PTA 130 - Fundamentals of Treatment I
Elbow & Forearm
Anatomy Review - Muscles
 Primary muscles involved in the following movements:
o Elbow flexion Brachialis, Biceps Brachii, Brachioradialis
o Elbow extension Triceps brachii, Anconeus
o Forearm pronation Pronator teres, Pronator quadratus
o Forearm supination Supinator, Biceps Brachii, Brachioradialis
Anatomy Review – Bones
 The elbow joint is made up of:
o Distal end of the humerus
o Ulna
o Radius
 Four joints involved in elbow and forearm function:
o Humeroulnar
o Humeroradial
o Proximal radioulnar
o Distal radioulnar
Anatomy Review - Ligaments
 The elbow joint has a lax joint capsule
 The elbow joint is supported by two major ligaments
o Medial (ulnar) collateral
 Provides support against valgus stresses
o Lateral (radial) collateral
 Provides support against varus forces
Elbow and Forearm Characteristics
 Function is to position the hand
 Most muscles crossing the elbow are two-joint muscles
o Examples?
 Biceps and triceps co-contract to provide weight-bearing stability to elbow
 Elbow instability occurs primarily due to tears of the medial collateral ligament
Relationship of Wrist and Hand Muscles to the Elbow
 The epicondyles of the humerus are attachment points for many of the muscles that act on the
wrist and hand
 The muscles provide stability at the elbow, but don’t contribute to motion at the elbow
 Wrist Flexor Muscles
o Originate on the medial epicondyle

Wrist Extensor Muscles
o Originate on the lateral epidondyle
Kinematic Considerations
 The elbow and forearm create coupled and patterned movement
o Elbow flexion with forearm supination
 Biceps brachii and supinator
 Lift and carry functions
o Elbow extension with forearm pronation
 Triceps brachii and pronator teres
 Push out and push down
Kinetic Considerations
 The elbow is inherently stabile to support lifting and carrying ability
o When the elbow becomes injured, it is one of the most difficult joints to restore full ROM
o When overloaded, the joint inflames and will dramatically decrease ability to handle
force
Forces at the Elbow
 Lifting weights with elbow extended:
o more stress anteriorly
 Lifting weights with elbow flexed:
o more stress posteriorly
Reducing Joint Forces
 Lighter weights or cuffs attached to mid-forearm
 Greatest compression forces in push-up position
o Widening hand position decreases force
 Low-resistance, high-rep exercises are most appropriate early in rehabilitation program
Referred Pain and Nerve Injury
 C5, C6, T1 and T2 nerve roots cross the elbowo Symptoms are not usually isolated in the elbow
 Nerve Disorders
o Ulnar nerve Compression at the cubital tunnel
o Radial nerve Entrapment of the deep branch under extensor carpi radialis brevis, or with radial
head fracture
o Median nerve Entrapment between the ulnar and humeral heads of the pronator teres muscle
Elbow Joint Hypomobility
 Typically caused by:
o Rheumatoid arthritis and/or Juvenile Rheumatoid Arthritis
o Degenerative Joint Disease
o Trauma
o Dislocation
o Fractures
o Immobilization
Joint Hypomobility: Common Impairments
 Acute Stage
o Joint effusion
o Muscle guarding
o Pain
 Subacute and Chronic Stages
o Capsular pattern is typically present
 Elbow flexion is more restricted than extension
o Decreased joint play
Common Functional Limitations
 Difficulty turning a key, doorknob, or jar lids
 Pain or difficulty with pushing and/or pulling activities
 Difficulty performing ADL’s
 Limited reach
 Inability to carry objects with an extended arm
 Difficulty pushing self up from a chair
Joint Hypomobility: Nonoperative Management
 Protection phase
o Patient education
o Reduce effects of inflammation
o Maintain soft tissue and joint mobility
o Maintain integrity and function of related areas
 Controlled motion phase
o Increase soft tissue and joint mobility
o Improve joint tracking of the elbow
o Improve muscle performance and functional abilities
Joint Hypomobility: Nonoperative Management
 Return to function phase
o Improve muscle performance
 Activities should replicate the demands of ADL’s
 Modification of activities to reduce stress on joint
o Restore functional mobility of joints and soft tissues
 Joint mobilizations
 Aggressive stretching techniques
Joint Surgery and Postoperative Management
 Surgical intervention is often necessary for management of severe fractures or dislocations
 In adults, the most common fracture in the elbow region is a fracture of the head and neck of the
radius
o Typically occurs when falling onto an outstretched hand
 Long standing arthritis may also need to be managed through surgery
 The goals of surgery are:
o Relief of pain
o Restoration of bony alignment and joint stability
o Sufficient strength and ROM to allow for functional mobility
Joint Surgery and Postoperative Management
 Surgical Options for Displaced Fractures of the Radial Head
o ORIF
o Arthroscopic Reduction and Internal Fixation
o Excision of the radial head
Joint Surgery and Postoperative Management – Excision of Radial Head
 Maximum Protection Phase
o Immobilization
o Pain Control
o Edema Control
o AROM exercises for shoulder, wrist, and hand
o PROM and/or AAROM exercises for the elbow when permitted
 AROM exercises are allowed within a week after exercises are initiated
o Submaximal isometrics when permitted
Joint Surgery and Postoperative Management –Excision of Radial Head
 Moderate and Minimum Protection Phases
o Begins when wound has healed and AROM of the elbow is relatively pain free
o Increase ROM
