Elbow Pathology Flashcards
examination and evaluation
- should include comprehensive exam of the upper quarter
- presence of co-morbidities requires different techniques than in those patients without these issues
- medical history along with objective information forms basis for chosen interventions
relevant scales
VAS DASH PSFS UEFS American shoulder and elbow surgeons elbow form Boston questionnaire
DASH
disabilities of the arm, shoulder and hand
PSFS
patient specific functional scale
UEFS
upper extremity functional scale
Boston questionnaire
carpal tunnel
general observations
- *posture- head and neck
- *limb position
- muscle tone
- quality, color, temp of skin
- carrying angle- elbow 10-13 deg
- swelling
- resting position of elbow
- ability to use limb
clearing tests
- joint above and below
- always consider c-spine
- shoulder girdle: AROM, PROM, break tests
mobility examination
AROM/PROM
overpressure- flexion/extension, pronation/supination
accessory motion exam:
1: humeroulnar joint
- distraction
- radial and ulnar gapping
2: humeroradial joint
- distraction
- dorsal and volar glides
3: prox & distal radioulnar joint
- dorsal and volar glides
muscle performance examination
MMT
Performance based functional measures (asterisk signs)
- pushing (push off test)
- pulling
- curling
- grip strength
other tests
- ligament stability
- soft tissue mobility
- neurologic status
- functional status
common pathologies of the elbow
- lateral epicondylitis (-algia)
- medial epicondylitis (-algia)
- olecranon bursitis
- dislocation/instability
- radial head subluxation
- Volkman’s contracture
- nerve entrapment syndromes
lateral epicondylitis
“tennis elbow”
-degeneration, micro/macro tearing, trauma of common extension insertion on the lateral epicondyle (focus ECRB, EDC 3 digit)
-initially a viscous cycle of I
inflammation>tissue weakness->tearing
more common >35 y/o
differential diagnosis of lateral epicondylitis
- radiohumeral DJD
- radial nerve entrapment
- ligamentous injury
- proximal pathology
mechanism of lateral epicondylitis
repetitive active forceful wrist extension, forceful gripping
clinical presentation of lateral epicondylitis
- tender over lateral humeral epicondyle, extensor tendon and proximal muscle belly
- possibly some edema noted in acute phase, possibly tight fascial bands noted in chronic phase
- pain on active wrist extension (esp w/ radial deviation)
- pain on passive wrist flexion (esp w/ ulnar deviation, elbow extended, pronated)
- plain films: 7% show abnormal calcification
medial epicondylitis
“Golfer’s elbow”
-micro/macro tearing, trauma of common flexor insertion on medial epicondyle
-initially a viscous cycle of:
inflammation->tissue weakness-> tearing
mechanism of medial epicondylitis
repetitive active forceful wrist flexion
clinical presentation of medial epicondylitis
- tender over medial humeral epicondyle, flexor tendon and proximal muscle belly
- possibly some edema noted in acute phase, possibly tight fascial bands noted in chronic phase
- pain on active wrist flexion and pronation
- pain on passive wrist extension (possible supination)
treatment of ACUTE lat & med epicondylitis
cochrane review supports:
- topical NSAIDS
- local injections of steriods > oral NSAIDS
- patient education: refrain from offending activities
- stretching
- splints/straps
treatment of SUBACUTE lat & med epicondylitis
- deep friction massage
- Mill’s manipulation & radial head mobs
- exercise (iso-> conc-> ecc) through pain
- acupuncture, laser, US
- assess cervical spine and wrist
Mill’s Manipulation
- designed to elongate and tear the scar formed in chronic lateral epicondylitis
- before performing, ensure full elbow extension PROM exists, and there is a restriction in extension ROM with wrist fully flexed (stretch pain over common extensor tendon)
- while maintaining full wrist extension, thrust into elbow extension
olecranon bursitis
- trauma- fall on elbow
- excessive friction
- infection
- systemic disease (RA, gout)
clinical presentation of olecranon bursitis
- confined swelling
- palpation painful, increased temp
- decreased elbow extension strength
- decreased extension ROM
treatment of olecranon bursitis
conservative “wait and see”
- symptom reduction tx (warm soaks, splinting, protection)
- no evidence that this is better or worse
aspiration: temp/permanent relief of swelling
- analyze fluid for infection
aspiration with steroid injection -faster reduction of symptoms -increase in complications skin atrophy-20% septic bursitis- 10% chronic pain or pressure 30%
elbow dislocation
dislocation is a medical emergency
- high chance of nerve and vascular
- often complicated by fx and log disruptions
elbow instability
medial: throwing athletes
- stretching/rupture of ulnar collateral ligament
lateral: trauma
- stretching/rupture of radial collateral ligament
clinical presentation of instability
- feeling of “giving way”
- pain on activities that stress the damaged ligaments
treatment of dislocation/instability
-ability to dynamically stabilize-FCU?
