PTA 130 Fundamentals of Treatment I Elbow & Forearm

Identify key anatomical muscles and structures of the elbow and forearm Identify common tissue injuries, conditions and surgical interventions Introduce interventions for common injuries, conditions, and surgical procedures Identify soft tissue specific mobilizations Identify flexibility, strengthening, functional, and stabilization exercises Lesson Objectives

Anatomy Review - Muscles Primary muscles involved in the following movements: Elbow flexion- Brachialis, Biceps Brachii, Brachioradialis Elbow extension- Triceps brachii, Anconeus Forearm pronation- Pronator teres, Pronator quadratus Forearm supination- Supinator, Biceps Brachii, Brachioradialis Use kines book for help For each movement, name the plane of movement and axis of rotation Anatomy Review - Muscles

Anatomy Review – Bones The elbow joint is made up of: Distal end of the humerus Ulna Radius Four joints involved in elbow and forearm function: Humeroulnar Humeroradial Proximal radioulnar Distal radioulnar Anatomy Review – Bones

Anatomy Review - Ligaments The elbow joint has a lax joint capsule The elbow joint is supported by two major ligaments Medial (ulnar) collateral Provides support against valgus stresses Lateral (radial) collateral Provides support against varus forces Anatomy Review - Ligaments

Brachialis Triceps Brachii Biceps Brachi (long & short head) – Brachioradialis – Triceps Triceps Brachii

Pronator Teres Pronation - Pronator Teres & Pronator Quadratus Supination - In older texts, the term "supinator longus" was used to refer to the brachioradialis and "supinator brevis" was used to the muscle now known as the supinator. Encircling the radius, supinator brings the hand into the supinated position. In contrast to the biceps brachii it is able to do this in all positions of elbow flexion and extension. Supinator always acts together with biceps, except when the elbow joint is extended. It is the most active muscle in forearm supination during unresisted supination, while biceps becomes increasingly active with heavy loading.

Elbow and Forearm Characteristics Function is to position the hand Most muscles crossing the elbow are two- joint muscles 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 Elbow and Forearm Characteristics

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 Originate on the medial epicondyle Wrist Extensor Muscles Originate on the lateral epidondyle Relationship of Wrist and Hand Muscles to the Elbow

Kinematic Considerations The elbow and forearm create coupled and patterned movement Elbow flexion with forearm supination Biceps brachii and supinator Lift and carry functions Elbow extension with forearm pronation Triceps brachii and pronator teres Push out and push down (review D1/D2 patterns) Kinematic Considerations

Kinetic Considerations The elbow is inherently stabile to support lifting and carrying ability When the elbow becomes injured, it is one of the most difficult joints to restore full ROM When overloaded, the joint inflames and will dramatically decrease ability to handle force Kinetic Considerations

Forces at the Elbow Lifting weights with elbow extended: more stress anteriorly Lifting weights with elbow flexed: more stress posteriorly Forces at the Elbow

Forces at the Elbow

Lighter weights or cuffs attached to mid- forearm Greatest compression forces in push-up position Widening hand position decreases force Low-resistance, high-rep exercises are most appropriate early in rehabilitation program Reducing Joint Forces

Referred Pain and Nerve Injury C5, C6, T1 and T2 nerve roots cross the elbow- Symptoms are not usually isolated in the elbow Nerve Disorders Ulnar nerve- Compression at the cubital tunnel Radial nerve- Entrapment of the deep branch under extensor carpi radialis brevis, or with radial head fracture Median nerve- Entrapment between the ulnar and humeral heads of the pronator teres muscle Referred Pain and Nerve Injury

Elbow Joint Hypomobility Typically caused by: Rheumatoid arthritis and/or Juvenile Rheumatoid Arthritis Degenerative Joint Disease Trauma Dislocation Fractures Immobilization Elbow Joint Hypomobility

Joint Hypomobility: Common Impairments Acute Stage Joint effusion Muscle guarding Pain Subacute and Chronic Stages Capsular pattern is typically present Elbow flexion is more restricted than extension Decreased joint play Joint Hypomobility: Common Impairments

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 Common Functional Limitations

Joint Hypomobility: Nonoperative Management Protection phase Patient education Reduce effects of inflammation Maintain soft tissue and joint mobility Maintain integrity and function of related areas Controlled motion phase Increase soft tissue and joint mobility Improve joint tracking of the elbow Improve muscle performance and functional abilities Joint Hypomobility: Nonoperative Management

