IRAT 2 Flashcards
Elbow joint type
Hinge
The elbow is far less commonly injured than the knee due in part to teh face that it is a
Non-weight bearing structure
Due to teh elbows link to the shoulder and wrist, it is more susceptible to
Wear and tear, repetitive stress, and micro trauma.
Overuse, misuse, overstrain, and trauma are the
Most common presentatiosn
Always distinguish between
Pain Stiffness Looseness Crepitus Locking Combination of above
Olecranon fractures will more likely result from
A fall on the tip of the elbow
A hyperextension injury will result in
A dislocation or supracondylar fracture
In overstretch or sudden stretch injuries,
Medial or collateral ligaments will be involved
Compressive injuries can occur to the
Radial head or capitellum in overstretch or sudden stretch injuries
Traction to the elbow can result in
Radial head subluxation (nursemaid’s elbow)
Repetitive or overuse injury is common where the patient performs supination or pronation excessively
Supination - radial nerve
Pronation - median nerve
Repetitive or overuse, soft tissue injury is more common with
Trigger poitns
Muscle strain
Nerve compression
Cocking or medial stretch to elbow is common
Medial collateral ligament sprain
Flexor muscle strain
Ulnar nerve entrapment
Dislocation and fracture are common following
Hyperextension injury to the elbow
Hyperextension injuries leading ot supracondylar fractures account for
2/3 of fractures in children
Dislocations at the elbow are usually posterior due to
Structures of the elbow
Valgus stress is more common from
Overuse
Acute cases of valgus trauma
Avulsion fracture to the medial epicondyle, medial collateral ligament sprain and capitellum fracture
Repetitive sports activities are probably the most common cause of
Persistent elbow pain
Elbow weakness
Biceps tendon rupture
Follows sudden flexion contration with proximal migration of biceps muscle belly
Instability will probably follow a past history of
Trauma to the elbow
Dislocation or
Constant valgus overload in immature atheletes
Restricted ROM will be as a result of
Joint effusion or fracture
Non-traumatic reasons for restricted ROM could follow
Tight muscles or
Capsular ligament sprains/adhesions
Locking/crepitus in young patients
Osteochondritis dissecans
Locking/crepitus in older patients
More suggestive of degenerative changes
Grinding during supination/pronation will be as a result of
Radial head-capitellum articular changes
In flexion and extension grinding or locking,
Medial epicondyle or olecranon degenerative changes are likely
Superficial complaints commonly involve
Skin such as psoriasis
Swelling indicates
Gout or
Olecranon bursitis
Numbness and tingling can be from
Nerve entrapment at the site, distal or proximal
Elbow assessment look for
Weakness Instability Pain Fracture Decreased ROM Swelling Spasm Tenderness Nerve entrapment
Little league elbow and panner’s disease will be diagnosed
Radiographically
Patients with ulnar nerve involvement can be evaluated with
Cubital tunnel view (15 degrees external rotation adn maximal flexion
Fractures and dislocations require
Referral
Tendinitis will respond to
PT and
Cross friction massage
Trigger point therapy
Myofascial release
Little league elbow without radiographic damage can be treated with
Ice and rest and modification of activity
LLE with x-ray damage evident should be
Referred for evaluation
Valgus overload will respond to
Taping
Bracing
Other support to prevent overextension of the elbow
Elbow joint 3 articulations
Humeroulnar
Humeroradioulnar
Proximal radioulnar
Elbow joint articulates
Trochlea of humerus with trochlear notch of ulna
Articulates captiulum of humerus with
Superior surface of radial head
Q3 main nerves of the forearm
Radial
Median
Ulnar
Innervate prime mover muslces
Brachial plexus
ROM elbow
Flexion 150 Extension 0 Valgus angle 15 Supination 90 Pronation 80-90
Prime movers in flexion
Biceps brachii
Brachioradialis
Prime movers in extension are
Triceps brachii
Anconeus is accessory
Prime supinators
Biceps brachii
Supinator
Pronation activated by
Pronator teres
Pronator quadratus
Complex movements that occur simultaneously around an axis
Pronation
Supination
Common elbow joint disorders
Lateral epicondylitis (tennis elbow) Medial epicondylitis (golfer’s elbow) Triceps tendinitis (posterior tennis elbow) Posterior impingement syndrome Nursemaid’s elbow Little league elbow Osteochondrosis Olecranon bursitis
Lateral epicondylitis presentations
Lateral elbow pain assocaited with repetitive sports or occupationalactivity
Anatomy and structures in lateral epicondylitis
Tearing of the extensor carpi radialis brevis origin.
Somtimes this may extend to the extensor-digitorum-communis
Cause/etiology lateral epicondylitis
Referred to histologically as an angiofibroblastic hyperplasia. Repetitive and forceful wrist extension, radial deviation and supination are most common causes. Seen often with tennis players, weavers, plumbers, and meat cutters.
Evaluation/assessment lateral epicondylitis
Tenderness on the lateral aspect of the epicondyle at the origin of the ECRB on palpation
Positive cozen and mill maneuvers. Chair lift test.
