Elbow Pathologies
Soft Tissue Pathologies
1. Olecranon Bursitis: inflammation of the olecranon bursa. It is commonly seen
with contusions of the elbow and concomitant periostitis.
a. History: direct trauma or repetitive grazing and WB.
b. Symptoms: pain, swelling, and exquisite tenderness.
c. Inspection and observation: swelling, redness, and heat  heat and
redness may indicate infection
d. Active motion testing: generally normal  may be limited depending
on pain and acuteness of injury
e. Passive motion testing: generally normal  may be painful at end
range with overpressure
f. Resistive testing: strength is generally normal, but may be limited
depending on pain and the acuteness of the injury
g. Palpation: exquisite tenderness over the olecranon
h. Special tests: none
i. Medical Management:
i. Aspiration and injection of corticosteroid followed by
immobilization (orthosis/sling/elbow pad)  re-evaluate in 1
week
ii. Anti-inflammatory medications
iii. Excision of bursa followed by 3 weeks immobilization
j. Physical Therapy Management:
i. Acute: ice, compression, iontophoresis, education, and
sling/padding
ii. Subacute: heat modalities, contrast baths, ROM in pain-free
ranges, and sub-maximal isometrics
iii. Chronic: strengthening, functional activities, education of
avoiding reoccurrence, and protective sling/padding to avoid
reoccurrence
Tendon Injuries
1. Bicipital Tendinopathy: overuse or repetitive motions can cause
inflammation and pain of the tendon or MTU.
a. History: repetitive hyperextension with pronation or repetitive
pronation and supination.
b. Subjective: pain located over the anterior aspect of the distal arm.
c. Inspection and observation: unremarkable
d. Active motion testing: pain with elbow and shoulder flexion and to a
lesser extent supination; pain with elbow and shoulder extension
e. Passive motion: pain with shoulder and elbow extension and
pronation  especially with overpressure
f. Resistive testing: pain with resisted shoulder and elbow flexion and
supination.
g. Palpation: tenderness to palpation over the distal muscle belly, the
MTU, and the insertion of the radial tuberosity.
h. Special tests: Yergason’s, Speed’s, and Mill’s.
i. Medical management: anti-inflammatory medications
j. Physical Therapy:
i. Modalities: ice and heat (depending on timeframe),
iontophoresis, transverse friction massage, STM (especially of
biceps)
ii. Initial therapy: education of avoiding repetitive activities,
compensation to avoid repetitive activity, resting the tendon,
postural education, correcting muscle imbalances proximally,
and proximal isometrics.
iii. Exercise progression: proximal eccentrics, continued
correction of muscle imbalances, posture, and continued
education on avoidance of repetitive activities.
2. Distal Biceps Tendon Rupture: proximal ruptures are more common than
distal ruptures and ruptures are more common in men (women have more
laxity in their tendons)
a. History: sudden contracture of biceps against a heavy load with the
elbows flexed to 90
b. Subjective: sharp, tearing pain (acute) or swelling and activity related
to pain in the cubital fossa (chronic)
c. Inspection and observation: ecchymosis and may see an observable
biceps defect
d. Active motion testing: pain with elbow flexion and supination
e. Passive motion testing: pain with elbow extension and pronation 
especially pain and the end ranges of each motion
f. Resistive testing: strength deficits with elbow flexion, supination, and
grip.
g. Palpation: palpate biceps defect (may or may not be painful)
h. Special testing: biceps squeeze test  high specificity and sensitivity
i. Medical management:
i. Primary repair of tendon avulsion
ii. Secondary repair using cadaver graft
iii. Post-op, elbow protected for 6-8 weeks (sling/splint) 
protected but not immobilized
j. Physical therapy:
i. Modalities: ice, heat, iontophoresis, HV, STM, PROM, grade I
and II PRUJ mobs, and HU mob (6-8 weeks post-op).
ii. Initial therapy: wrist and hand ROM, wrist and hand
strengthening, posture, correcting scapular imbalances, and
PNF.
iii. Exercise progression (6-8 weeks post-op): PROM, AAROM, and
AROM at the HU joint, gentle strengthening (begin with
isometrics and progress to eccentrics)  return to
unrestricted activity is generally not allowed until 6 months
3. Lateral Epicondylitis: usually affects the dominant arm and involves the
ECRB
a. History: repetitive, overuse injury of forearm rotation, wrist extension
and flexion, and grasping.
b. Subject: gradual onset of pain over the lateral epicondyle, pain at
night, stiffness in the morning, and dropping objects when arm is in
pronation.
