Chapter 23: The Elbow
Jennifer Doherty-Restrepo, MS, LAT, ATC
Academic Program Director, Entry-Level ATEP
Florida International University
Acute Care and Injury Prevention
Anatomy of the Elbow
Review
Functional Anatomy
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Elbow ROM = flexion, extension, pronation and
supination
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Stable joint: protection from overuse and traumatic
injuries
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Bony limitations, ligamentous support, and muscular
stability at the elbow help to
Carrying angle due to distal projection of humerus
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145 degrees of flexion
90 degrees of supination and pronation
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 does it hurt?
Where does it hurt?
Motions that increase
pain?
Motions that decrease
pain?
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Type of, quality of,
duration of, pain?
Sounds or feelings?
How long were you
disabled?
Swelling?
Previous treatments?
Observations
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Deformities and swelling?
Carrying angle
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Flexion and extension
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Cubitus valgus vs. Cubitus varus
Cubitus recurvatum
Elbow at 45 degrees
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Isosceles triangle formed by the olecranon and
epicondyles
Palpation: Bony and Soft Tissue
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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
Wrist extensors
Special Tests: Circulatory and
Neurological Function
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Pulse
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Skin sensation
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Assessed at brachial artery and radial artery
Determine presence of nerve root compression or
irritation in cervical or shoulder region
Tinel’s sign
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Ulnar nerve test
Tap on ulnar nerve in ulnar groove
Positive test = numbness/tingling along the
forearm and hand
Special Tests: Capsular Injury
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Tested after hyperextension of elbow
Athlete position
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Elbow is flexed to 45 degrees
Wrist is fully flexed and extended
Positive test = pain in elbow joint
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If joint pain is severe, sprain or fracture should be
suspected
Joint pain may indicate chronic injury as well
Special Tests: Ligament Injury
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Valgus/Varus Stress Test
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Assess injury to the medial and lateral collateral
ligaments, respectively
Positive test = joint laxity or complaint of pain
Special Tests: Muscle Injury
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Medial Epicondylitis Test
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Athlete position
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Elbow flexed to 45 degrees
Resist wrist flexion
Positive test = pain at medial epicondyle
Lateral Epicondylitis Test
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Athlete position
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Elbow flexed to 45 degrees
Resist wrist extension
Positive test = pain at lateral epicondyle
Special Tests: Muscle Injury
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Pinch Grip Test
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Pinch thumb and index finger together
Positive test = inability to touch fingers together
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Indicates entrapment of anterior interosseous nerve
between the heads of pronator muscle
Pronator Teres Syndrome Test
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Resist forearm pronation
Positive test = increased pain over pronator teres
Special Tests: Functional Evaluation
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Evaluate AROM, PROM
and RROM
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Flexion
Extension
Pronation
Supination
Positive test = pain and
weakness
Elbow Injuries
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Subject to injury due to…
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Broad range of motion
Weak lateral bone structure
Exposure of soft tissue
Many sports place excessive stress on joint
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Locking motion of some activities
Use of implements
Throwing motion
Elbow Injuries: Contusion
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MOI = direct blow or repetitive blows
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Signs and Symptoms
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Vulnerable area due to lack of padding
Rapid swelling due to irritation of bursa or
synovial membrane
Management
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PRICE immediately, for at least 24 hours
If severe, refer for X-ray to rule out fracture
Elbow Injuries: Olecranon Bursitis
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MOI = direct blow
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Superficial location makes it
extremely susceptible to injury
Signs and Symptoms
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Pain, swelling, and point
tenderness
Swelling will appear almost
spontaneously without the pain
and heat
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Management
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Acute: compression for at
least 1 hour
Chronic: requires superficial
therapy primarily involving
compression
If swelling fails to resolve,
aspiration may be necessary
May be padded to return to
competition
Elbow Injuries: Muscle Strains
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MOI = overstretching or too forceful a
contraction
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Falling on outstretched arm
Repeated microtears may cause chronic injury
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Rupture of distal biceps is most common in UE
Signs and Symptoms
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Pain with AROM and RROM
Point tenderness in muscle, tendon, or lower part
of muscle belly
Elbow Injuries: Muscle Strains
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Management
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PRICE
