Elbow Flashcards
Brachialis
C5-C6, musculoskeletal
C7-C8, radial
Radial
C7-C8
brachiorad, triceps, supinator, anconeus
PT
C6-C7
median
Varus/Valgus
LCL/MCL
Pinch Grip Test
entrapment of ant IO nerve
Tinel’s Sign
ulnar nerve compromise
Lateral Epicondylagia (tests)
Cozen’s Sign (resisted wrist ext), Mill’s Test (passive ext stretch, wrist/elbow)
Maudsley’s - resisted middle finger ext
MCL involvement (tests)
Milking sign, moving valgus
LCL involvement (tests)
Chair sign
Pitch Type/Age
fastball (8-10) change up (10) curveball, knuckleball (14) slide, forkball, splitter (16-18) screwball (17-18)
Pitch Count/Rest Days
21-35 (1)
36-50 (2)
51-65 (3)
66 (4)
Little League Elbow
possibilities: med epi frag/avul, delayed or accel apop growth of med epi, forms osteochondritis/rosis
Panner’s Disease (CET)
AVN of capitellum
C - not associated w/ trauma, common 7-12 yo
E - stiffness, pain at let elbow
T - rest
OCD (CET)
art cart separates from subchondral bone
C - repetitive trauma
E - pain at lat elbow, pop, swell, lock
T - conservative unless loose bodies (surgery)
Lat Epi (CET)
C - tennis elbow, excessive gripping (ECRB sometimes indicated)
E - Cozen and Mill, dec grip strength
T - conservative
Med Epi (CET)
C - golfer’s elbow, too much elbow flex on trailing arm w/ follow through, repeated use or chronic strain (FCR, PT, FCU indicated)
E - pain medially, swelling, passive wrist ext (pain)
T - conservative
Med Epi Apop (CET)
C - repetitive stress w/ throwing, 9-12 yo most common
E - pain at med elbow, dec strength
T - rest, conservative
Volkmann’s Contracture (CET)
C - ischemic contracture from brachial artery injury, major complication of elbow injury
E - pain in forearm that increased with passive finger ext, cessation of brachial/radial pulses
T - referral to MD
PT Syndrome (CET)
C - entrapment of median nerve due to edema and hypertrophy
E - neuropathy, sensory, and motor deficits
T - anti-inflammatories, rest, possible surgery
MCL bundles
ant (tight ext, loose flex)
post (tight flex, loose ext)
MCL injury (CET)
C - repetitive valgus stresses, valgus loads during throwing
E - pain medially, dec strength, milking sign, moving valgus
T - docking technique - surgery focus on ant bundle
MCL Reconstruction
Wk 1-4
- ROM 40-90 wk 1-3, 30-105 wk 4
- splint 50-60 wk 1
Wk 4-6
- ROM 15-115, pain free iso, scap stab
Wk 12-16
- begin plyo, light forearm/wrist strengthening
Mo 4-9
- interval throwing 4 mo, batting 5 mo
- throwing off mound 9 mo
- pitch competitively 1 yr
Flexor Contracture (loss of ext) (CET)
C - most often result of valgus ext overload syndrome, osteophytes may develop and prevent ext
E - restricted ROM, pain at end range
T - LLLD, stretching, jt mobs, dynamic splinting at night
Heterotrophic Ossification (CET)
C - direct trauma, surgical intervention
E - swelling, hyperemia, loss of motion
T - surgical excision
Dislocation of Elbow (CEIT)
C - FOOSH, severe trust in flexed position, 90% post
E - hemorrhage, swelling, severe pain,
I - A/P, lat, oblique
T - elbow splint 5-7 days in hinged elbow brace 30-90; inc 10-15 per week, PROM avoided
full flex 6-12 weeks, full ext 3-5 mo
OCD Capitellum (CET)
C - osteochondral injury, loose bodies
E - MRI best
T - non-op, arthroscopic
Olecranon Bursitis (CET)
C - superficial nature makes it more susceptible to chronic injury or direct blows
E - pain, swelling, pt tender
T - protect with padding
Monteggia Fx
dislocation of prox RU jt w/ forearm fx
Nightstick Fx
at midpoint of ulna
Galenzzi Fx
dislocation of ulnar head w/ fx of distal radius
Nursemaid’s Elbow
dislocation of radius common from when child pulled up by hand
CRITOE
capitellum radial head internal/med epi trochlea olecranon external/lat epi
Tendinitis
Lat Epi
- ECRB (wrist ext uln dev), EDC, ECRL (wrist ext rad dev), ECU
- shear stress
Med Epi
- PT (pro elbow flex), FCR (wrist flex rad dev)
- tension overload
Bi/Tri - shear stress and tendon overload
Pitching and Tendinitis
Lat epi/LCL - decal/follow through Med epi/PT - late arm cocking/early accel UCL/ulnar nerve lesion - cocking Tri tendinitis/avulsion - accel/decel Radial/median nerve lesion - accel/decel
Affected vs Healthy Arm
limited active wrist flex/ext, passive pro
Biceps