c. Inspection: may see swelling over the lateral epicondyle
d. Active motion testing: full ROM, pain with wrist flexion, pronation,
and elbow extension.
e. Passive motion testing: full ROM, pain with wrist flexion, pronation,
and elbow extension.
f. Resistive testing: pain with wrist extension, radial deviation, elbow
extension, weakness in scapular muscles, grip strength weakness, and
muscle imbalances in the shoulder girdle and forearm.
g. Palpation: pain over the lateral epicondlye
h. Special tests: Cozen’s, Mill’s, and 3rd finger test.
i. Differential diagnosis: cervical radiculopathy, radial tunnel syndrome,
and posterolateral instability (posterior bundle of the UCL).
j. Medical management:
i. Imaging:
1. Radiographs: osteophytes formation of the common
extensor origin, soft tissue calcification, and bone
thickening over the lateral epicondyle.
2. Diagnostic ultrasound: being used more commonly to
diagnosis soft tissue pathologies.
3. Conservations: corticosteroid injections (temporary
relief, multiple injects have a poor outcome) and
treatments that create an inflammatory response.
4. Surgical: debridement, release of the tendon, and
microfractures to the lateral epicondlye
k. Physical therapy management:
i. Modalities: ice, cross friction massage, HV, STM, cervical and
thoracic manipulations, radial head distraction, MWM, and
lateral gapping.
ii. Initial: proximal stabilization, posture, education on activity
modification, shoulder isometrics, AROM of shoulder, elbow,
and wrist (we want them to rest but not stop moving), total
body conditioning, and correcting proximal muscle imbalances.
iii. Exercise Progression: eccentric exercises at the wrist and
elbow, progress proximal strengthening, activity modification,
and dynamic stabilization (proximally, elbow, and wrist).
4. Medical Epicondylitis: less common, overuse injury.
a. History: overuse injury  repetitive wrist flexion
b. Subjective: pain over medial epicondlye and pain radiating down
anterior forearm
c. Inspection: unremarkable
d. Active motion: pain with wrist flexion and extension
e. Passive motion: pain with wrist extension and supination
f. Resistive: pain with wrist flexion and pronation
g. Special test: Golfer’s elbow
h. Palpation: pain over medial epicondyle
i. Medical management: anti-inflammatory and corticosteroids
j. Physical therapy:
i. Modalities: ice, cross friction, medial gapping, PRUJ dorsal
glide, and HU distraction.
ii. Initial treatment: proximal stabilization, proximal isometrics,
education, and AROM in pain-free ranges.
iii. Progression: stretching into wrist extension and supination,
eccentrics at the elbow and wrist, continued proximal
strengthening, and dynamic stabilization.
5. Elbow Sprain: commonly the result of hyperextension force or isolated
varus/valgus force (first degree  micro-tear with pain, second degree 
partial tear with pain and laxity/instability, third degree  full tear with
definite laxity)
a. History: FOOSH or isolated varus/valgus force
b. Subjective: isolated pain over involved tendon
c. Inspection: swelling, bruising, and muscle guarding
d. Active motion: non-capsular pattern with extension > flexion
e. Passive motion: pain into extension due to muscle guarding
f. Resistive: pain due to guarding and swelling
g. Palpation: tenderness over involved tendon
h. Accessory motions: assess lateral and medial gapping as well as
lateral and medial glides.
i. Special test: ligamentous instability test, posterolateral pivot-shift
apprehension test, and moving valgus stress test.
j. Medical management: anti-inflammatory, immobilization with sling or
brace to prevent full extension, and surgical repair is not common.
k. Physical therapy:
i. Modalities: lateral and medial gapping (b/c open packed), RH
distraction, STM of guarded muscles, and PROM.
ii. Initial: AROM and PROM in pain-free range, strengthening if
immobilized and avoiding hyperextension, and stretching of
tight muscles.
iii. Progression: rhythmic stabilization, close chain exercises, and
eccentric exercises.
6. Elbow Dislocation: separation of joint surfaces accompanied by complete
rupture of ligaments (posterior dislocation is most common).
a. History: trauma in hyperextension
b. Subjective: severe and constant pain; possible numbness and tingling
c. Inspection: swelling, ecchymosis, and muscle guarding.
d. Active, passive, and resistive (after reduction): same as elbow sprain
e. Accessory motions: assess lateral and medial gliding, assess lateral
and medially gapping, and look at all HU, HR, and PRUJ motions.
f. Neurological testing: after acute phase, neurodynamic testing to
assess median and ulnar nerve.
g. Special tests: ULNT of median and ulnar nerve
h. Medical management: reduce immediately followed by
immobilization in 90 degrees flexion for 2-3 weeks (still allows to
move through an arc to prevent contractures). Surgical repair and
transposition of the ulnar nerve may be necessary.
i. Physical therapy:
i. Modalities: ice, STM for muscle guarding, mobs (no gapping),
and PROM.
ii. Initial: sub-maximal isometrics, AROM (wrist, hand, and
shoulder), proximal stabilization, and avoiding ROM extremes.
iii. Progression: AROM of all joints, stretching, strengthening, and
dynamic stabilization.