Sling in severe cases
Follow-up treatment
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Cryotherapy, ultrasound, ROM and PRE exercises
If severe loss of function, refer for X-ray to rule
out avulsion or epiphyseal fracture
Elbow Injuries: Ulnar Collateral
Ligament Injuries
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MOI = valgus force from repetitive trauma
Secondary injuries may include…
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Ulnar nerve inflammation
Wrist flexor tendinitis
Overuse flexor/pronator strain
Ligamentous sprains
Elbow flexion contractures
Joint instability
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Signs and Symptoms
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Pain along medial aspect of elbow
Point tenderness over UCL
Associated paresthesia
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Positive Valgus Stress Test
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Positive Tinel’s sign
Possible end-point laxity
X-ray may show evidence of…
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Hypertrophy of humeral condyle and/or
posteromedial aspect of olecranon; and osteophytes
Calcification within the UCL
Loose bodies in posterior compartment
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Management
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Conservative treatment
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PRICE and NSAID’s
ROM and PRE exercises as pain decreases
Analysis of the throwing motion (if applicable)
Surgical intervention may be necessary
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Tommy John Procedure
Throwing athlete may be able to return to activity
approximately 22-26 weeks post surgery
Elbow Injuries: Lateral Epicondylitis
(Tennis Elbow)
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MOI = repetitive microtrauma to insertion of
wrist extensor muscles
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Tendinosis may result
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Degeneration of tendon without inflammation
Signs and Symptoms
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Aching pain at lateral epicondyle after activity
Decreased elbow ROM
Pain with AOM and RROM wrist extension
Pain and weakness in wrist and hand develop
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Management
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PRICE
NSAID’s and analgesics
Mobilization and stretching in pain free ranges
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Deep friction massage
Hand grasping while in supination
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ROM and PRE exercises as pain decreases
Avoid pronation motions
Use of neoprene sleeve
Mechanics and skills training in order to avoid
recurrence of injury
Elbow Injuries: Medial Epicondylitis
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MOI = repeated forceful wrist flexion and
extreme valgus torque on the elbow
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May involve pronator teres, flexor carpi radialis,
flexor carpi ulnaris, and palmaris longus tendons
Can be associated with ulnar nerve neuropathy
Signs and Symptoms
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Pain with AOM and RROM wrist extension
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Pain with wrist flexion as well in severe injuries
Point tenderness and mild swelling at medial
epicondyle
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Management
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PRICE
NSAID's and analgesics
Sling in severe cases
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Severe cases may require splinting and complete rest
for 7-10 days
Cryotherapy, Ultrasound
Curvilinear brace
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Below elbow to reduce stress at the elbow joint
Elbow Injuries: Osteochondritis
Dissecans
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MOI = Repetitive microtrauma
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Injurious movements include elbow rotation and
extension
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Excessive valgus stresses causes compression of the radial
head, which adds shearing forces at the radiocapitular joint
Impairment of blood supply may result, which causes
degeneration of articular cartilage creating loose bodies
Panner’s disease
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Occurs in children (age <10)
Osteochondrosis of capitellum due to localized avascular
necrosis
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Signs and Symptoms
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Sudden pain at radiohumeral joint
Swelling, creptitus
Decreased ROM (full extension)
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ROM usually returns in a few days
Grating with pronation and supination
Locking of the joint
X-ray
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May show flattening and crater of capitulum
May show loose bodies in joint
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Management
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Activity restriction for 6-12 weeks
NSAID’s
Splint and cast applied in severe cases of
deterioration
If repeated locking of the elbow joint occurs,
loose bodies are removed surgically
Elbow Injuries: Little League Elbow
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MOI = repetitive microtraumas that occur
from throwing motion (Not due to the type of pitch)
Linked to:
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Accelerated apophyseal growth and delayed
medial epicondyle epiphysis growth
Traction apophysitis with possible fragmentation
of medial epicondylar apophysis
Avulsion fracture at medial epicondyle or radial
head
Osteochondrosis of humeral capitellum
Non-union stress fracture of olecranon epiphysis
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Signs and Symptoms
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Onset is slow
Slight flexion contracture
Tight anterior joint capsule
Weakness in triceps
“Locking” or “Catching” sensation
Decreased ROM
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Especially forearm pronation and supination
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Management
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PRICE
NSAID’s and analgesics
Stop throwing until…
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Pain resolved
Full ROM is regained
Gentle ROM exercises
Gently triceps strengthening exercises
