Besides elbow impairments specifically, what else needs to be considered in an examination and evaluation of the elbow? (3 things)
- Upper quarter comprehensive exam (c-spine, clearing other joints)
- Comorbidity consideration
- Medical history
What are 6 relevant scales used to assess the elbow?
- VAS
- DASH
- PSFS
- UEFS
- American Shoulder and Elbow Surgeons Elbow Form
- Boston Questionnaire (carpal tunnel)
What are 7 general considerations when treating the elbow?
- Posture of the head and neck
- Muscle tone
- Quality, color, and temperature of skin
- Carrying angle - elbow (10 - 13 degrees)
- Swelling
- Resting position of elbow
- Ability to use limb
What should be cleared when treating the elbow?
- Shoulder
- Wrist
- C-spine
What are the accessory motions of the elbow and forearm?
- Distration and radial and ulnar gapping of the humeroulnar joint
- Distraction and radial and volar glides of the humeroradial joint
- Dorsal and volar glides of the proximal and distal radioulnar joints
What are 4 performance based functional measures of the elbow?
- Pushing (push-off test)
- Pulling
- Curling
- Grip strength
What are 4 non-muscular tests for the elbow?
- Ligament stability
- Soft tissue mobility
- Neurologic status
- Functional status
What are 7 common pathologies of the elbow?
- Lateral epicondylitis/algia
- Medial “
- Olecranon bursitis
- Dislocation/ instability
- Radial head subluxation
- Volkman’s contracture
- Nerve entrapment syndromes
What is the etiology of lateral epicondylitis?
- Degeneration
- Micro/macro tearing of common extensor tendon insertion
- Often due to repetitive forceful wrist extension and gripping
What muscles are especially effected by lateral epicondylitis?
- ECRB
- EDC III
What is the 3 part vicious cycle of lateral epicondylitis?
- Inflammation
- Tissue weakness
- Tearing
What 4 other diganoses must lateral epicondylitis be discriminated from?
- Radiohumeral DJD
- Radial nerve entrapment
- Ligamentous injury
- Proximal pathology
Past what age does lateral epicondylitis become more common?
35.
Where is the elbow usually tender in lateral epicondylitis?
- Over lateral humeral epicondyle
- Extensor tendon
- Muscle belly
In what phase is edema sometimes present in lateral and medial epicondylitis?
- Acute phase
In what phase are tight fascial bands noted in lateral and medial epicondylitis?
- Chronic phase
What active movements provoke pain, and what passive movements provoke pain in lateral epicondylitis?
- Active wrist extension (+ with radial deviation)
- Passive wrist flexion (+ with ulnar deviation, elbow extension, pronation)
What do 7 % of plain films show in lateral epicondylitis?
- Calcification.
What is the etiology of medial epicondylitis?
- Micro/macro tearing of common flexor tendon insertion
- Repetitive active forceful wrist flexion.
What is another name for lateral epicondylitis?
- Tennis elbow
What is another name for medial epicondylitis?
- Golfer’s elbow
What active and passive motions provoke pain in medial epicondylitis?
- Active wrist flexion and pronation
- Passive wrist extension (+ with supination)
What is the treatment for lateral and medial epicondylitis in the acute phase? Refer to medication, patient education, and 2 interventions.
- Topical NSAIDS
- Local injection of steroids
- Pt Ed: Refrain from aggravating activities
- Stretching
- Splints and/or Straps
What treatment should be performed for lateral/ medial epicondylitis in the subacute phase? State manual therapy, exercises, and modalities.
- Deep friction massage
- Mill’s manipulation and radial head mobilizations
- Exercise progressed from iso to concentric to eccentric
- Acupuncture, laser, and ultrasound
What type of contraction promotes the realignment of collagen?
Eccentric.
Do corticosteroid injections or PT have better long term effects?
PT.
Corticosteroids have better effects than PT after 6 weeks, but what was the problem after that?
Higher recurrence/ regression of cases.
Is PT or wait and see a better method for lateral epicondylitis after a year?
No difference.
Did wait and see, steroid injections, or PT treatments result in lower additional treatments of lateral epicondylitis?
PT.
In what amount of patients with lateral epicondylitis are C-spine impairments prevalent?
57 - 90 %.
What are 4 common causes of elbow bursitis?
- Fall on elbow/ trauma
- Excessive friction
- Infection
- Systemic disease (RA, Gout)
How are ROM and strength affected by olacranon bursitis?
- Decreased extension ROM and strength
What will palpation of olecranon bursitis reveal?
- Swelling confined to elbow
- Pain
- Increased temperature
What is conservative treatment of olecranon bursitis?
- Symptom reduction treatment
- Warm soaks
- Splinting
- Protection
What are 2 more aggressive treatments of olecranon bursitis?
- Aspiration
- Aspiration with a steroid injection
What are risks of aspiration of elbow in olecranon bursitis?
- Skin atrophy
- Septic bursitis
- Chronic pain on pressure
What are 2 common risks of elbow dislocation?
- Nerve compromise
- Vascular compromise
What 2 things can sometimes complicate elbow dislocations?
- Fracture
- Ligament disruptions
What individuals are prone medial elbow instability? Why?
- Throwing athletes
- Stretching/ rupture of ulnar collateral ligament
What often leads to lateral elbow instability?
- Trauma to radial collateral ligament
What are 2 clinical signs of an elbow dislocation or instability?