Pediatric Pathologies
1. Nursemaid’s Elbow: inferior dislocation of the radial head through the
annular ligament.
a. History: traction injury with the elbow extended and in pronation.
b. Subjective: pain in forearm, wrist, and/or elbow.
c. Active, passive, and resistive: unable to perform until reduced  will
avoid supination.
d. Neurological: usually not a concern
e. Palpation: tender over the radial head and there is generally a
palpable deformity.
f. Medical management: reduction of radial head by manipulation.
g. Physical therapy intervention: parent education
2. Little Leaguer’s Elbow: usually an overuse/repetitive motion injury that
occurs in throwers. May be causes by an avulsion fracture of the medial
growth plate. Generally see inflammation, pain, swelling, loose bodies, and
tendon sprain/rupture.
a. History: insidious and sudden onset (if avulsion fracture) or could be
related to overuse throwing injury (repetitive valgus stress with
throwing).
b. Symptoms: pain over medial epicondlye with and without throwing,
elbow stiffness, and locking and clicking (if loose body is present from
avulsion fracture).
c. Inspection: may be swelling over the medial epicondlye.
d. AROM: all motions may be limited due to pain.
e. PROM: all motions may be limited due to pain  especially with
overpressure.
f. Resistive: may not give an accurate picture because pain may limit
strength.
g. Accessory: medial gapping and medial gliding may reveal ligamentous
instability or laxity.
h. Medical management: anti-inflammatory (conservative); surgery is
required if there are loose bodies.
i. Physical therapy:
i. Avoid aggravating activity for 3-6 weeks
ii. Patient, parent, and coach education
iii. Limiting pitching count, days pitching, etc.
iv. Modalities: grade I and II mobs, ice, rest, STM of wrist flexors,
and PROM in pain-free ranges, I.
v. Initial: proximal stabilization, proximal isometrics, patient
education, rest, motion in pain-free ranges, and light wrist
flexor stretching.
vi. Progression: proximal strengthening (shoulder, core, and LE),
throwing program, strengthening at elbow, stretching of wrist
flexors, and dynamic stabilization.
Nerve Compression Syndromes
1. Cubital Tunnel Syndrome: compression may be causes by repetitive motion
that causes edema and inflammation that impairs tendon gliding. Repetitive
elbow flexion and vibration in flexion can cause compression. Sleeping with
bent elbows can cause compression that leads to inflammation and edema.
a. History: repetitive elbow flexion activities, trauma, and sleeping with
bent elbows.
b. Subjective: paresthesia in ulnar nerve distribution, clawing of small
and ring finger, pain in the cubital tunnel, decreased grip and pinch
strength, decreased dexterity.
c. Inspection: atrophy of the ulnar intrinsic muscles and clawing of the
ring and small finger.
d. AROM: WNL, later stages may show impaired ring and small finger
extension and thumb adduction.
e. PROM: WNL and may experience pain with overpressure into elbow
flexion.
f. Resistive testing: weak in ulnar deviation, little and ring finger MP
flexion, grip strength, and pinch grip (key, three jaw chunk, and tip
pinch).
g. Accessory motion: WNL, may have laxity of UCL
h. Neurological testing: Semmes Weinstein monofilament testing and
two-point discrimination.
i. Palpation: may or may not have pain in the cubital tunnel.
j. Special tests: elbow flexion test, Tinel’s sign, Froment’s, Wartenberg’s,
wrinkle test, ULNT, grip strength, and pinch strength.
k. Medical management: anti-inflammatory and ulnar nerve
decompression/transposition (do if extensive hypothenar atrophy
and sensory impairments).
l. Physical therapy:
i. Modalities: pain and inflammation reduction, nerve glides,
grade I and II mobilizations, STM of wrist flexors and muscle in
the hand, and night splint (anti-claw and elbow extension)
ii. Initial: proximal stabilization, proximal isometrics, nerve
glides, pain-free ROM, posture, and desensitization.
iii. Progression: essential the same as initial  but will strengthen
proximally, strengthening at the elbow, wrist, and hand.
