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Elbow Flashcards

1
Q

What phase of throwing to most elbow injuries occur in?

A

Acceleration

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2
Q

The different medical diagnoses that can happen for medial elbow pain in thrower?

A
  1. UCL sprain
  2. Ulnar neuritis
  3. Flexor pronator injury
  4. Medial epicondyle avulsion/apophysitis
  5. Valgus extension overload with posterior impingement
  6. Olecranon stress fractures
  7. Osteochondritis dissecans of capitellum
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3
Q

What structures are the PRIMARY contributors to stability in the elbow during different ROM’s?

A

Bony stability of ulna in olecranon fossa <20 and >120.

Radial head for valgus stress at 30.

Soft tissues from 20-120.

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4
Q

Name the bundles of UCL?

A
  1. Anterior (Anterior and posterior portions of this
    - Anterior band is primary restraint at 30-90flexion
  2. Transverse oblique
  3. Posterior
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5
Q

Different types of stresses in the different elbow compartments during throwing?

A

Medial = tensile
Posterior = shear
Lateral = compressive

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6
Q

What other regions of the elbow become important for stability as UCL becomes incompetent?

A

The osseous restraints of posteromedial elbow.

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7
Q

Elbow trochlea

A

The part next to the capitellum in the front where the ulna (trochlear notch) sits.

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8
Q

How can UCL injuries lead to ROM loss?

A

The posterior joint takes more stress and lead to:
1. Olecranon tip osteophytes
2. Loose bodies
3. Articular damage to posteromedial trochlea

Can cause loss of extension up to 20 degrees.

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9
Q

What/where might tenderness of bone in the elbow mean?

A

Lateral olecranon might indicate stress fracture.

Proximal/medial olecranon may be related to impingement.

Radial head during passive supination/pronation may be osteochondral defects, joint incongruency, and injury to annular ligament.

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10
Q

Differential for snapping at medial elbow through flexion/extension ROM?

A

Ulnar nerve subluxation vs medial triceps.

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11
Q

Valgus extension overload test

A

Forearm supinated and elbow slightly flexed. Rapidly extend the elbow while applying valgus stress. Pain indicates impingement of posteromedial tip of olecranon on medial wall of olecranon fossa.

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12
Q

What imaging is best for detecting bony stress changes early on?

A

MRI. CT not sensitive for stress injuries in early stages.

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13
Q

Anconeus Epitrochlearis

A

Anomalous accessory muscle known to compress ulnar nerve at elbow. Goes from medial epicondyle to medial/proximal ulna.

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14
Q

Types of surgeries for ulnar nerve symptoms and drawbacks?

A
  1. Decompression: only addresses compression issues, not traction
  2. Medial epicondylectomy: muscle weakness and valgus instability
  3. Transposition (subcutaneous): faster recovery but may have persistent symptoms
  4. Transposition (submuscular): longer recovery but better long term results
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15
Q

Typical TTP for flexor/pronator vs UCL

A

Flexor/Pronator: TTP anterior to medial epicondyle
UCL: TTP posterior to medial epicondyle

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16
Q

Little league elbow

A

Medial sided stress injuries that can occur in skeletally immature throwing athletes.

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17
Q

Treatment recommendations for avulsion fractures of medial epicondyle?

A

If displacement > 5 mm then recommmend ORIF. Non-operative otherwise and use of splint immobilization for 5-7 followed by early motion.

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18
Q

Strengthening mainstay for valgus extension overload?

A

Emphasis on eccentric strengthening of elbow flexors to control rapid extension of elbow.

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19
Q

Non-Operative Management of Olecranon Stress Fractures

A

Rest and immobilization. Avoid valgus stress for 6 weeks. Full extension avoided with splint/orthosis set to 20 degrees extension for first 4 weeks. Sports specific rehab initiated at 6 weeks and interval throwing at 8 weeks.

20
Q

Histopathology of elbow tendinopathy?

A
  1. Hypervascularization and increased free nerve endings
  2. Degenerative process characterized by large amounts of fibroblasts, disorganized collagen, and vascular hyperplasia.
  3. More recent studies have found inflammatory mediators in tendons with tendinopathy (macrophages, mast cells, B & T lymphocytes).
21
Q

Primary tendon(s) involved with tennis elbow?

A

ECRB is number 1. 1/3 of cases involve EDC.

22
Q

Mechanical loading of tendon. Times for anabolic and catabolic properties?

A

Collagen gene expression is unregulated and peaks at 24 hours but remains elevated for 70-80 hours. Collagen proteins also degrade and there is a net loss of collagen 24-36 hours after training but a net gain after this. Thus, rest time interval is needed.

23
Q

Healthy tendons and nerve fibers?

A

Healthy tendons are almost aneural.

24
Q

Common elbow ROM adaptations in throwers

A

50% have flexion contracture of dominant elbow, 30% have valgus deformity.

5-7 degree extension loss in competitive throwing athletes.

25
Q

Shoulder ROM losses for baseball and tennis players?