- Feeling of “giving way”
- Pain on activities that stress the ligaments
What is conservative treatment for an elbow dislocation or instability?
- Dynamic stability from FCU
- Stabilize proximal to the elbow
- Practice proper form
What is stressed during rehab following a surgical reconstruction of the elbow or its associated tissues?
Early protected motion.
What is conservative treatment for medial elbow instability for non-throwing athletes?
- Don’t overstress healing tissue
- Establish flexibility
- Muscle balance
- Neuromuscular control
What is medial epicondyle apophysitis?
- Traction apophysitis at medial epicondyle
- Result of valgus stresses in immature elbow
- Inflammation along medial apophsysis.
What is a valgus extension overload?
- Olecranon on fossa with combined valgus
- Swelling, medial and posterior pain
Which medial elbow pain is found in a skeletally immature individual?
Medial epicondyle apophysitis.
What is a common mechanism of injury for an olecranon fracture?
- FOOSH w/ elbow flexed
- Triceps contracts
What nerve is vulnerable in an olecranon fracture?
Ulnar.q
What is a common mechanism of injury for a fracture of the radial head?
- FOOSH with supination
What is the common 3 step process of treatment for olecranon or radial head fractures?
- Short immobilzation with early motion To address resultant biceps shortening: - Contract-relax stretches and arm swings To address extension loss: - Joint mobilization - Joint distraction
What is the etiology of a radial head subluxation?
- Longitudinal force at pronated forearm
- Radial head pulled from annular ligament
What are clinical signs of a radial head subluxation?
- Localized pain
- Reluctancy to move forearm, and elbow held in pronation
- Palpate a sulcus between humerus and radial head
What is the 3 step treatment process for a radial head subluxation?
- Reduction at ER
- Guarded motion
- PT to control inflammatin, symptoms, and improve impairmentos
What is another name for a radial head subluxation?
Nurse-maid’s elbow.
What is a Volkmann’s Ischemic Contracture?
- Deformity of hand fingers and wrist caused by trauma induced ischemia
What type of trauma typically causes the ischemia associated with Volkmann’s ischemic contracture?
- Crush injury to forearm
- Elbow fracture in children
What does the swelling from trauma associated with Volkmann’s ischemic contracture cause?
- “Compartment Syndrome”
- Pressure reduces blood inflow and prevents outflow
- Tissue death
- Tissue fibrotic and shortened
What are 2 treatments for Volkmann’s contracture?
- Fasciotomy
- Followed up by rehab to regain strength and ROM
What structures impinge on the ulnar nerve to cause cubital tunnel syndrome?
- Medial epicondyle
- Olecranon
- MCL
- Ligament of Struthers
What position causes further compression of the ulnar nerve and blood supply in the cubital tunnel?
- Flexion
What are signs and symptoms of Cubital tunnel syndrome?
- Parathesias/ pain of the medial forearm and ulnar hand
- Provoked by flexion
What 4 common positions can cause flexion impingement of the ulnar nerve in the CT?
- Sleeping
- Combing hair
- Driving
- Telephone
What are 3 signs of chronic cubital tunnel syndrome?
- Weak key turning
- Grip/ pinch weakness
- Dropping objects
What are 4 areas of concern in suspected cubital tunnel syndrome during the exam?
- Upper limb tension tests
- Muscle bulk atrophy
- Digits 4 - 5
- Sensory testing
What 3 other pathologies may be confused with cubital tunnel?
- C8 - T1 nerve root impingement
- Thoracic Outlet Syndrome
- Guyon’s Canal
What are 6 conservative treatments for cubital tunnel?
- Avoiding elbow flexion activities
- Night splints with 40 - 60 degrees flexion
- TENs and physical agents to reduce inflammation
- Nerve gliding
- Stretching of extrinsic flexors and ulnar innervated intrinsics
What is the surgical treatment for cubital tunnel?
- transposition of the nerve anteriorly.
What nerve becomes entrapped in radial tunnel syndrome?
Posterior interosseus nerve.
What 4 structures impinge on the posterior interosseus nerve and its associated vasculature in radial tunnel syndrome?
- Leash of henry
- ECRB tendon
- Arcade of Frohse
- Supinator origins
What repetitive actions cause radial tunnel syndrome?
- Pronation/ supination
- Wrist flexion/ extension
What are 3 symptoms of radial tunnel syndrome?
- Pain in common extensors mid belly
- Can appear similar to tennis elbow
- Decreased strength
How can pain from radial tunnel be differentiated from pain due to tennis elbow?
- It is 3 - 4 centimeters below the extensor wad.
What are 5 conservative treatments for radial tunnel syndrome?
- Avoid aggravating activities (keep forearm in neutral)
- Cock-up splint at wrist for 3 - 6 motnhs
- Physical agents and TENS to control inflammation
- Nerve gliding
- Stretching of extrinsic extensors. flexors, and supinators
What is the surgical intervention for radial tunnel syndrome?
- Transposition of nerve anteriorly
What are 2 tests for lateral epicondylitis?
- Cozen’s test
- Lateral epicondylitis test
What are 4 tests for elbow stability?
- Moving valgus stress test
- Posterior lateral rotary instability
- Varus stress test
- Valgus stress test
What are 3 tests for nerve entrapment at the elbow?
- Elbow flexion test
- Pressure provocation
- Tinel’s sign