Analysis of throwing motion
Elbow Injuries: Cubital Tunnel
Syndrome
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MOI = narrowing of cubital canal or
irregularity of cubital tunnel
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Pronounced cubital valgus may cause deep
friction contributing to injury
Ulnar nerve injury may result
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Ulnar nerve subluxation or dislocation
Traction of ulnar nerve from valgus force
Ulnar nerve compression from ligaments
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Signs and Symptoms
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Pain on medial aspect of elbow
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Pain may be referred proximally or distally
Point tenderness in cubital tunnel
Pain with hyperflexion
Intermittent paresthesia in 4th and 5th fingers
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Management
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Rest, immobilization for 2 weeks
NSAID’s
Splinting, surgical decompression or
transposition of subluxating nerve may be
necessary
Avoid hyperflexion and valgus stresses
Elbow Injuries: Dislocation
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MOI = fall on outstretched hand with elbow
extended or severe twist while elbow flexed
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High incidence in sports
Dislocation may be posterior, anterior, or lateral
Signs and Symptoms
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Swelling, severe pain, disability
Median and radial nerves may be compromised
Blood vessels may be compromised
Often a radial head fracture is involved
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Management
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Pack with ice and apply sling immediately
Refer for reduction immediately
Following reduction…
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Immobilize in elbow flexion for 3 weeks
PRE exercises for grip and shoulder strenthening
Following immobilization…
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Heat and PROM exercises to regain full ROM
ROM and PRE exercises should be initiated by athlete
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Exercises that are too strenuous should be avoided before
complete healing due to high probability of developing
myositis ossificans
Forced stretching should be avoided
Elbow Injuries: Fractures
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MOI = fall on flexed elbow or direct blow
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May occur in one or more of bones in elbow joint
Fall on outstretched hand may fracture the
humerus above condyles or between condyles
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Condylar fracture may result in gunstock deformity
Direct blow may fracture olecranon or radial head
Signs and Symptoms
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May not result in visual deformity
Hemorrhaging, swelling, muscle spasm
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Management
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Monitor neurovascular status
Non-surgical treatment
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Appropriate for stable fractures
Immobilize with cast or removable splint for 6-8
weeks
Surgical treatment
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Used to stabilize unstable fractures in adults
ROM exercises initiated early to prevent frozen elbow
Elbow Injuries: Volkmann’s
Contracture
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MOI = impaired circulation or ischemia
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Associate with humeral supracondylar fractures,
which compromises the brachial artery and
inhibits circulation to forearm
May be loss of motor and sensory function
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Classic case involves median nerve
Edema further impairs circulation via condition
called compartment syndrome
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Muscle necrosis may occur with irreversible muscle
damage after 4-6 hours, which may lead to secondary
fibrosis and calcification
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Signs and Symptoms
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Pain in forearm which increases with PROM
finger extension
Cessation of brachial and radial pulses
Coldness in arm
Decreased ROM
Management
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Monitor neurovascular integrity
Rehabilitation of the Elbow
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General Body Conditioning
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Must maintain pre-injury CV and LE strength
fitness levels
Flexibility
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Restoring ROM is critical in elbow rehab
Variety of approaches can be used as long as they
do not “force” the joint
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Joint Mobilizations
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Loss of proper arthrokinematics following
immobilization is expected
Joint mobilization and traction
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Very useful to increase mobility
Useful to decrease pain
Restores accessory motions
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Strengthening
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Achieved through low-resistance, high-repetition
exercises
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Shoulder and hand grip exercises
Isometrics can be used while immobilized
PNF and isokinetics are useful in early and
intermediate stages of rehabilitation
PRE exercises with tubing, weights, or manual
resistance
Closed kinetic chain activities
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Must be pain free
Assist in both static and dynamic stability to the elbow
Proprioceptive training should also incorporated
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Functional Progressions
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Will enhance healing and performance
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Should include steps
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PNF, swimming, pulley machines, and rubber tubing
Simulate sports activities
Warm-up
Gradual build up to activity, becoming increasingly
more difficult
Return to Activity
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ROM must be WNL
Strength should be restored without pain