A

Baseball: Increased ER but decreased IR and total ROM for both sides is equal.

Tennis: Less IR on the dominant side but no increased changes in ER. Total ROM can decrease by 10 degrees.

26
Q

Wrist and elbow strength deficits for pro baseball players.

A

Increased wrist flexion and pronation on dominant side but no difference in wrist extension and supination.

Increased elbow flexion and extension strength (about 5-20%).

27
Q

Protection phase during elbow tendon injuries?

A

Need to rest from throwing and serving for medial-based humeral symptoms. Can continue batting and fielding in baseball and double handed backhands in tennis.

28
Q

Cortisone injections with elbow tendon injuries?

A

Given immediate pain relief but after 3 on this 51% of cortisone group has return of primary symptoms versus 5% of PT group.

29
Q

Set/Rep/Speed for training patients on isokinetic dynamometer?

A

5-6 sets of 15-20 reps between 180-300 degrees/second.

30
Q

Strategies to help with return to tennis program?

A
  1. Low-compression tennis balls that decrease impact shock.
  2. Proper grip for tennis racquet (when gripping you should be able to fit your opposite pinky finger between the space of your thenar eminence and middle finger)
  3. Lowering string tension and a softer string
31
Q

When can patient return to sporting activity after pain for tendinopathy?

A

Pain-free ROM and strength equal to contralateral extremity.

32
Q

Little League Elbow: Tissues that are more and less likely injured?

A

Younger children: apophysitis
Older children: Avulsion fracture

Not ligamentous injuries in children. Once medial epicondyle fuses during young adulthood, mm/tendinous and ligmentous injuries predominate.

33
Q

Panner’s Disease

A

Osteochondrosis of capitellum or radial head

34
Q

Arm positions during varus/valgus stress tests

A

Varus = internally rotation/pronated arm

Valgus = ER’d/supinated arm

35
Q

Phases of Elbow Rehab

A

Phase 1: Immediate motion
Phase 2: Intermediate
- Criteria: full ROM, minimal pain/tenderness, >4/5 MMT
Phase 3: Advanced Strengthening
- Criteria: Strenth 70% of opposite sit
- Eccentrics, functional movements, plyometrics
Phase 4: Return to activity
- Criteria: satisfactory isokinetic testing

36
Q

Brachialis and ROM

A

Attaches to capsule before becoming tendinous and can contribute to flexion contractures.

37
Q

Primary motion to focus on in immediate ROM phases?

A

Elbow extension ROM, trying to prevent flexion contractures.

38
Q

Elbow ROM Differences in Baseball PLayers?

A

Throwing side often 3-5 degrees less, even in pain-free elbows.

39
Q

Isokinetic Testing for Athlete’s: 1. What speeds 2. Differences in healthy dominant/non-dominant arms

A
  1. 180-300 degrees/sec
  2. Flex: 10-20 percent stronger
  3. Extension: 5-15 percent stronger
40
Q

When are breaking pitches re-started after injury during return to throwing program?

A

Once thrower can do 40-50 pitches at 80% intensity without symptoms

41
Q

Where should wrist strengthening initially be performed after UCL injury to minimize stressed on UCL?

A

30-45 degrees elbow flexion

42
Q

UCL Reconstruction Procedure Types: For the main type, what other details/things done

A
  1. Modified Jobe Procedure (Uses Palmaris Longus)
    - Subcuteneous ulnar nerve transposition done with this
    - Tries to restore anterior bundle of UCL at connection to sublime tubercle of UNLC
  2. Docking Procedure
  3. DANE Procedure
43
Q

UCL Reconstruction Protocol

A
  1. Brace
    - Immobilized 90 degrees for 7 days
    - 2nd week: 15-105
    - 3rd week: 5-120
    - 4th week: 0-135
    - 5th week: D/C brace
  2. 1st Week:
    - wrist AROM
    - Gripping, shoulder isometrics (no ER), bicep isometrics
  3. 2nd Week:
    - AROM in brace
    - Elbow extension isometrics
  4. 3rd Week:
    - Continue elbow ROM
    - Shoulder AROM exercises, scapular exercises (light)
  5. 4th week:
    - Light elbow/wrist resistance exercise
  6. 6th week:
    - Thrower’s 10
  7. 8th Week:
    - advanced strengthening: eccentrics, plyometrics
  8. 12th week:
    - Return to sport program (easing into)
  9. 16th week:
    - Interval throwing program
  10. 30th week:
    - Start return to sports/competition
44
Q

Ulnar nerve position relative to UCL?

A

Travels over top of the UCL

45
Q

Position To Assume When Resisting Wrist Flexion For Golfer’s Elbow?

A

Elbow needs to be extended and arm in supination.

46
Q

Progression of exercises (arm position) for medial epicondylalgia?

A

Start with elbow bent and then progress to elbow extended.

47
Q

Symptom progression in tennis elbow?

A

Symptoms last, on average, from 2 weeks to 2 years. 89% of people recover within 1 year without any treatment.

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