1. Upper Arm, Elbow, and Forearm Conditions

2. Anatomy

3. Anatomy Cont’d… Carrying angle 3 articulations (single capsule)
Humeroulnar (elbow joint)
Humeroradial
Proximal radioulnar
Carrying angle
Angle between humerus and ulna (arm in anatomic position)
10-15° angle
Greater in females

4. Anatomy Cont’d… Ligaments Ulnar (medial) collateral
Radial (lateral) collateral
Annular

5. Anatomy Cont’d…
Bursae
Several small
Olecranon bursa
Superficial

6. Anatomy Cont’d…

7. Anatomy Cont’d…

8. Anatomy Cont’d…
Nerves
Musculocutaneous
Median
Ulnar
Radial

9. Anatomy Cont’d… Muscles
Flexors (at the humeroradial and humeroulnar joints)
Brachialis; biceps; brachioradialis
Effectiveness depends on supination/pronation position
Extensors (at the humeroradial and humeroulnar joints)
Triceps; anconeus
Pronation and supination (at the proximal radioulnar joint)
Pronator quadratus; pronator teres; supinator; biceps

10. Kinematics Non–weight bearing but still sustains significant loads
Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises

11. Injury Prevention Protective equipment Physical conditioning
Pads
Braces
Physical conditioning
Flexibility and strength
Focus on entire arm
Proper skill technique
Throwing
Falling

12. Contusions Susceptible due to: S&S Chronic blows
Lack of padding
General vulnerability
S&S
Rapid swelling – can limit ROM
Chronic blows
Development of ectopic bone
Tackler’s exostosis
Painful periostitis and fibrositis may develop
Management: standard acute; NSAIDs

13. Olecranon Bursitis Acute and chronic Mechanism S&S
Fall on a flexed elbow
Constantly leaning on elbow
Repetitive pressure and friction
S&S
Tender, swollen, relatively painless
Rupture – goose egg visible
50% history of abrupt onset; 50% insidious onset over a few weeks
Motion limited at extreme of flexion – tension increases over bursa
Management: standard acute; NSAIDs; possible aspiration

15. Sprain Mechanism Ulnar nerve may also be affected S&S
FOOSH - Fall on outstretched hand (hyperextension injury)
Valgus or varus force
More common; repetitive forces irritate and tear ligaments, especially UCL
Ulnar nerve may also be affected
S&S
Localized pain
Point tenderness
Instability with stress test
Management: standard acute

16. Dislocation Proximal radial head
Adolescents: often associated with immature annular ligament
Due to: longitudinal traction of an extended and pronated upper extremity
Inability to pronate and supinate pain free warrants immediate physician referral
Immobilization for 3-6 weeks in flexion is usually necessary

17. Dislocation Ulnar dislocation Younger than 20 years old Mechanism:
Hyperextension
Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral
Associated conditions
fractures of the medial epicondyle, radial head, coronoid process, and olecranon process
disruption of the anterior capsule
tearing of the brachialis muscle
injury to the ulnar collateral ligament

18. Dislocation Cont’d… S&S
Snapping or cracking sensation
Severe pain, rapid swelling
Total loss of function
Obvious deformity
Arm held in flexion, with forearm appearing shortened
Olecranon and radial head palpable posteriorly
Slight indentation in triceps visible just proximal to olecranon
Nerve palsy
Management: immediate immobilization in vacuum splint; activation of EMS

21. Strains Flexors and pronator teres Extensor S&S
Repetitive tensile stresses
Extensor
Decelerating type injury
S&S
Typical muscle strain S&S
Self-limiting
Management: standard acute

22. Triceps Brachii Rupture
Mechanism:
Direct blow to posterior elbow
Uncoordinated triceps contraction during a fall
80% involve olecranon avulsion fracture
S&S
Pain and swelling in distal attachment
Palpable defect in the triceps tendon or a step-off deformity of the olecranon
Active extension weak – partial tear; nonexistent – total rupture
Management: standard acute; immobilize in sling; immediate physician referral

