LECTURE 12: ELBOW COMPLEX Flashcards
What are most common things with elbow injuries?
- tendon issue
- instability
nerve involved or not?
elbow complex interventions need to be:
- sequential (gradual)
- progressive (1 lb, 2 lb, 3 lb, etc)
- multi-phase approach
elbow interventions should MAXIMIZE
FUNCTION
elbow complex research: not a lot, but top 3 are…
- lateral elbow tendinopathy
- UCLR (reconstruction)
- elbow joint STIFFNESS
What are the MOST IMPORTANT drivers of intervention strategies for elbow complex
- conservative or sx?
- desired function (ball thrower, people mover?)
- underlying pathology/trauma (RA, OA, Panner’s, sport history)
Why does the elbow joint get stiff?
We don’t walk on it, don’t use it in WB or anything if it hurts -> gets STIFF
What 3 types of return to sport UE athletes are there? (not a CPG for return to sport guidelines out there bc they are so different)
- collision athlete (football, hockey, rugby)
- incidental contact athlete (basketball)
- overhead athlete
Acute phase elbow complex rehab goals
1. protect injury site
**2. increase pain free ROM **in shoulder, wrist, hand elbow
3. improve patient comfort (decrease pain, inflamm)
4. slow mm atrophy (isometrics)
5. minimize effects of immob/activity restrictions
6. maintain general CV fitness
7. HEP independence
acute phase interventions for the elbow complex
- decrease pain and swelling
- modify activity as needed (if it hurts dont do it)
- get everything around it moving! (let pain be your guide)
- elbow flexion contracture MUST BE AVOIDED
- sub max isometrics (pump out all the swelling)
- once full pain free AROM is restored, progressive resistance exercises
For elbow acute phase interventions: PROM vs AAROM
conservative management: AAROM
surgical management: PROM
should you do submax isometrics at the elbow during acute phase if you injure an active structure or UCL repair
NO (elbow instability –> yes)
but you can do shoulder isometrics
2 criteria to transition from acute to subacute elbow rehab
- full pain free ROM
- mm strength 70% or more of other limb
subacute phase goals (functional phase)
- restore normal joint kinematics
- improve mm strength to WNL
- improve NM control
- restore normal strength (if you injure your dominant limb, need to gain that much strength, not same as other limb)
sub-acute phase interventions
- entire UQ chain moving efficiently
- CKC introduced
- dynamic mm co-contractions (PNF diagonals)
- **progress **to UE plyometrics
- onece they have more than 90% strength of other limb = gradual return to sport activities
non-dominant limb: want 10-15% weaker than dominant limb (less strength is okay)
dominant limb: needs to be ___ compare to non dominant limb
STRONGER than
not equal to
In order to gradually return to sport activities, what strength do you need in the injured limb?
more than 90% of contralateral limb
*strength, power, endurance
What are goals of the chronic phase of elbow rehab
- max function
- pay attention to yellow flags
- use multi-modal approach
UCL instability and lateral elbow tendinopathy CHRONICITY IS VERY COMMON (PAIN LONGER THAN 3 MONTHS+ )
lateral elbow tendinopathy:
degeneration of ___ seen in 1-2% of population
extensor tendon origin
most common elbow pain! etiology unclear
Is there consensus on optimal treatment for lateral elbow tendinopathy?
No, over 40 different in literature
conservative management is best/most common! KITCHEN SINK
Is surgery indicated for lateral elbow tendinopathy?
No
causes lateral elbow instability
but if symptoms over 6 months and cannot function….Sx (reattachment or debridement) but NOT POSITIVE OUTCOMES
Lateral Elbow Pain CPG
multimodal, therapy exercise
B. **ALL exercise of wrist extensors **to treat subacute/chronic LET (iso, concentric, eccentric)
F. use phased approach to reintroduce stress
B. use resisted wrist extension in combo WITH other (manual therapy) to treat subacute/chronic
C. shoulder/scap stab exercises (not 1st thing, only if there are deficits)
If they have mild-mod pain with all motion, load it as long as it doesn’t INCREASE pain
phased approach of introducing strength
- strength
- endurance (strength over time)
- Power (strength over short time)
lateral elbow pain CPG manual therapy recommendations
MANUAL THERAPY:
B. use local elbow joint manip or mob to decrease pain and increase grip strength (short term)
C. manip or mob at c-spine, t-spine, wrist as adjunct to local treatment for short term pain WHEN IMPAIRMENTS in those regions are identified.
lateral elbow pain CPG soft tissue mobs
C. soft tissue mobilizations, including manual release therapy for chronic
C. instrument-assisted soft tissue mobs + exercise for pain and function with chronic
D. cannot recommend cross friction massage
lateral elbow pain CPG recommendations
additional intervention strategies
- DRY NEEDLING (B)
- counterforce bracing (D long term, F acute –> reminds you that elbow is injured to allow healing)
- Taping (rigid-B, kinesio-tape-C)
- cryotherapy (CP + TENS-C) , level E evidence for CP only
phonophoresis, iontophoresis, TENS, laser all have level __ evidence for lateral elbow pain CPG
C
therapeutic ultrasound has _ evidence
ergonomics has level _ evidence
lateral elbow pain CPG
ultrasound: D
ergonomics: E
out of all the additional intervention strategies, which has the best evidence for lateral elbow pain?