2. Radial Nerve Entrapment: most common nerve entrapment, commonly
injured in a humerus fracture. There are three sites of entrapment: high
radial nerve palsy, posterior interosseous syndrome, and radial tunnel
syndrome.
a. High Radial Nerve Palsy: caused by humerus fracture or compression
of the radial nerve by the lateral head of the triceps or the latissimus
dorsi.
i. History: humerus fracture or extended crutch ambulation
ii. Subjection: loss of wrist extension, thumb extension, thumb
abduction, and finger extension. Loss of sensation over the 1st
dorsal web-space.
b. Posterior Interosseous Nerve Syndrome and Radial Tunnel Syndrome:
caused by repetitive motion that causes compression of the nerve
between the supinator heads  only difference is RTS is painful.
i. History: insidious onset (lateral epicondylitis is usually more
gradual) and usually due to repetitive motion.
ii. Symptoms: weakness, aching, and cramping over forearm,
sensation changes in the radial nerve distribution, difficulty
extending wrists and fingers, difficulty with radial abduction of
the thumb, difficulty grasping objects, and difficulty stabilizing
the wrist during activity.
iii. Inspection: wrist drop
iv. AROM: wrist extension, finger extension, and radial abduction.
v. PROM: painful with wrist flexion and pronation
vi. Resistive: weak wrist extension, finger extension, and radial
abduction.
vii. Neurological testing: Semmes Weinstein, two-point
discrimination, and ULNT.
viii. Palpation: pain over radial tunnel with RTS  not as much
with PINS.
ix. Special testing: Mill’s, 3rd finger test, and ULNT.
x. Medical management: referral to therapy and nerve release if
extreme atrophy is present.
xi. Physical therapy:
1. Modalities: ice or heat (depends on timeframe and what
feels good), mobs, nerve glides, PROM, and STM of
forearm.
2. Initial: desensitization, nerve glides, proximal
stabilization, proximal isometrics, gentle stretch, painfree PROM and AROM.
3. Progression: essentially the same but may add more
distal strengthening.
3. Median Nerve Entrapment Syndromes:
a. Humerus Supracondylar Entrapment: compression of the median
nerve by the ligament of Struthers.
i. History: insidious onset and etiology of onset is unknown.
ii. Subjective: sensation changes along median nerve distribution,
pain in wrist and forearm. Pain exacerbated by elbow
extension and pronation and may not be able to pronate
forearm.
b. Pronator Teres Syndrome: compression of the median nerve between
the heads of the pronator teres  the superficial layer is mostly
affected (pronator teres, flexor digitorum superficialis, FCR, and
1/2LOAF.
i. History: insidious onset; often associated with overuse and
repetitive motion.
ii. Subjective: experiences a feeling of heaviness, pain in the radial
aspect of the thumb, index finger, and middle finger, and
sensation changes in the median nerve distribution.
iii. AROM: WNL and may be painful with wrist extension, elbow
extension, and supination.
iv. PROM: WNL and may be painful with wrist extension, elbow
extension, and supination.
v. Resistive: weak and painful with wrist flexion, radial deviation,
pronation, thumb palmar abduction, and thumb opposition.
vi. Palpation: may be tender over the pronator teres.
vii. Special tests: ULNT, wrinkle test, grip strength, and pinch test
(specifically three jaw chuck and tip pinch test)  key grip is
more for ulnar nerve.
viii. Medical management: physical therapy referral, surgery is
rarely required.
ix. Physical therapy:
1. Modalities: ice, heat, mobs, STM, and nerve glides.
2. Initial and progression: proximal stabilization, posture,
patient education, nerve glides, gentle stretching, ROM,
and splinting in neutral.
c. Anterior Interosseous Syndrome: compression of the anterior
interosseous between the heads of the pronator teres. Affects the
deep flexor layer  flexor pollicis longus, flexor digitorum profundus,
and pronator quadratus.
i.
ii.
iii.
iv.
v.
History: insidious.
Symptoms: inability to make OK sign
AROM: WNL expect inability to make OK sign
PROM: WNL
Resistive testing: weakness in thumb MP flexion and index DIP
flexion.
vi. Neurological: ULNT and sensation should be unimpaired.
vii. Special tests: ULNT, AIN OK sign, pinch test (tip pinch), and
grip strength.
viii. PT: usually resolves on own, nerve glides, pinch strengthening,
and grip strengthening.