23. Overuse Conditions Medial epicondylitis (aka – Little League Elbow)
Due to repeated valgus forces during acceleration phase of throwing motion
Commonly involved tendons: pronator teres and flexor carpi radialis
S&S
Swelling, ecchymosis, and point tenderness at humeroulnar joint or over the flexor/pronator origin
Severe pain; aggravated by:
Resisted wrist flexion and pronation
Valgus stress applied at 15-20° of elbow flexion
Ulnar nerve involved – tingling and numbness
Management: ice; NSAIDs; sling immobilization for 2-3 weeks with wrist in slight flexion; therapeutic exercise

24. Overuse Conditions Cont’d…
Lateral epicondylitis (aka – Tennis Elbow)
Due to eccentric loading of extensor muscles (especially extensor carpi radialis brevis) during deceleration phase of throwing motion or tennis stroke
Contributing factors
S&S
Pain anterior or just distal to lateral epicondyle; may radiate into forearm extensors during and after activity
Repetition produces pain that becomes more severe and ↑ with resisted wrist extension
Management: ice; NSAIDs; rest; support

25. Overuse Conditions Cont’d…
Ulnar nerve Entrapment
Vulnerable to compression and tension
S&S
Shocking sensation (medial elbow), radiating as if “hitting their funny bone.”
+ Tinel sign – ulnar groove (tingling and numbness of medial forearm into ring and little finger)
Pain not present, ROM is not limited
Grip strength may be weak

27. Fractures Ulna (forearm fracture) Olecranon
Direct blow
Triceps tension pulls bone fragment superiorly
Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention
Ulna (forearm fracture)
Also known as “nightstick” fracture

28. Assessment History Observation/inspection Palpation
Carrying angle
Position of function
Palpation
Physical examination tests

29. Assessment Cont’d… AROM AAROM PROM RROM Elbow flexion Elbow extension
Supination
Pronation
Wrist flexion
Wrist extension
AAROM
PROM
RROM

30. ROM (cont.) 30

31. Special Tests Ligamentous instability Valgus stress Varus stress
**Test at multiple angles

32. Special Tests Common extensor tendinitis (lateral epicondylitis)
Resisted extension and radial deviation of wrist
Passive stretching of wrist extensors
Resisted extension of extensor digitorum communis in middle finger with wrist extended
Common flexor tendinitis (medial epicondylitis)
Epicondylitis
Lateral (tennis elbow or lateral epicondylitis)
Pt is seated or standing; elbow flexed ~90°, forearm pronated
Examiner uses one hand to grasp forearm at elbow, palpating lateral epicondyle with thumb (fingers grasp around posterior elbow); other hand grasps pt’s hand/fist
Pt is instructed make a fist and pronate the forearm
Pt is instructed to radially deviate and extend wrist against examiner resistance
Test is + if: pain over lateral epicondyle is present = lateral epicondylitis 32

33. Special Tests (cont.) Tinel’s sign for ulnar neuritis
Medial (golfer’s elbow or medial epicondylitis)
Pt is seated or standing; elbow flexed; forearm pronated/neutral
Examiner uses one hand to palpate medial epicondyle and support elbow; other hand grasps hand/wrist
Examiner extends wrist and elbow; pt is instructed to resist this movement
Test is + if: pain over medial epicondyle is present = medial epicondylitis
Tinel’s sign for ulnar neuritis
Pt is seated or standing; elbow flexed 90°; forearm neutral/supinate
Examiner stands to side/behind pt; uses one hand to support forearm and the other hand to palpate ulnar nerve in groove at elbow (between olecranon process and medial epicondyle)
Examiner taps nerve in/over groove
Test is + if: tingling sensation into ulnar distribution of forearm/hand = nerve compression
Elbow flexion test for ulnar neuritis
Pt is seated or standing; instructed to completely flex the elbow and hold that position for 5 minutes
Test is + if: tingling or numbness in ulnar distribution of forearm/hand = ulnar neuropathy
Pronator teres syndrome test (test for median nerve compression)
Pt is seated or standing; elbow flexed 90°
Examiner resists forearm pronation while elbow is extended
Test is + if: tingling or paresthesia in median distribution of forearm/hand = median nerve compression 33

34. Rehabilitation (cont.)
Restoration of motion
Use of opposite hand to supply load
UBE 34

35. Rehabilitation (cont.)
Restoration of proprioception and balance
Closed-chain exercises
Muscular strength, endurance, and power
Open-chain exercises
PNF-resisted exercises
Cardiovascular fitness 35