dry needling
Lateral elbow pain w/ active wrist extension and supination
Gripping tasks or end range stretch
lateral elbow tendinopathy
treatment for lateral elbow tendinopathy
eatment:
No consensus
↓ inflammation (consider activity modification)
Joint mobs
Progressive resistive ex’s
Gradual return to function
Medial elbow pain w/ active wrist flexion and pronation
Gripping tasks or end range stretch
medial elbow tendinopathy = flexor pronator strain
baseball
treatment of medial elbow tendinopathy
No consensus – must determine ALL structures involved to effectively manage
↓ inflammation (consider activity modification)
Joint mobs
Progressive resistive ex’s
Gradual return to function
causes of elbow stiffness
Post-trauma, fracture and/or dislocation
Following cast/sling/brace use
Joint arthropathy (OA, etc)
Pathologic bone formation (HO, myositis ossificans, etc
elbow stiffness clinical presentation
significant loss of ROM in 1 or more direction
pain may or may not limit ROM
treatment of elbow stiffness
- joint mobs
- LLLD
- dynamic splints
UCL sprain: medial elbow instability willl present clinically:
- dull ache –> sharp pain at HU joint line (medial)
- medial elbow pain w/ valgus stress
- may or may not have ulnar nerve involv
- decreased grip strength w/without pain
treatment for UCL sprain: medial elbow instability
- Optional bracing in pain free ROM (~10º-100º) for variable period of time (~3 wks)
- Avoid ER stretching and IR strengthening initially
- Restore full pain-free UE ROM and strength as tolerated
- Gradually return to prior level of activity
why avoid IR strengthening with UCL sprain?
turn on flexor/pronators –> next to UCL, stress
UCL sprain/medial elbow instability prognosis
3-5 month return to activity timeline
may progress to surgical reconstruction if symptoms continue (esp throwers, heavy manual laborers)
causes of RCL sprain (posterolateral = rotary elbow instability)
- axial compression + ER + valgus force applied to elbow
- iatrogenic if LET debridement Sx too aggressive
gymnast, cheerleader, etc.
RCL sprain/ rotary elbow instability needs Sx if you want to do what
continue with Axial compression + ER + valgus
(cheerleading, gymnast, etc)
clinical presentation of RCL sprain
Dull ache → sharp pain at H-R joint line (postero-lateral typically)
Feelings of joint slipping or unstable (may have clicking)
Pain and symptoms w/ CKC UE tasks
↓ grip strength w/ or w/o pain
elbow instability 5 item classification system
- Timing (acute, chronic, recurrent)
- Articulations involved (1, 2 or 3 joints)
- Direction of displacement (valgus, varus, anterior, posterolateral)
- Degree of displacement (subluxation vs dislocation)
- Presence or absence of associated fractures
most commonly affected nerve in elbow
ulnar nerve
Surgical management if symptoms do not resolve in 3-4 months
ulnar nerve transposition Sx (put in soft tissue sling)
conservative managment for cubital tunnel syndrome: does it work?
yeah! as long as activity modification happens
*use a pad/protect medial elbow
*avoid end ROMs
*sleep and awake positions!
list of common surgeries at the elbow
- ORIF
- UCLR
- Arthoscopic debridement/loose body removal
- distal biceps repair
- total elbow arthroplasty
fx management of elbow: ORIF
takes __ to heal
4-5 months
UCLR takes _ to heal
9-12 months (to get back to sport, not previous level)
Arthroscopic debridement/loose body removal
takes _ to heal
2-3 months
Distal biceps repair takes _ to heal
6 + months
total elbow arthroplasty takes _ months to heal
3 months
If elbow Sx, make sure you as the PT get __ and ask questions to other PTs!
get the operative report!
ORIF phase 1
week 1-2
- Early ROM of shoulder, wrist and hand
- Active ROM of elbow
- Minimize edema (BONE BLEEDS)
NWB don’t want to re-break it!
ORIF phase 2
week 2-6
* ↑ elbow ROM
* Progression to light functional activities
NWB to involved UE, lift nothing heavier than coffee cup
ORIF phase 3
week 6-12
can begin WB on involved UE
regain full ROM
regain functional strength of involved UE
return to PLOF
phase 4 ORIF
Advanced strengthening
RTS or RTW
week 12-20 (5 months)
UCL reconstruction general phase 1
hinge double brace for 6 weeks
avoid valgus stresses
1. protect
2. reduce pain and inflammation
3. decrease mm atrophy
4. regain full wrist/shoulder motion
What are yellow flags with UCL reconstruction rehab
- pain following increase in rehab intensity
- persistent pinching in elbow with ROM
decrease intensity, manage pain, educate pt on activity modification
phase 2 of UCLR
lot of elbow distraction mobs here
1. gradual elbow joint ROM restored
2. improve mm strength, endurance
3. normalize joint arthrokinematics
controlled mobility phase
phase 3 of UCLR
- maintain/restore UE mobility
- improve mm strength and endurance
- continue functional progression of activity
week 6-7
phase 4: advanced strengthening phase of UCLR
week 8-9
gradually increase strength, power, endurance, nm control
phase 5: return to activity phase of UCLR
week 16+
progress to return to play
