ANATOMY AND INJURIES OF ELBOW

WHAT MOTIONS OCCUR AT THE ELBOW?

THE ELBOW

BONY ANATOMY OF THE ELBOW Humerus Lateral Epicondyle Medial Epicondyle Olecronon Process Trochlea Capitulum Ulna Radius

ELBOW ARTICULATIONS  Joints  Humeroradial  Radial head w/ capitulum of humerus  Humeroulnar  Olecranon process of ulna w/ trochlea of humerus  Proximal Radioulnar  Radial head w/ radial notch of ulna

MUSCLES – FLEXORS AND SUPINATORS Biceps Brachii Brachialis Brachioradialis

MUSCLES OF THE ELBOW Triceps Brachii Anconeus

MUSCLES OF THE ELBOW AND FOREARM Supinator Pronator Quadratus Pronator Teres

NERVES AND BLOOD SUPPLY  Nerves – 3 primary nerves at the elbow  Median nerve- middle of elbow- C7  Ulnar nerve- “funny bone”- C8  Radial nerve- thumb and pinky- C6  Arteries  Brachial- middle  Splits into radial and ulnar  Medial- medial  Veins  Superficial  Close to the skin in front of the elbow

ELBOW LIGAMENTS  A capsule surrounds each joint in the body  Medial (ulnar) collateral ligament  Medial epicondyle to olecranon  Prevents valgus force  Lateral (radial) collateral ligament  Radius up to lateral epicondyle head  Prevents varus force  Annular ligament  Radial head to ulna  Keeps radial head in place (rotation)

LIGAMENTS OF ELBOW

ELBOW INJURIES

ELBOW TRAUMA

SPRAINS  Ligament/Capsule under ↑ stress  Excessive motion  Hyperextension  Valgus  Varus  Partial tear  Types  Hyperextension  Falling on an extended arm  Injury to anterior capsule  UCL  Injury to primary stabilizing unit of elbow  Tommy John Surgery  Complete tear

STRAINS  Partial tear of muscle fibers  Result from:  Inadequate warm-up  Excessive training past point of fatigue  Inadequate rehabilitation of previous muscular injuries  S/S:  Point tenderness  ↑ pain w/ passive elbow extension and resisted elbow flexion  weakness

EPICONDYLITIS  Common injury, chronic condition  MOI: overuse injury  Prolonged stress may result in stress or avulsion fracture  Pattern of injury:  Poor technique  Fatigue  Overuse  Two types:  Medial  Lateral

MEDIAL EPICONDYLITIS  A.k.a Golfer’s Elbow  Repeated, medial, tension/lateral compression (valgus) forces placed on the arm  During acceleration phase  S/S:  Swelling/pain  Possible ecchymosis  Pt. tenderness over humeroulnar joint  Pain over medial epicondyle  ↑ pain w/ resisted wrist flexion and forearm pronation  ↑ pain w/ valgus stress at 30° flexion  Management  Ice/NSAIDs  Immobilization for 2-3 weeks w/ wrist in slight flexion  EMS, US  Work early ROM  Gentle ROM isometric→isotonic  Wrist flexors  Bracing

LATERAL EPICONDYLITIS  A.k.a. Common Extensor Tendinitis/Tennis Elbow  Most common overuse injury  Eccentric loading of extensor muscles  Predominately Extensor carpi radialis brevis  During deceleration phase  Faulty mechanics  Leading w/ elbow  Off-center hits in racquet sports  Poorly fitted equipment  Handle size  String tension  S/S:  Pain anterior or just distal to lateral epicondyle  Radiating pain into extensors  Pain comes and goes  Comes back more severe w/ repitition  Pain increases w/ resisted wrist extension  Management  Same as Medial epicondylitis  Increase strength, endurance, and flexibility of extensor muscle  Wear counterforce/neoprene elbow sleeve

OLECRANON BURSITIS  Inflammation of the subcutaneous olecranon bursa  Acute/Chronic  Largest bursa in elbow  Facilitates smooth gliding of the skin over the olecranon process during elbow flexion and extension  Superficial  Predisposed to direct macrotrauma or cumulative microtrauma  Tx:  NO COMPRESSION!  Cryotherapy  NSAIDS

