees supination
Capsular Pattern of the Humeroradial Joint
Flexion > extension
Equal limitation of supination and pronation
What is convex and concave in the Proximal Radioulnar Joint
Convex: radial head held by the annular ring
Concave: radial notch of the ulna
What provides the stability for the Proximal Radioulnar Joint?
Annular ligament
Interosseus membrane
Quadrate ligament
Oblique cord
Resting Position for the Proximal Radioulnar Joint
70 degrees flexion
35 degrees forearm supination
Closed Packed Position for the Proximal Radioulnar Joint
5 degrees of forearm supination
Capsular Pattern for the Proximal Radioulnar Joint
Pronation = supination
Minimal to no loss of motion
Pain at the end ranges of pronation and supination
What is convex and concave in the Distal Radioulnar Joint?
Convex: ulnar head
Concave: ulnar notch of the radius
What provides the stability for the Distal Radioulnar Joint?
Interosseus membrane
Articular disc
Anterior radioulnar ligament
Posterior radioulnar ligament
Close Packed Position of the Distal Radioulnar Joint
5 degrees supination
Loose Packed Position of the Distal Radioulnar Joint
10 degrees supination
Capsular Pattern Position of the Distal Radioulnar Joint
Pronation = supination
Full ROM
Pain at extreme ranges
Ulnar abduction occurs with….
Pronation
Extension
Ulnar adduction occurs with…
Supination
Flexion
Ulnar Nerve’s area of entrapment
Wraps around posterior to elbow at ulnar groove
When is the Ulnar Nerve the most stressed?
Flexion
The Median Nerve can go through which muscle?
Pronator teres
When is the Median Nerve the most stressed?
Extension
The Radial Nerve can go through which muscle?
Supinator
Cubitus valgus
Excessive angulation of the carrying angle
Cubitus Valgus stresses…
MCL
Ulnar N
Cubitus varus
Decreased carrying angle
Cubitus Varus stresses…
LCL
Radial N
Epicondylitis
Inflammation of the epicondyle
Has fallen out of favor due to lack of evidence that these tissues become inflamed
Epicondylagia
Preferred to lack of inflammatory condition
Histological degeneration similar to that of the RC
Lateral Epicondylitis Pathology
“Tennis Elbow”
4-7 times more common than medial epicondylitis
Tendinitis of wrist extensor at common origin on lateral epicondyle
EDC, ECRB involved
Lateral Epicondylitis History
Repetitive wrist extension and/or grasp
Dull ache at rest, sharp pain at lateral epicondyle with lifting
Acute: recognizable mechanisms with acute pain, occasional bruising, and feeling of “giving away”
Chronic: associated with gradual onset
Lateral Epicondylitis Examination
Pain with resisted wrist extension
Tenderness over lateral epicondyle
Elbow extension, forearm pronation, wrist flexion
Lateral Epicondylitis Intervention
Radial head mobility
Soft tissue mobilization
Ergonomic assessment
Deep Friction Massage
Reduce pain and promote tissue healing
Promote hyperemia and collagen realignment
Reduce scar formation
Perpendicular to tissue fibers
5-10 min
Medial Epicondylitis Pathology
“Golfer’s Elbow”
Tendinitis of wrist flexors at common origin on med epicondyle
FCR and Pronator teres
Medial Epicondylitis History and Examination
Gradual Onset
Repetitive wrist flexion
Dull ache at rest, sharp pain at medial epicondyle with lifting
Pain with resisted wrist flexion and/or pronation
Tenderness over medial epicondyle
Elbow extension, forearm supination, wrist extension
Medial Epicondylitis Intervention
Biomechanics assessment
Joint mobility
Activity modifications
Modalities
Little Leaguer’s Elbow
Epiphysitis of medial epicondyle
Little Leaguer’s Elbow History and Examination
Pain or tenderness of medial epicondyle Gradual onset History of forceful pronation Loss of full extension Pain with resisted flexion
Little Leaguer’s Elbow Intervention
Decrease inflammation
Gentle ROM
May immobilize
Throwing technique
Panner Disease
Begins as degeneration or necrosis of capitulum and followed by regeneration, decalcification
Ages 7-12
Non-traumatic, self-limiting
Panner Disease Examination
Acute onset, no locking/catching in elbow
Dull lateral ache of elbow
Possible swelling
Loss 5-20 degrees extension
Panner Disease Intervention
Rest
Avoid valgus stress
Symptomatic splinting
Healing may require up to 3 years
Osteochondritis Dissecans Pathology
Possibly arterial injury with subsequent bone necrosis results in increased radiohumeral lateral compression forces
Causes: ischemia, trauma, genetic predisposition
High risk: adolescent boy baseball pitchers and adolescent girl gymnasts
Osteochondritis Dissecans History and Examination
Gradual onset Trauma, changes in circulation Diffuse pain lateral or anterior elbow Limited AROM and PROM extension Clicking/locking Pain increased with supination and pronation
Osteochondritis Dissecans Intervention
Rest from stress
Emphasize biceps/triceps strength and muscle balance
Possible motion-limiting brace
Full activity at 6 months
Possible surgery if loose bodies, fracture or articular cartilage
Long term: loss extension, large radial heads, degenerative changes
Olecranon Bursitis