X-ray may show calcification in 25% of cases
Management lateral epicondylitis
Acute phase responds well to ice while splinting and myofascial release techniques are also indicated
Chiro adjustments, cross friction massage and mobilization are recommended in subacute phase. Rehab to include stretching adn strengthening.
Bracing during the sub-acute phase while playing tennis helps and modification of equipment is recommended
Co-manage approaches might recommend topical nitric-oxide application
Medial epicondylitis presentation
Medial elbow pain after repetitive activity such as hammering or using a screwdriver. Golfing or throwing can also cause symptoms and weakness on gripping is common
Anatomy/structures medial epicondylitis
Medial epicondyle pain with an accompanying tendinopathy of the wrist flexors adn pronator teres. Ulnar nerve neuropathy may coexist with medial epicondylitis.
Cause/etiology of medial epicondyltis
Pain on wrist flexion and pronation from overuse, repetitive motions or athletic pursuits like golf. Tendinitis of the wrist flexors adn pronator teres results
Evaluation medial epicondyltisi
During activity from teh sub-acute phase onwards
Mills and cozen are positive for lateral
Golfer and reverse mill test positive for medial epicondylitis
Tinel might be positive if ulnar nerve is involved
Elbow flexion contractures can occur in chronic cases, leading to restricted motion in extenstion and supination
X-ray may reveal calcifications over teh medial epicondyle in 20-30% of patients.
Management medial epicondylitis
Acute phase - ice and rest - if flexor group involved, splinting in 10 degeres of flexion may relieve tension. If flexor carpi radialis is involved splinting in 10 degrees of radial deviation is recommended.
Myofascial release of flexor muscle mass and pronator teres is very effective
Cross friciton massage and mobilization is good for sub-acute phase
Chiro adjustments during subacute phase
Elbow braces will be effective
Cubital tunnel syndrome caused
Traction forces,
cubitus valgus, subluxating ulnar nerve
Elbow synovitis (edema)
Anconeus muscle has also been implicated
Clinical signs cubital tunnel syndrome
Pain and paresthesia’s in 4-5 digit, pain worse at night, inability to adduct/abduct fingers (wartenberg’s sign), loss of power grip, atrophy over teh hypothenar eminence with benediction or claw hand noticeable, positive flexion provocative test, positive tinel’s sign, positive froment’s sign, positive maximum elbow flexion/compression test
Triceps tendinitis presentation
Pain at the tip of the elbow after forceful elbow extension or repetitive extension motion
Anatomy/structures triceps tendinitis
Olecranon process tenderness with accompanying bursitis. Strain injury to the triceps insertion on the olecranon
Cause/etiology triceps tendinitis
Repetitive atheltic activity/motion/exertion that strains the tendinous insertion of the triceps to the olecranon process.
Common in boxers, weight lifters, pitchers, shot-putters and sometimes tennis players
Triceps tenditinitis evaluation
Pain elicited with resisted elbow extension from a starting point of elbow flexion
Triceps tendinitis management
Myofascial release/cross friction to the insertion point of the triceps. Ice, rest and modification of activity
Chiro adjustments to improve functional proprioception
Usually atheletes complaining of posterior elbow pain following quick/sudden extension of the elbow.
CLlicking, popping and locking on elbow extension are occasionally reported.
Posterior impingement syndrome
Anatomy/structures posterior impingement syndrome
Olecranon trochlea and olecranon fossa compression
Cause/etiology posterior impingement syndrome
Repetitive extension between the olecranon trochlear and fossa which causes reactive synovitis and which can progress to degeneration.
Osteophytes and loose bodies will form in some cases
Evaluation posterior impingement syndrome
Active and passive extension displays an end range blockage with pain
Valgus extension overload test will be positive with crepitus and grinding
X-ray shows cartilaginous loose bodies on axial or cubital tunnel views
Management posterior impingement syndrome
Loose bodies will need to be surgically removed
Pain managment program should include ice, rest and activity modificaiton
Chiro adjustments to improve functional proprioception/ROM
Extension-block bracing or taping will be recommended
Child between 2 and 4 years old with lateral elbow pain after being swung or jerked aggressively by a parent or a caregiver
Nursemaid’s elbow
Anatomy/structures involved nursemaid’s elbow
Damage to the annular ligament with radial head tenderness. The radial head is not fully formed
Cause/etiology nursemaid’s elbow
Entrapment/rupture of the annular ligament by a forceful distraction/rotation. Radial head under-formation predisposes annular ligament damage.
Evaluation nursemaid’s elbow
Immense pain without an obvious trauma such as a fall or blow to the elbow is indicative. Palpation will reveal a misplaced or mal-positioned radial head.
Managemnet nursemaid’s elbow
Elbow flexion and rotation will be accomplished by reduction
Chiro extremity assessment and adjustment
Adolescent baseball pitcher complaining of medial or lateral elbow pain
Little league elbow
Anatomy/structure little league elbow
Medial pain is due to injury of the medial anterior oblique ligament and fragmentation of the medial epicondylar epiphysis. Lateral pain is associated with degrees of radial head injury and growth plate immaturity. An osteochondritis dessicans of the capitellum is indicative of a lateral elbow injury.