Joint Hypomobility: Nonoperative Management Return to function phase Improve muscle performance Activities should replicate the demands of ADL’s Modification of activities to reduce stress on joint Restore functional mobility of joints and soft tissues Joint mobilizations Aggressive stretching techniques Joint Hypomobility: Nonoperative Management

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 Typically occurs when falling onto an outstretched hand Long standing arthritis may also need to be managed through surgery The goals of surgery are: Relief of pain Restoration of bony alignment and joint stability Sufficient strength and ROM to allow for functional mobility Joint Surgery and Postoperative Management

Joint Surgery and Postoperative Management Surgical Options for Displaced Fractures of the Radial Head ORIF Arthroscopic Reduction and Internal Fixation Excision of the radial head Joint Surgery and Postoperative Management

Joint Surgery and Postoperative Management – Excision of Radial Head Maximum Protection Phase Immobilization Pain Control Edema Control AROM exercises for shoulder, wrist, and hand PROM and/or AAROM exercises for the elbow when permitted AROM exercises are allowed within a week after exercises are initiated Submaximal isometrics when permitted Joint Surgery and Postoperative Management – Excision of Radial Head

Joint Surgery and Postoperative Management –Excision of Radial Head Moderate and Minimum Protection Phases Begins when wound has healed and AROM of the elbow is relatively pain free Increase ROM Gentle stretching Mobilizations once the joint capsule is well healed (typically 6 weeks postoperatively) 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 –Excision of Radial Head

Joint Surgery and Postoperative Management - TEA Indications for Total Elbow Arthroplasty Severe joint pain Articular destruction of the humeroulnar and humeroradial joints RA is one of the most common pathologies leading to a TEA Significant instability of the elbow joint Failed radial head resection Joint Surgery and Postoperative Management - TEA

Joint Surgery and Postoperative Management - TEA Maximum Protection Phase (0-4 weeks) Immobilization – position varies Control of pain, inflammation, and edema Early AAROM exercises Maintain mobility of the shoulder, wrist, and hand Regain motion of the elbow and forearm Minimize atrophy of UE musculature Joint Surgery and Postoperative Management - TEA

Joint Surgery and Postoperative Management - TEA Moderate and Minimum Protection Phase Improve elbow ROM Low-intensity manual self-stretching Regain strength and endurance of elbow musculature Isometrics Light ADL’s UBE Open-chain resistance exercises Use operated arm for gradually demanding functional activities Joint Surgery and Postoperative Management - TEA

Total Elbow Arthroplasty

Also known as heterotopic or ectopic bone formation- The formation of bone in atypical locations of the body Etiology of symptoms Most often develops in the brachialis muscle or joint capsule Caused by trauma, radial head fracture, etc Management Active, pain-free ROM Massage, passive stretching, and resistive exercise are CONTRAINDICATED Myositis Ossificans

Overuse Syndromes - Epicondylitis Lateral epicondylitis- Tennis Elbow Pain in the common wrist extensor tendons What activities are typically associated with this diagnosis? Medial epicondylitis- Golfer’s Elbow Pain in the common wrist flexor tendons Overuse Syndromes - Epicondylitis

Overuse Syndromes - Epicondylitis Treatment- Protection Phase Avoid provoking activities Immobilization- rest the muscle Relieve pain, swelling, and scar tissue adhesions Modalities Cross-friction massage Brace/Splint Low-intensity isometrics Active ROM and resistive exercise of shoulder/scapular muscles Overuse Syndromes - Epicondylitis

Overuse Syndromes - Epicondylitis Treatment - Controlled Motion and Return to Function Phases Increase muscle flexibility Manual stretching Self-stretching Restore joint tracking of the RU Joint Cross-friction massage Improve muscle performance and function Isometrics, dynamic exercises, functional patterns, etc. Patient education Activity modification Overuse Syndromes - Epicondylitis

Caused by excessive traction forces on medial epicondyle epiphyseal plate during acceleration Curve and breaking pitches create the greatest forces Treatment Rest, ice, active exercises to tolerance No heavy weights Avoid valgus stresses early in rehab Avoid aggressive exercises Little League Elbow

