Chapter 23: The Elbow
Anatomy of the Elbow
Functional Anatomy
• Complex that allows for flexion, extension,
pronation and supination
– 145 degrees of flexion and 90 degrees of
supination and pronation
• Bony limitations, ligamentous support and
muscular stability at the elbow help to
protect it from overuse and traumatic
injuries
• Elbow demonstrates a carrying angle due to
distal projection of humerus
– Normal in females is 10-15 degrees, males 5
degrees
• Critical link in kinetic chain of upper
extremity
Assessment of the Elbow
• History
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Past history
Mechanism of injury
When and where does it hurt?
Motions that increase or decrease pain
Type of, quality of, duration of, pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?
• Observations
– Deformities and swelling?
– Carrying angle
• Cubitus valgus versus cubitus varus
– Flexion and extension
• Cubitus recurvatum
– Elbow at 45 degrees
• Isosceles triangle (olecranon and epicondyles)
•Palpation: Bony and Soft Tissue
• Humerus
• Medial and lateral
epicondyles
• Olecranon process
• Radial head
• Radius
• Ulna
• Medial and lateral
collateral ligaments
• Annular ligament
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Biceps brachii
Brachialis
Brachioradialis
Pronator teres
Triceps
Supinator
Wrist flexors and
extensors
• Special Tests
– Circulatory and Neurological Function
• Pulse should be taken at brachial artery and radial
artery
• Skin sensation should be checked - determine
presence of nerve root compression or irritation in
cervical or shoulder region
• Tinel’s sign
– Ulnar nerve test
– Tap on ulnar nerve (in ulnar groove)
– Positive test is found when athlete complains of sensation
along the forearm and hand
– Test for Capsular Injury
• Tested after hyperextension of elbow
– Elbow is flexed to 45 degrees, wrist is fully flexed and
extended
– If joint pain is severe, moderate/severe sprain or fracture
should be suspected
– Valgus/Varus Stress Test
• Assess injury to the medial and lateral collateral
ligaments, respectively
• Looking for gapping or complaint of pain
– Medial and Lateral Epicondylitis Tests
• Elbow flexed to 45 degrees and wrist extension or
flexion is resisted
• Pain at lateral or medial epicondyle, respectively
indicates a positive test
– Pinch Grip Test
• Pinch thumb and index finger together
• Inability to touch fingers together indicates
entrapment of anterior interosseous nerve between
heads of pronator muscle
– Pronator Teres Syndrome Test
• Forearm pronation is resisted
• Increased pain proximally over pronator teres
indicates a positive test
•Functional Evaluation
• Pain and weakness are
evaluated through
AROM, PROM and
RROM
– Flexion, extension,
pronation and supination
– ROM of pronation and
supination are particularly
noted
Recognition and Management of
Injuries to the Elbow
• Subject to injury due to broad range of
motion, weak lateral bone structure, and
relative exposure to soft tissue damage
• Many sports place excessive stress on joint
• Locking motion of some activities, use of
implements, and involvement in throwing
motion make elbow extremely susceptible
• Contusion
– Etiology
• Vulnerable area due to lack of padding
• Result of direct blow or repetitive blows
– Signs and Symptoms
• Swelling (rapidly after irritation of bursa or synovial
membrane)
– Management
• Treat w/ RICE immediately for at least 24 hours
• If severe, refer for X-ray to determine presence of
fracture
• Olecranon Bursitis
– Etiology
• Superficial location makes it extremely susceptible
to injury (acute or chronic) --direct blow
– Signs and Symptoms
• Pain, swelling, and point tenderness
• Swelling will appear almost spontaneously and
w/out usual pain and heat
– Management
• In acute conditions, compression for at least 1 hour
• Chronic cases require superficial therapy primarily
involving compression
• If swelling fails to resolve, aspiration may be
necessary
• Can be padded in order to return to competition
• Strains
– Etiology
• MOI is excessive resistive motion (falling on
outstretched arm), repeated microtears that cause
chronic injury
• Rupture of distal biceps is most common muscle
rupture of the upper extremity
– Signs and Symptoms
• Active or resistive motion produces pain; point
tenderness in muscle, tendon, or lower part of
muscle belly
– Management
• RICE and sling in severe cases
• Follow-up w/ cryotherapy, ultrasound and exercise
• If severe loss of function encountered - should be
referred for X-ray (rule out avulsion or epiphyseal fx
• Ulnar Collateral Ligament Injuries
– Etiology
• Injured as the result of a valgus force from repetitive
trauma
• Can also result in ulnar nerve inflammation, or wrist
flexor tendinitis; overuse flexor/pronator strain,
ligamentous sprains; elbow flexion contractures or
increased instability
– Signs and Symptoms
• Pain along medial aspect of elbow; tenderness over
MCL
• Associated paresthesia, positive Tinel’s sign
• Pain w/ valgus stress test at 20 degrees; possible
end-point laxity
• X-ray may show hypertrophy of humeral condyle,
posteromedial aspect of olecranon, marginal
osteophytes; calcification w/in MCL; loose bodies in
posterior compartment
• Ulnar Collateral Ligament Injuries (cont.)