secondary flexor, greatest torque 80-100 flex
active during elbow flex except when pro
Brachialis
primary flexor, 100 flex
unaffected by forearm/sh position
Triceps
primary ext, 90 flex
LH affected by shoulder
Tennis
Serve
- ticeps, PT(accel/decal), ECC of biceps/sup
- taping/mvmt retrain - proper control of elbow ext/pro
Groundstroke
- high ECRB, ERCL, EC
- backstroke (ECRB and biceps)
- avoid wrist flex on impact
short backswing = greater impact
Stages of Tendon Healing
Inflam (1-7 days) - rest, protect, control inflame
Prolif (1-2 weeks) - controlled stretching/ROM
Maturation (1-2 mo) - controlled stretching and strengthening (avoid disuse/atrophy)
Fibrosis - repeated inflame episodes leading to scarring of tendon
Lat Epi Non-Op
acute - steroid injection if unresponsive to modalities
subacute - ecc
chronic - plyo
Lat Epi Post-Op
day 3 - gentle painfree ROM
day 17 - 80% ROM, light activity only
day 18-21 - submax isos, antigravity wrist no pain
wk 3-6 - RTC, elbow scap stab, aerobic, light stretch
wk 8-12 - UE plyo, CKC added
RTP 4 mo
conservative fails, pain 6-12 mo after onset; 3+ failed injections
Med Epi Non-Op
RTP 8-10 weeks
similar to lat epi - focus on flex/pro
throwers at wk 6
Post-Op RTP 3-4 mo
Bi Ten Non-Op
RTP 8-10 weeks
splint elbow 90 flex and neutral forearm, 3 weeks
PREs 8 weeks
Bi Ten Post-Op
splint elbow 90 flex, sup forearm 6 weeks
Wk 3 - passive elbow flex/sup, active elbow ext 30 deg, A/PROM pro/sup Wk 4- passive wrist and shoulder Wk 6 - DC splint Wk 7 - AAROM/PROM elbow flex; PRE Wk 10-12 - ECC, throwing 3 mo - plyo 6 mo - contact sports
Tri Ten Non-Op
splint elbow 45
PREs 8 weeks
Tri Ten Post-Op
splint elbow 45, 3 weeks
wk 3 - ROM (AROM inc 20-30 deg/week)
wk 6 - PRE
3 mo - RTP
Joint Integrity Tests
Valgus Stress - UCL ant
Milking - UCL complex
Moving Valgus - UCL complex (best Sn, Sp; max pain 90 deg)
Varus - LCL, annular
O’Driscoll - P/L rot instability, LCL ulnar, rot sublux/dislocation of UH jt
UCL Info
provocation or valgus stress
FCR, FCU, and PT deficits
UCL Non-Op
4-6 weeks, normal; start plyo, throwing/throwers wk 6
interval throwing wk 12
RTP 14-16 wks
UCL Post-Op
Phase I - Wk 1-3
- post splint 1-2 weeks, hinge brace 30-100 (15-115 wk 3), submax sh isos, wrist flex/ext (wk 2)
Phase II - Wk 4-8
- 10-120 (inc 5-10 per week), isotonics (no ER)
wk 6 - 0-130, add ER
Phase III Wk 9-13
- plyo, ECC elbow flex/ext
- PNF, RTC, scap stab, sh arom isotonics
- throwers ten
Phase IV Wk 14-26
- interval warm up throwing program
- fastball at 75% before breaking pitches
- RTP 22-28 wks
pitch from mound 9 mo, competitively 1 yr
Radial Tunnel Syndrome
Entrapment - radiocapitaller jt, tender ECRB origin, supinator (fibrous distally)
- distal tri, mid/post hum (spiral groove), sup head of supinator, ECRB/L and brachiorad
surgery after 12 wks pain - sig tender with resisted middle finger ext, along course of supinator
Post-op - grip wk 4, PRE 6, plyo 8, sports 10
Cubital Tunnel Syndrome
cocking phase
Entrapment - FCU, FDC, retroepicondylar groove
Non-Op
- volar splint, elbow 30-40 deg flex 6- 8 wks; avoid repetitive elbow flex/ext, full elbow flex
- PRE wk 6
Post-Op
- post splint 60 flex, neutral forearm
- isos 3 weeks; AROM wk 3, PRE 7th, throwers 9th, RTP 12
Stages of Fx Healing
Inflammation (1-7 days) - fx frag moving freely Soft Callus (3 wks) - angulation at fx site can still occur Hard Callus (3-4 mo) - frag united firmly by new bone Remodeling (after) - fx united solidly
Splinting
Inflam - support tissues, prevent overstretch
Prolif - gentle stretch/inc ROM, prevent loss of align
Mat - provide support chronic jt lax/lig injury, traction to correct contracture
Static - I
Serial Static - IPM
Static Progressive - late I, PM
Dynamic - late I, P, early M
Throwing
Wind up to Stride - low load = uncommon for injuries
- elbow flex (ISO to ECC), wrist/finger ext (ISO to CON)
Cocking to Accel - pelvis vs trunk rot
early - valgus stresses begin (flex/pro mass; pro resist valgus, tri ISO elbow flex)
late - max valgus (olecranon impinges vs groove/fossa = loose bodies)
Decel to Follow through - ECC loads to decal arm SH complex GH vs scap elbow complex - PT, bi, sup, brach - ECC (brach, biceps, sup, wrist ext) CON (PT, wrist flex)