 Gentle stretching
 Mobilizations once the joint capsule is well healed (typically 6 weeks
postoperatively)
o Improve functional strength and muscular endurance
 Low-load resistance exercises with high repetitions
 Use of affected UE for light ADL’s
Joint Surgery and Postoperative Management - TEA
 Indications for Total Elbow Arthroplasty
o Severe joint pain
o Articular destruction of the humeroulnar and humeroradial joints
o RA is one of the most common pathologies leading to a TEA
o Significant instability of the elbow joint
o Failed radial head resection
Joint Surgery and Postoperative Management - TEA
 Maximum Protection Phase (0-4 weeks)
o Immobilization – position varies
o Control of pain, inflammation, and edema
o Early AAROM exercises
o Maintain mobility of the shoulder, wrist, and hand
o Regain motion of the elbow and forearm
o Minimize atrophy of UE musculature
Joint Surgery and Postoperative Management - TEA
 Moderate and Minimum Protection Phase
o Improve elbow ROM
 Low-intensity manual self-stretching
o Regain strength and endurance of elbow musculature
 Isometrics
 Light ADL’s
 UBE
 Open-chain resistance exercises
o Use operated arm for gradually demanding functional activities
Myositis Ossificans
 Also known as heterotopic or ectopic bone formationo The formation of bone in atypical locations of the body
 Etiology of symptoms
o Most often develops in the brachialis muscle or joint capsule
o Caused by trauma, radial head fracture, etc
 Management
o Active, pain-free ROM
o Massage, passive stretching, and resistive exercise are CONTRAINDICATED
Overuse Syndromes - Epicondylitis
 Lateral epicondylitis- Tennis Elbow
o Pain in the common wrist extensor tendons
o What activities are typically associated with this diagnosis?
 Medial epicondylitis- Golfer’s Elbow
o Pain in the common wrist flexor tendons
o What activities are typically associated with this diagnosis?
Overuse Syndromes - Epicondylitis
 Treatment- Protection Phase
o Avoid provoking activities
o Immobilization- rest the muscle
o Relieve pain, swelling, and scar tissue adhesions
o Modalities
o Cross-friction massage
o Brace/Splint
o
o
Low-intensity isometrics
Active ROM and resistive exercise of shoulder/scapular muscles
Overuse Syndromes - Epicondylitis
 Treatment - Controlled Motion and Return to Function Phases
o Increase muscle flexibility
 Manual stretching
 Self-stretching
o Restore joint tracking of the RU Joint
o Cross-friction massage
o Improve muscle performance and function
 Isometrics, dynamic exercises, functional patterns, etc.
o Patient education
 Activity modification
Little League Elbow
 Caused by excessive traction forces on medial epicondyle epiphyseal plate during acceleration
 Curve and breaking pitches create the greatest forces

Treatment
o Rest, ice, active exercises to tolerance
o No heavy weights
o Avoid valgus stresses early in rehab
o Avoid aggressive exercises
Sprains
 Hyperextension spraino Anterior capsule injury; can cause bone bruise in olecranon region
 Medial collateral ligament spraino Injures the primary stabilizing unit of elbow
 Treatmento Cross-friction massage to adhesions is contraindicated during initial 7-10 days after
injury
o Immobilization
o Pain-free ROM
Elbow Dislocation
 Most dislocations are posterior and follow sudden hyperextension and abduction
 Injury is obvious due to deformity
 Treatment
o Splint is worn for 2 weeks with motion beginning after first week
o Initiate isometrics during first week
o Rehabilitation may take 16-26 weeks
Elbow Arthroscopy
 Usually performed for debridement
 Treatment
o Sling is worn for 1-3 days
o Rehabilitation may take 8 weeks
o May initiate shoulder, wrist range-of-motion exercises, isometrics early
o Begin with straight plane, progress to diagonal plane
o Progression depends on patient response
Elbow Bursitis (Olecranon Bursitis)
 Inflammation of the olecranon bursa
 May follow a traumatic incident
 Treatment:
o Stretches
o ROM
o Ice massage
o Modalities
Nursemaid's Elbow (“Pulled” Elbow Syndrome)
 A partial dislocation of the elbow joint –
o Involves the head of radius slipping out from the annular ligament
 Common condition in children under the age of five
 May occur when a child is pulled too hard by the hand or wrist
EXERCISE INTERVENTIONS FOR THE ELBOW AND FOREARM
Exercises for Flexibility and ROM
 Manual, mechanical, and self-stretching techniques
o To increase elbow extension
o To increase elbow flexion
o To increase forearm pronation and supination
 Self-stretching techniques—muscles of the medial and lateral epicondyles
o To stretch the wrist extensor muscles
o To stretch the wrist flexor muscles
Exercises to Develop & Improve Muscle Performance & Functional Control
 Isometric exercises
o Elbow flexion, elbow extension, and forearm pronation/supination
o Rhythmic stabilization
 Dynamic strengthening and endurance exercises
o Elbow flexion, elbow extension, pronation, and supination
o Wrist flexion and extension
 Functional exercises
o PNF patterns
o Pulling, lifting, and carrying activities
o Simulated tasks and activities
Strengthening Exercises
 Progression
o Isometrics
o Isotonic
 Straight plane
 Multi-plane
o Plyometrics
o Functional exercises
o Activity specific exercises
Functional and Sport Specific Activities
 Warm up and cool down
 Begin with low level and progress to overhead exercises
o Use easy activities at diminished distances, forces, and speeds
o Gradually increase one component at a time
 If pain occurs, return to previous level of exercises