stabilize proximal/proper form
-surgical reconstruction
post op rehab stresses early protected motion
medial elbow pain- differential diagnoses
Medial elbow instability: conservative rx in nonthrowing athletes; reconstruction for athletes. don’t over-stress healing tissue, establish flexibility, muscle balance, neuromuscular control
medial epicondyle apophysitis- traction apophysitis at ME as result of valgus stresses in immature elbow- inflammation along medial apophsysis
valgus extension overload-olecranon on fossa with combined valgus; swelling, medial and posterior pain, +valgus extension overload
olecranon fractures
mechanism of injury: FOOSH w/ elbow flexed, triceps contracts
-ulnar nerve vulnerable
radial head fractures
MOI: FOOSH w/ supination (dislocation?)
FOOSH
fall on out stretched hand
fracture treatment
- short immobilization and early motion
- biceps shortening: C/R stretch, arm swing
- extension loss: jt mobs w/ distraction
Nursemaid’s elbow
radial head subluxation
radial head subluxation
“nursemaid’s elbow”
- longitudinal force at forearm (pronated)
- pulls radial head from annular ligament
clinical presentation of nursemaid’s elbow
- localized pain
- reluctant/inability to move (held in pronation)
- often palpate sulcus
treatment of nursemaid’s elbow
- reduction (emergency room)
- guarded motion
- PT for inflammation/symptom/impairments
Volkmann’s ischemic contracture
=deformity of the hand, fingers and wrist caused by trauma induced ischemia
- crush injury to the forearm
- elbow fracture in children
swelling of Volkmann’s ischemic contracture causes…
“compartment syndrome”
pressure causes ischemia and tissue death
- pressure reduced blood inflow
- pressure prevents blood outflow
tissue dies/becomes fibrotic and shortened
treatment of volkmann’s contracture
- medical emergency
- fasciotomy
- later rehab to regain strength & ROM
nerve entrapment syndromes
1: cubital tunnel syndrome
2: radial tunnel syndrome
cubital tunnel syndrome
ulnar nerve in tunnel (medial epicondyle, olecranon, MCL, ligament of Struthers
flexion tightens nerve in the tunnel
- decreased blood supply
- parasthesias & pain
- decreased sensation
- decreased strength
signs & symptoms of cubital tunnel syndrome
parasthesias medial forearm/ulnar hand
prolonged/repeated end range flexion
- sleep, combing hair, driving, phone
- Chronic: weak turning keys, grip/pinch, dropping objects
exam for cubital tunnel syndrome
special tests ULTT muscle bulk digits 4 & 5 sensory testing
differential diagnosis for cubital tunnel syndrome
C8-T1 nerve root
TOS
Guyon’s canal
treatment for cubital tunnel syndrome
Conservative:
- refrain from activities w/ elbow flexion
- night splints in 40-60 deg flexion to prevent full flexion
- physical agents to reduce inflammation (TENS)
- nerve gliding (ulnar bias)
- stretching (extrinsic flexors, intrinsics (ulnar innervated)
Surgery: transposition of nerve anteriorly
radial tunnel syndrome
posterior interosseous nerve in tunnel
- radial tunnel entrance
- leash of Henry (radial recurrent vessels)
- ECRB tendon
- Arcade of Froshe
- supinator origins
Caused by repetitive:
- pronation/supination
- wrist flexion/extension
symptoms of radial tunnel syndrome
- pain in common extensors mid belly
- can appear similar to tennis elbow
- decreased strength
treatment for radial tunnel syndrome
Conservative:
- refrain from symptom producing activities; keep forearm in neutral
- cock-up splints at wrist (3-6 months)
- physical agents to reduce inflammation (TENS)
- nerve gliding (radial bias)
- stretching: extrinsic extensors & flexors, supinator
Surgery: transposition of nerve anteriorly
lateral epicondylitis special tests
1: Cozen’s test
2: Lateral epicondylitis test
Cozen’s test
indicates lateral epicondylitis
positive test= reproduced pain along the lateral epicondyle/ common extensor tendons
pt seated. makes a fist with forearm in pronation and radial deviation of wrist.