Elbow Fractures
1. Supracondylar Humeral Fracture:
a. Incidence: 50-60% of fractures seen in children; more common in
boys than in girls.
b. Mechanism: FOOSH with hyperextended elbow or falling on a flexed
elbow.
c. Medical Management:
i. Closed: rare, down if little displacement, posterior cast or sling,
casted at 120 degrees flexion.
ii. Open: plates and screws (usually posterior)
2. Condylar Fracture:
a. Incidence: very rare, typically someone will fracture the radial head
before they fracture the condyle; generally the lateral column is
fractures.
b. Mechanism: FOOSH that cause an axial load through the radial head.
c. Medical Management:
i. Closed: only for non-displaced fractures, casting for 4-5 weeks.
ii. Open: screw fixation alone provides stable fixation, a plate may
enhance stability in presence of communition.
3. Intercondylar Fracture:
a. Incidence: difficult to estimate because of the multiple classification
systems
b. Mechanism: common denominator is the “wedge” affect of the
longitudinal axis of the olecranon; the actually position at the time of
fracture is open to debate
c. Typical Patterns: T and Y  both result in disruption of the joint
surfaces.
d. Medical Management:
i. Closed: rarely done because joint surfaces are disrupted
ii. Open: preferred method of treatment; uses screws and plates.
4. Olecranon Fracture:
a. Incidence: common due to superficial location of olecranon
b. Mechanism: falling backwards on elbow or FOOSH
c. Medical Management:
i. Closed: rare
ii. Open: screws, plates, and wires
5. Radial Head Fracture:
a. Incidence: accounts for 1-6% of all fractures; accounts for 33% of all
elbow fractures.
b. Mechanism: FOOSH that produces an axial load through the radial
head
c. Typical Patterns:
i. Type I: non-displaced
ii. Type II: at the margin of the radial head with displacement
iii. Type III: radial head is displaced
d. Medical Management:
i. Closed: most common because we want to minimize time
spend immobilized and the radial head is rarely displaced
during fracture and after fracture:
1. Type I: cast or sling for 3 days
2. Type II: cast or sling for 2-3 weeks
ii. Open: rarely done; only doe for Type III
6. Coronoid Process Fracture:
a. Incidence: uncommon, usually occurs with a posterior elbow
dislocation  generally missed after a dislocation and can get stuck in
the joint
b. Mechanism: FOOSH with elbow flexed 0-20 during axial loading;
FOOSH with elbow flexed >30 during axial loading can result in a
radial head fracture.
c. Medical Management:
i. Type III and some type II require ORIF.
ii. Radial head needs to be repaired or replaced.
iii. RCL is always repaired.
7. Monteggia Fracture: fracture of the ulna with dislocation of the proximal
radius
a. Incidence: relatively rare
b. Mechanism: direct blow to the forearm or FOOSH with
hyperextension or hyperpronation
c. Medical Management:
i. ORIF required along with immobilization for 4 weeks 
generally a poor prognosis because these individuals must be
immobilized for 4 weeks (capsule tightens, flexion contracture)
d. Complications:
i. Annular ligament disruption
ii. Damage to the posterior interosseous nerve  branch of radial
nerve
iii. Damage to anterior interosseous nerve  branch of median
nerve
iv. Damage to ulnar nerve
v. Poor ROM due to immobilization
8. Essex-Lopresti Fracture: fracture of the radial head with disruption to the
DRUJ and interosseous membrane.
a. Incidence: relatively rare
b. Mechanism: falling from a height
c. Medical Management:
i. ORIF with immobilization in a Muenster cast for 6 weeks 
poor prognosis due to immobilization
Therapy Management for Elbow Fractures
1. Immobilization phase (first 6-8 weeks): STM, ROM at uninvolved joints, mobs
at uninvolved joints, edema control, and proximal stabilization.
2. Mobilization phase (@ 6-8 weeks): STM, edema control, pain control,
PROM/AAROM/AROM at involved joint, mobs at involved joint, stretching,
and strengthening (begin with isometrics and progress to dynamic
stabilization and close chain), and return to function activity training
3. Complications of elbow fractures:
a. Mal-union, non-union, avascular necrosis of the radial head,
epiphyseal damage, permanent loss of motion, secondary OA, nerve
damage, myositis ossificans, chronic stiffness, and vascular damage.
b. Vascular damage:
i. Volkmann’s Ischemic Contracture: kinking, laceration, or
spasm of the brachial artery. It can be caused due to
compression in the flexor compartment that is the result of
swelling, excess traction, excessive elbow flexion, or an
immobilization device that is too tight.
1. Symptoms: extreme pain in forearms, swelling and
discoloration of hand, finger motions are painful 
especially passive extension, loss or radial pulse, loss of
capillary refill and return, and impaired sensation in the
hands.
2. If untreated with result in necrosis and fibrosis of the
musculature in the flexor compartment  will lead to
permanent clawing of the hand.