Sprains Hyperextension sprain- Medial collateral ligament sprain- Anterior capsule injury; can cause bone bruise in olecranon region Medial collateral ligament sprain- Injures the primary stabilizing unit of elbow Treatment- Cross-friction massage to adhesions is contraindicated during initial 7-10 days after injury Immobilization Pain-free ROM Sprains

Most dislocations are posterior and follow sudden hyperextension and abduction Injury is obvious due to deformity Treatment Splint is worn for 2 weeks with motion beginning after first week Initiate isometrics during first week Rehabilitation may take 16-26 weeks Elbow Dislocation

Posterior Dislocation of Elbow

Elbow Arthroscopy Usually performed for debridement Treatment Sling is worn for 1-3 days Rehabilitation may take 8 weeks May initiate shoulder, wrist range-of-motion exercises, isometrics early Begin with straight plane, progress to diagonal plane Progression depends on patient response Elbow Arthroscopy

Elbow Bursitis (Olecranon Bursitis) Inflammation of the olecranon bursa May follow a traumatic incident Treatment: Stretches ROM Ice massage Modalities Elbow Bursitis (Olecranon Bursitis)

Nursemaid's Elbow (“Pulled” Elbow Syndrome) A partial dislocation of the elbow joint – 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 Nursemaid's Elbow (“Pulled” Elbow Syndrome)

“Pulled” Elbow Syndrome Radial Head Subluxation

Exercise Interventions for the Elbow and Forearm

Exercises for Flexibility and ROM Manual, mechanical, and self-stretching techniques To increase elbow extension To increase elbow flexion To increase forearm pronation and supination Self-stretching techniques—muscles of the medial and lateral epicondyles To stretch the wrist extensor muscles To stretch the wrist flexor muscles Exercises for Flexibility and ROM

Supination Self Stretch with Weight

Supination Self-Stretch

Pronator Self-Stretch

Assisted Elbow Flexion-Extension Stretches

Exercises to Develop & Improve Muscle Performance & Functional Control Isometric exercises Elbow flexion, elbow extension, and forearm pronation/supination Rhythmic stabilization Dynamic strengthening and endurance exercises Elbow flexion, elbow extension, pronation, and supination Wrist flexion and extension Functional exercises PNF patterns Pulling, lifting, and carrying activities Simulated tasks and activities Exercises to Develop & Improve Muscle Performance & Functional Control

Strengthening Exercises Progression Isometrics Isotonic Straight plane Multi-plane Plyometrics Functional exercises Activity specific exercises Strengthening Exercises

Supination/Pronation Strengthening

Elbow Flexion Strengthening

Elbow Extension Strengthening (continued)

Elbow Extension Strengthening

Functional and Sport Specific Activities Warm up and cool down Begin with low level and progress to overhead exercises Use easy activities at diminished distances, forces, and speeds Gradually increase one component at a time If pain occurs, return to previous level of exercises Functional and Sport Specific Activities

Orthopedic Special Tests

Ligamentous Test Varus and Valgus Stress Testing Note any laxity, decreased mobility or altered pain with testing The patient's arm is stabilized with one of the examiners hand at the elbow and the other hand placed above the wrist. The patient's elbow is flexed to 20 to 30 degrees and stabilized. A varus force is applied to the distal forearm and the ligament is palpated. The opposite direction is done for valgus. Ligamentous Test

Tests for Epicondylitis Lateral Epicondylitis – Cozen’s Test A positive test is indicated by sudden severe pain in the area of the lateral epicondyle of the humerus The patient's elbow is stabilized by the examiner's thumb., which rests on the patient’s lateral epicondyle. The patient is then asked to male a fist, pronate the forearm, and radially deviate and extends the wrist while the examiner resists the motion. Tests for Epicondylitis

Tests for Epicondylitis Lateral Epicondylitis – Mill’s Test A positive test is indicated by sudden severe pain in the area of the lateral epicondyle of the humerus While palpating the lateral epicondyle, the examiner pronates the patient's forearm, flexes the wrist fully and extends the elbow. Tests for Epicondylitis

Tests for Epicondylitis Medial Epicondylitis A positive sign is indicated by pain over the medial epicondyle of the humerus. The examiner palpates the patient's medial epicondyle, the patient's forearm is supinated and the elbow and wrist are extended by the examiner. Tests for Epicondylitis

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