Inflammation of the olecranon bursa
Olecranon Bursitis History and Examination
Continuous pressure on olecranon Direct trauma or repetitive grazing Obvious swelling posterior elbow Limited ROM Pain to palpation of bursa
Olecranon Bursitis Intervention
RICE
Padding
Iontophoresis
Arthritis
Most common: RA
Joint swelling
Differentiate from bursitis (lab tests)
Arthritis Intervention
Pain control
Joint mobilization
Low-load strengthening
Biomechanics
Biceps Tendon Rupture
Disruption of biceps from attachment (usually distal)
Biceps Tendon Rupture History and Examination
Quick, forceful biceps contraction Trauma Usually occurs in males in 5th decade Pain at area of biceps Discontinuity of biceps with bulge Loss of elbow flexion and supination strength Ecchymosis in antecubital fossa
Biceps Tendon Rupture Intervention
May need surgical intervention
- May require palmaris longs or semitendinosus graft
- Posterior splint at 90 degrees 1-2 weeks
- Full ROM at post-op week 4
- Unrestricted activity 8 weeks
Cubital Tunnel Syndrome
Ulnar nerve compression distal to the medial epicondyle
Repetitive motion increases inflammation that inhibits normal gliding of the nerve
Traction forces caused by elbow flexion contribute to compression
Cubital Tunnel Syndrome History and Examination
Paresthesia radiating to dorsal 4th and 5th digits Trauma Pain or paresthesias worse at night Decreased sensation in ulnar distribution of hand Weak pinch grasp Claw hand Neurodynamics Rule out cervical
Cubital Tunnel Syndrome Intervention
Relative rest Splinting Joint mechanics Elbow pad Stretch FCU
Pronator Teres Syndrome
Median nerve compression at pronator teres
Pronator Teres History and Examination
Paresthesia in thumb, index finger, middle finger aggravated with activity
Pain volar aspect of forearm
Not nocturnal
Possible dislocation
Weakness in muscles of forearm innervated by median N
Pain reproduced with pressure at pronator teres with resistance against pronation, elbow flexion and wrist flexion
Rule out cervical spine
Pronator Teres Syndrome Intervention
Relative rest
Splinting
Joint mechanics
Stretch pronator teres
Radial Nerve Entrapment
Most frequently injured nerve associated with humeral fractures
Radial Tunnel Syndrome
Radial nerve compression at the elbow
Posterior Interosseus Syndrome
Radial nerve compression at arcade of Frohse
Radial Tunnel Syndrome History and Examination
Pain over lateral humeral epicondyle Tender radial head Numb radial head Trauma Resisted middle finger extension reproduces pain No motor loss
Posterior Interosseus Syndrome History and Examination
Tender to palpation distal from lateral epicondyle Trauma History old lateral epicondylitis Symptoms with resisted wrist extension Unable to extend thumb or fingers at MCP No sensation loss
Radial Nerve Entrapment Intervention
Relative rest
Splinting
Joint mechanics
Activity modification
Subluxation of radial head
Annular ligament is torn when arm extended and pronated
Torn surface slips into radiohumeral joint and gets trapped
Posterior dislocation
Ulna and radius are displaced posterior to the humerus
Caused by fall on outstretched hand with elbow extended
Rapid edema usual
Nerve injuries common
Splinting or surgical intervention
Outcomes: lack extension ROM, weakness
MCL Instability
Posttrauma (FOOSH)
Overuse: rapid/forceful extension, valgus stress, forceful pronation
Overhead athletes and pitchers
MCL Instability Examination
May be confounded by muscle strain, inflammation, tendinsosis
Medial elbow pain
“Pop” at time ligament rupture
Tender at ulnar insertion ligament 2 cm distal of epicondyle
Gradual onset of pain aggravated by throwing or pain following episode with inability to complete maximal effort
Valgus stress test
Instability worse in pronation
MCL Rupture Intervention
Without surgery: -Immobilization -Activity modification Surgical: -Repair vs reconstruction -Recovery longer than 26 weeks -Return sport for elite athletes ~12 months
Extension Valgus Overload Syndrome
Compression of the olecranon against the humerus with a valgus stress
Extension Valgus Overload Syndrome Examination
Flexion contracture and painful active extension
Posterior pain with passive elbow pronation, valgus, extension
Extension Valgus Overload Syndrome Intervention
Rest
NSAIDs
Correct throwing mechanics
Eccentric strength of elbow flexors
Radial head fracture
Adults
From a fall
Start active motion within 7-10 days since immobilization can lead to permanent loss of motion
Olecranon fracture
Avulsion
Fall onto elbow, outstretched hand or strong triceps contraction
ORIF
Intercondylar fracture
Wedge fracture of humerus associated with a lot of tissue swelling and damage
Supracondylar fracture
Children
Hyperextension or fall on flexed elbow
Humeral fragment displaced posteriorly and can injure muscles, arteries and nerves
Fracture Intervention
Dependent on stability of joint
Dependent on physician’s protocol
Dependent on patient’s functional needs
Usually addresses ROM, strength, tissue flexibility and joint mobility