Cause/etiology little league elbow
Actually a syndrome
Repetitive valgus stress incurred while pitching causes a stretch injury to the medial elbow and compression injury to the lateral elbow
Tenderness at both medial and lateral aspects of the elbow. Supination and pronation alternatively whether performed actively or passively can cause a palpable click or audible crepitus at the head of the radius (osteochondritis dissecans)
Little league elbow
Little league elbow evaluation
Flexion contracture evident on passive ROM. Popping, clicking, and locking might occur on full-range active movment.
X-ray special views are required to see proper structures. Would order radial head-capitellum and valgus stress view
Little league elbow management
Modification of activity is highly recommended if x-ray appears normal while clinical signs confirm. This would include proper mechanics training and teaching while avoidance of certain types of throws.
Acute pain modalities during the initial phase and proper warm up and stretching before resuming activity
Chiro adjustments to assist in resotring proper bio-mechanical fucntion.
Young male complaining of one sided (dominant) arm pain and stiffness. Usually a sports related injury with a history of excessive throwing. Clicking and locking is associated
Osteochondrosis (panner’s disease)
Anatomy/structures involved osteochondrosis/panner’s
Involves the capitellum of the elbow, more exactly the chondro-epiphysis. There is a decrease of blood supply to the structures causing avascular necrosis.
Cause/etiology osteochondrosis/panner’s disease
Trauma or repetitive strenuous motion results in a disturbance of blood circulation to the cartilaginous epiphysis of the capitellum. Avascular necrosis results leading to deformity.
Evaluation osteochondrosis
Elbow pain in children should often indicate necessity for x-rays following history of repeated weight bearing or excessive throwing.
Diagnosis for panner’s is largely radiographic - radial head capitellum and oblique views are essential. Fragmentation or loose bodies will be a clear indicator
Management osteochondrosis (panner’s disease)
Best prognosis is with an open epiphysis
Rest and elimination of activity is required with splinting indicated
Stretchign and strengthening after acute phases subsides
Loose bodies and fragments if evident might need surgical removal if elbow locks
Chiro adjustments to help recuperation/recovery
Swelling and redness just distal tot eh point of elbow. Following fall/trauma/repetitive activity injury such as wrestling
Olecranon bursitis
Anatomy/structures involved olecranon bursitis
Olecranon bursa is injured/inflamed
Cause/etiology olecranon bursitis
Olecranon bursa is injured following dragging or fall on the elbow resulting in the cushion like structure becoming inflamed, irritated, or infected.
Evalutation olecranon bursitis
The large, egg sized swelling on the point of the elbow is hard to miss. Gout associated with kidney disease must be ruled out on history. Infection is distinguished if a visible wound is noticeable or if the site is warm and more tender than traditional bursitis.
Management olecranon bursitis
Protection with a donut shaped support
Ice and pulsed US are indicated and very effective espeicially when chrnoic
Medical aspiration and excision might at times be necessary and if infectied would require immediate referral.
Medial collateral ligament test (abduction stress test)
Pt seated, examiner stabilizes the lateral asepct of the arm and places an abduction/valgus pressure on the emdial forearm
Excessive gapping and pain indicates medial collateral ligament tear and/or instability
Lateral collateral ligament test (adduction stress test)
Pt seated, examiner stabilizes teh medial aspect of the arm and places an adduction (varus) pressure on pt;s lateral forearm
Excessive gapping and pain indicates lateral collateral ligament tear and/or instability
Tinel elbow sign
Pt seated, reflex hammer taps over ulnar groove
Pain and/or tenderness at the site being tapped and paresthesia in the ulnar nerve distribution area (fingers 4,5) indicates neuroma of the ulnar nerve
Cozen test
Pt seated examiner instructs pt to make a fist and place wrist into extension. Examiner instructs pt to resist as ex tries to push extended wrist into flexion.
Pain over the lateral epicondyle indicates lateral epicondylitis (tennis elbow)
Mills test/maneuver/Evans
Pt seated arms supinated. Dr. Passively maximally flexes pts fingers and wrist and then extends the elbow to pronation
Pain over the lateral epicondyle indicates lateral epicondylitis (tennis elbow)
Golfer elbow test
Pt seated, extends elbow and supinate hand, ex instructs pt to flex wrist against resistance
Pain over medial epicondyle indicates medial epicondylitis
Maximum elbow flexion test/compression test
Pt asked to place elbows in maximum elbow flexion for up to 3 minutes to close down the cubital tunnel
Reproduction of parasthesia’s into the ulnar nerve distribution with possible weakness on handshake (power grip) indicates cubital tunnel syndrome (ulnar nerve entrapment at the cubital tunnel)
Valgus overload test of the elbow
Elbow is placed into 90 degress flexion. Ex places valgus stress into elbow while passively extending the elbow fully
Pain in the posterior elbow with a reproduction of a locking or catching sensation of an inability to fully extend the elbow due to pain indicates posterior elbow impingement syndrome
Reverse mills test
Elbow is extended and forearm supinated. Wrist then passively extended fully. Designed to confirm golfers elbow test
Reproduction of pain in the medial elbow indicates medial epicondylitis or golfers elbow