PT palpates origin of common extensor tendon at the lateral epicondyle with own thumb. resists wrist extension
Lateral epicondylitis test
indicates lateral epicondylitis
positive test=reproduction of pain along lateral epicondylitis, pain over radial head or common extensor tendon
pt elbow in full extension and full pronation
strongly resist wrist extension and ulnar deviation supporting the wrist
elbow stability special tests
1: moving valgus stress test
2: posterior lateral rotary instability
3: varus stress test:
4: valgus stress test
moving valgus stress test
indicates chronic MCL tear of the elbow
Positive test=reproduced medial elbow pain between 120-70 deg of flexion
with pt in upright position, passively abduct shoulder to 90 deg. place elbow in full flexion. PT applies modest valgus force to elbow until shoulder reaches full ER. maintaining constant valgus force, quickly extend elbow to 30 deg extension.
- *speed is patient dependent
- *sit in chair to stabilize shoulder
posterior lateral rotary instability
indicates posterior lateral instability of the radius
positive test=post lat displacement, apprehension of the radius, reduction of the radius as elbow approaches 90 deg
pt lies supine
PT flexes shoulder above head. elbow in full extension and supinated. 1 hand prevents ER. other hand grasps forearm maintaining supination.
PT brings elbow into flexion (maintaining supination) and a valgus force at the elbow
**stabilize the humerus, don’t allow ER!
Varus stress test (LCL)
indicates the integrity of the lateral collateral complex
positive test=reproduction of distraction pain laterally at joint line
- reproduction of compression pain medially at joint line
- joint line laxity with stress
pt seated or standing.
PT has 1 hand at the elbow and other hand over proximal wrist.
**elbow fully extended
PT applies varus force while palpating LCL
**compare bilaterally
valgus stress test (MCL)
indicates integrity of the medial collateral complex
positive test=reproduction of distraction pain medially at the joint line, reproduction of compression pain laterally at the joint line, joint pain with stress
- *compare bilaterally
- don’t allow elbow flexion
nerve entrapment tests
1: elbow flexion test
2: pressure provocation
3: tinel’s sign
elbow flexion test
indicates cubital tunnel syndrome
positive test=reproduction of pain, tingling, numbness along ulnar nerve distribution
pt is sitting. shoulders neutral, elbows fully flexed (not forcibly) with full wrist extension.
pt describes any symptoms after holding for 3 minutes
pressure provocation
indicates cubital tunnel syndrome
positive test=reproduction of symptoms along ulnar nerve
PT’s 1st and 2nd fingers pressed over pt’s ulnar nerve proximal to cubital tunnel with elbow in 20 deg flexion and supinated
test is held for 60 sec
Tinel’s sign
indicates cubital tunnel syndrome
positive test=reproduction of symptoms along ulnar nerve
PT applies 4-6 taps to the pt’s ulnar nerve just proximal to cubital tunnel
medial epicondylitis test
indicates medial epicondylitis
positive test= reproduction of pain over the medial epicondyle or common flexor tendon
PT resists wrist flexion
humero-ulnar joint mobilizations
1: distraction
2: medial gap (valgus force)
3: lateral gap (varus force)
humero-radial joint mobilizations
1: distraction
2: dorsal glide- also affects prox RU jt
3: ventral glide- also affects prox RU jt
4: Mill’s manipulation
distal radio-ulnar joint
1: dorsal glide
2: ventral glide
- *do your best to stabilize one while gliding the other, use grades 3&4 mostly.
- *half grip
elbow short axis distraction
supine, elbow in 90 deg