DISLOCATION  Most common traumatic injury  Longitudinal traction of an extended and pronated upper extremity  i.e. Small child swung by arms  Immature/weakened annular ligament  Outstretched hand w/ elbow in a position of hyperextension or severe twist while in a flexed position  Associated fractures:  Medial epicondyle  Radial head  Coronoid process  Olecranon process  Ulna/radius displacement  Posteriorly (most common for both)  Anteriorly  Laterally

DISLOCATIONS  S/S:  Obvious deformity, loss of ROM  Rupturing and tearing stabilizing ligamentous tissue  Profuse hemorrhage and swelling  Severe pain and disability  Injury to median and radial nerves, major blood vessels and arteries  Management  EMERGENCY!!!!  Ice, compression, sling, and refer to physician IMMEDIATELY!!!  NEVER reduce

PALPATIONS  Olecranon fossa, olecranon process, medial epicondyle, lateral epicondyle, cubital tunnel, capitulum, radius, ulna, humerus, bicep, tricep, flexor muscles, extensor muscles, brachioradialis

ROM  AROM Flexion, AROM Extension, AROM Pronation, AROM Supination, MMT Flexion, MMT extension, MMT pronation, MMT Supination

LATERAL EPICONDYLITIS TEST/RESISTIVE TENNIS ELBOW TEST/COZEN'S TEST  Steps Athlete is sitting  Examiner stabilizes the involved elbow while palpating along the lateral epicondyle  With closed fist, the athlete pronates and radially deviates the forearm and extends the wrist against the examiner's resistance  Positive Test  Pain along the lateral epicondyle region of the humerus or objective muscle weakness as a result of complaints of discomfort  Positive Test Implications  Lateral epicondylitis 

LATERAL EPICONDYLITIS TEST/PASSIVE TENNIS ELBOW TEST  Steps Athlete is sitting with elbow fully extended  Examiner passively pronates the forearm and flexes the athlete's wrist  Positive Test  Pain along the lateral epicondyle region of the humerus  Positive Test Implications  Lateral epicondylitis

MEDIAL EPICONDYLITIS TEST/GOLFER'S ELBOW TEST  Steps Athlete is sitting or standing and makes a fist with the involved side  Examiner faces the athlete and palpates along the medial epicondyle with one hand and grasps the athlete's wrist with the other hand  Examiner passively supinates the forearm and extends the elbow, wrist and fingers  Positive Test  Complaints of discomfort along the medial aspect of the elbow  Positive Test Implications  Medial epicondylitis 

ELBOW FLEXION TEST  Steps Athlete is sitting or standing  Athlete maximally flexes the elbow and holds the position for 3 to 5 minutes  Positive Test  Radiating pain into the median nerve distribution in the athlete's arm and/or hand  Positive Test Implications  Cubital fossa syndrome 

VARUS STRESS TEST  Steps Athlete is sitting with elbow flexed to 20 to 30 degrees  Examiner stands with the distal hand around the athlete's wrist (laterally) and the proximal hand over the athlete's elbow joint (medially)  Examiner stabilizes the wrist and applies a varus stress to the elbow with the proximal hand  Positive Test  Lateral elbow pain and/or increased varus movement with diminished or absent endpoint  Positive Test Implications  Radial (lateral) collateral ligament sprain 

VALGUS STRESS TEST  Steps Athlete is sitting with the elbow flexed to 20 to 30 degrees  Examiner stands with distal hand around the athlete's wrist (medially) and the proximal hand over the athlete's elbow joint (laterally)  Examiner stabilizes the wrist and applies a valgus stress to the elbow with the proximal hand  Positive Test  Medial elbow pain and/or increased valgus movement with a diminished or absent endpoint  Positive Test Implications: Ulnar (medial) collateral ligament sprain 

TINEL'S SIGN TEST  StepsAthlete is sitting with the elbow in slight flexion  Examiner grasps athlete's wrist (laterally) with distal hand  Examiner stabilizes the wrist and taps on the ulnar nerve in the ulnar notch with the index finger  Positive Test  Tingling along the ulnar distribution of the forearm, hand and fingers  Positive Test Implications  Ulnar nerve compromise 

PINCH GRIP TEST  StepsAthlete is sitting or standing  Examiner instructs athlete to pinch the tips of the thumb and index finger together  Positive Test  Inability to touch the tips of the thumb and index finger together or touching the pads of the thumb and index finger together  Positive Test Implications  Pathology of the anterior interosseous nerve between the two heads of the pronator muscle