– Management
• Conservative treatment begins w/ RICE and
NSAID’s
• W/ resolution, strengthening should be performed;
analysis of the throwing motion (if applicable)
• Surgical intervention may be necessary (Tommy
John procedure)
– Throwing athlete can return to activity 22-26 weeks post
surgery
• Lateral Epicondylitis (Tennis Elbow)
– Etiology
• Repetitive microtrauma to insertion of extensor
muscles of lateral epicondyle
– Signs and Symptoms
• Aching pain in region of lateral epicondyle after
activity
• Pain worsens and weakness in wrist and hand
develop
• Elbow has decreased ROM; pain w/ resistive wrist
extension
• Lateral Epicondylitis (continued)
– Management
• RICE, NSAID’s and analgesics
• ROM exercises and PRE, deep friction massage,
hand grasping while in supination, avoidance of
pronation motions
• Mobilization and stretching in pain free ranges
• Use of a counter force or neoprene sleeve
• Mechanics training
• Medial Epicondylitis
– Etiology
• Repeated forceful flexion of wrist and extreme
valgus torque of elbow
– Signs and Symptoms
• Pain produced w/ forceful flexion or extension
• Point tenderness and mild swelling
• Passive movement of wrist seldom elicits pain, but
active movement does
– Management
• Sling, rest, cryotherapy or heat through ultrasound
• Analgesic and NSAID's
• Curvilinear brace below elbow to reduce elbow
stressing
• Severe cases may require splinting and complete
rest for 7-10 days
• Elbow Osteochondritis Dissecans
– Etiology
• Impairment of blood supply to anterior surface
resulting in degeneration of articular cartilage,
creating loose bodies
• Repetitive microtrauma in movements of elbow
rotation, extension, valgus stress causing
compression of the radial head ad shearing of the
radiocapitular joint
• Seen in young athletes involved in throwing motion
• Panner’s disease in incidents of children age <10
– Signs and Symptoms
• Sudden pain, locking; range usually returns in a few
days
– Signs and Symptoms (continued)
• Swelling, pain at radiohumeral joint, creptitus,
decreased ROM (full extension); grating w/
pronation and supination
• X-ray may show flattening and crater of capitulum
w/ loose bodies
– Management
• Activity restriction for 6-12 weeks; NSAID’s
• Splint and cast applied for cases of extensive
deterioration
• If repeated locking occurs, loose bodies are removed
surgically
• Little League Elbow
– Etiology
• Caused by repetitive microtraumas that occur from
throwing (not type of pitch)
• May result in numerous disorders of growth in the
pitching elbow
– Signs and Symptoms
• Onset is slow; slight flexion contracture, including
tight anterior joint capsule and weakness in triceps
• Athlete may complain of locking or catching
sensation
• Decreased ROM or forearm pronation and
supination
• Little League Elbow (continued)
– Management
• RICE, NSAID’s and analgesics
• Throwing stops until pain resolved and full ROM is
regained
• Gentle stretching and triceps strengthening
• Throwing under supervision w/ good technique to
prevent recurrence
• Cubital Tunnel Syndrome
– Etiology
• Pronounced cubital valgus may cause deep friction
problem
• Ulnar nerve dislocation
• Traction injury from valgus force, irregularities w/
tunnel, subluxation of ulnar nerve due to lax
impingement, or progressive compression of
ligament on the nerve
– Signs and Symptoms
• Pain medially which may be referred proximally or
distally
• Tenderness in cubital tunnel on palpation and
hyperflexion
• Intermittent paresthesia in 4th and 5th fingers
• Cubital Tunnel Syndrome (continued)
– Management
• Rest, immobilization for 2 weeks w/ NSAID’s
• Splinting or surgical decompression or transposition
of subluxating nerve may be necessary
• Athlete must avoid hyperflexion and valgus stresses
• Dislocation of the Elbow
– Etiology
• High incidence in sports caused by fall on outstretched
hand w/ elbow extended or severe twist while flexed
• Bones can be displaced backward, forward, or laterally
• Distinguishable from fracture because lateral and
medial epicondyles are normally aligned w/ shaft of
humerus
– Signs and Symptoms
• Swelling, severe pain, disability
• Complications w/ median and radial nerves and blood
vessels
• Often a radial head fracture is involved
– Management
• Cold and pressure immediately w/ sling
• Refer for reduction
• Neurological and vascular fxn must be assessed
prior to and following reduction
• Physician should reduce - immediately
• Immobilization following reduction in flexion for 3
weeks
• Hand grip and shoulder exercises should be used
while immobilized
• Following initial healing, heat and passive exercise
can be used to regain full ROM
• Massage and joint movement that are too strenuous
should be avoided before complete healing due to
high probability of myositis ossificans
• ROM and strengthening should be performed and
initiated by athlete (forced stretching should be
avoided
Elbow Dislocation
• Fractures of the Elbow
– Etiology
• Fall on flexed elbow or from a direct blow
• Fracture can occur in any one or more of the bones
• Fall on outstretched hand often fractures humerus
above condyles or between condyles
– Condylar fracture may result in gunstock deformity
• Direct blow to ulna or radius may cause radial head
fracture as well
– Signs and Symptoms
• May not result in visual deformity
• Hemorrhaging, swelling, muscle spasm
• Elbow Fractures (continued)
– Management
• Decrease ROM, neurovascular status must be
monitored
• Surgery is used to stabilize adult unstable fracture,
followed by early ROM exercises
• Stable fractures do not require surgery
– Removable splints are used for 6-8 weeks
• Volkmann’s Contracture
– Etiology
• Associate w/ humeral supracondylar fractures,
causing muscle spasm, swelling, or bone pressure on
brachial artery, inhibiting circulation to forearm
• Can become permanent
– Signs and Symptoms
• Pain in forearm - increased w/ passive extension of
fingers
• Pain is followed by cessation of brachial and radial
pulses, coldness in arm
• Decreased motion
– Management
• Remove elastic wraps or casts
• Close monitoring must occur
Rehabilitation of the Elbow
• General Body Conditioning
– Must maintain pre-injury fitness levels cardiovascular and strength (lower body)
• Flexibility
– Restoring ROM is critical in elbow rehab
– Variety of approaches can be used as long as
they don’t force the joint
• Joint Mobilizations
– Loss of proper arthrokinematics following
immobilization is expected
– Joint mobilization and traction can be very
useful to increase mobility and decrease pain
through restoration of accessory motions
• Strengthening
– Achieved through low-resistance, high-repetition
exercises - must be pain free
– Shoulder and grip exercises should also be
performed
– Continuous passive motion units followed by
dynamic splinting is ideal following surgery
– Isometrics can be used while elbow is immobilized
– PNF and isokinetics are useful in early and
intermediate active stages of rehab
– A graded PRE program w/ tubing, weights or
manual resistance should be included
– Closed kinetic chain activities should also be
incorporated - assist in both static and dynamic
stability to the elbow
– Proprioceptive training should also incorporated
• Functional Progressions
– Will enhance healing and performance
• PNF, swimming, pulley machines and rubber tubing
• to simulate sports activities
– Should include steps
• Warm-up
• Gradual build up to activity, becoming increasingly
more difficult
• Return to Activity
– Can re-engage in activity when criteria has
successfully been completed
– ROM w/in normal limits, strength should be
equal w/ no complaint of pain
– Return should progress with use of restrictions
in an effort to objectively measure activity
progression
• Protective Taping and Bracing
– Should be continued until full strength and
flexibility have been restored
– Chronic conditions usually cause gradual
debilitation of surrounding soft tissue
• Must restore maximum state of conditioning w/out
encouraging post-injury aggravation