1. Do Now Draw or trace the bony anatomy of the elbow on page 111 (Figure 11.1). Identify: Humerus Medial epicondyle Lateral epicondyle (not labeled in figure 11.1) Radius Ulna

2. Elbow and Forearm

3. Anatomy Preview Bones Simple: three bones Muscles: Complex: 7 major muscles that move the elbow; 9 muscles that move the wrist and hand. Ligaments: Present throughout the elbow, but the medial ligaments are the most relevant to sports medicine Anatomy Video

4. Bones Humerus (distal portion) Medial and lateral epicondyles Radius (thumb side) Ulna (pinky side) Olecranon (posterior ulna) “Elbow bone”

5. Anatomy Type of Joint: Hinge joint Range of motion (ROM) Flexion (aka “bending”) up to about 150° Extension (aka “straightening”) to 0°, but my have hyperextension to -10°

6. Pronation and Supination Pronation and supination occur at the radioulnar joint, not the elbow Radius has to cross over the ulna to produce pronation

7. Muscles

8. Biceps (anterior) = elbow flexor Triceps (posterior) = elbow extensor Anterior View Posterior View

9. Wrist Flexors Originate on medial epicondyle of humerus Insert onto anterior hand/wrist

10. Wrist Extensors Originate on lateral epicondyle of humerus Insert onto posterior hand/wrist

11. Ligaments Many ligaments necessary to provide stability. Medial: The ulnar collateral ligament (UCL) is most commonly discussed in sports medicine UCL sprain/tear may lead to “Tommy John” surgery, especially for overhead athletes.

12. Ligaments Lateral Important for stability of radioulnar joint, especially with pronation

13. Group Assignment (5 pts) Groups of up to 3 people (you can work independently). One sheet of printer paper per group. You can use the book, your notes, or internet/cell phone to complete this assignment. Draw, color, and identify anatomical landmarks of the elbow. Choose from one of the following groups (pick one): Anterior and posterior bony anatomy. ID 10 different landmarks. Any view of the elbow muscle mass (Medial, lateral, anterior, or posterior view of muscles). ID 5 muscles. Write which view you used. Lateral and medial view of elbow ligaments. ID 5 ligaments. Points: Anatomically accurate drawing (2 pts) Details added to drawing (color, shading, etc) (1/2 pt) Accurate labeling of anatomical structures (2 pt) Identified the appropriate number of structures(1/2 pt)

14. Quiz on Thursday Identify the following three bones: The olecranon is the posterior portion of which bone? 1 2 3 Anterior View

15. Quiz # 1-3. Identify the following three bones. 4. The olecranon is the posterior portion of which bone? 1 2 3 Anterior View

16. Remember H.O.P.S.? History How did the injury occur? (MOI) Where does it hurt? (Injury location) What activities increase the pain? How long has the injury bothered you? (Acute vs. chronic) Describe the pain. (Sharp, dull, shooting pain?) Observation Look for anything unusual around the elbow as well as down to the hand/wrist. Palpation Feeling for anything unusual around the elbow. Special tests To help determine the injury (will be discussed with some injuries)

17. Elbow Dislocation Occurs when the olecranon (posterior ulna) no longer articulates (attaches) to the humerus. MOI: In sports, usually due to hyperextension from FOOSH. Video

18. Elbow Dislocation s/s: Severe pain Obvious deformity Lack ROM (unable to flex/extend) Loss of feeling into hand and fingers Possible nerve damage Patient states that elbow is “out” and felt a “pop”

19. Treatment Call 9-1-1 if: No radial pulse or capillary refill (finger nail) is present Possible injury to the artery Numbness or tingling is present in hand Possible nerve damage Patient cannot get to the ER immediately The athletic trainers is not able to safely move the patient from the site of injury E.g. unstable fracture is also suspected or the patient is does not want to move from the site

20. Treatment On-field treatment: Splint in the position that is most comfortable for the patient. Apply sling (if possible) Non-Steroidal Anti-inflammatory (NSAID) Immediate referral to orthopedist or hospital. Ortho/ER: X-ray (to rule-out fracture) Reduce the dislocation Splint Surgery may be necessary to repair damaged ligaments and joint capsule Reduction

21. Hyperextension Tape Demo Video

22. Olecranon Bursitis Bursa: fluid-filled sacs that provide a buffer between bones, tendons, and ligaments. Many present throughout the body’s joints MOI: In athletics, usually direct impact to the elbow (e.g. fall or hit with helmet or by a baseball).

23. Olecranon Bursitis Signs and Symptoms (s/s) Posterior elbow pain. Noticeable swelling Point tenderness: severe pain with palpation Warmth and redness if infection is present

24. Olecranon Bursitis Treatment Initially: Ice bag or ice cup Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Ibuprofen (Advil), Naproxen Sodium/ Naproxen (Aleve), Aspirin Elbow pad Modify activities to prevent direct pressure to elbow If unresponsive to treatment: Aspiration (remove with needle) Corticosteroid injection

25. Video Aspiration and corticosteroid injection

26. Lateral & Medial Epicondylitis A.k.a. Lateral = “Tennis Elbow” Medial = “Golfer’s Elbow” MOI: repetitive microtrauma of the wrist extensor/flexor muscles.

27. Lateral & Medial Epicondylitis History: a chronic condition (effects are persistent or long- lasting) Onset of injury: insidious (gradual pain and dysfunction) s/s: aching pain that worsens over time and with activity Weakness in hand and wrist Pain with palpation near lateral/medial epicondyle

28. Lateral & Medial Epicondylitis Initial treatment is conservative: Rest Ice NSAIDs Heat (before activity) Forearm Strap To provide a counterforce Effective at treating symptoms Can use pre-wrap

29. Lateral & Medial Epicondylitis Active Therapy Stretch wrist extensors and flexors Deep tissue massage Therapeutic Ultrasound Provides deep tissue heating Electric Stimulation For pain control Strengthening Flexors Extensors

30. Distal Biceps Tendon Tear/Rupture Biceps tendon tears near the attachment site of the biceps tendon MOI: Elbow is forced into extension against resistance

31. Distal Biceps Tendon Tear/Rupture Most often seen in football with arm tackles

32. Distal Biceps Tendon Tear/Rupture s/s Reports feeling “pop” Decrease elbow flexion strength Edema (“swelling”) and Ecchymosis (“discoloration”) Obvious deformity of biceps, especially when compared bilaterally (both sides) Appears balled-up

33. Distal Biceps Tendon Tear/Rupture Treatment: Tear Ice and compression NSAIDs Progressive ROM Rupture Usually responds best to surgerysurgery ROM after 1 week Submaximal strengthening about 4 weeks post-op

34. UCL Sprain UCL = Ulnar Collateral Ligament A tear to at least one of the three ligaments of the UCL.

35. UCL Sprain MOI: in sports, due to overload of the medial elbow, usually with overhand throwing Onset: Insidious or acute (recently occurring, due to a traumatic event)

36. UCL Sprain Palpation: Pain over UCL, but probably no deformity s/s Edema (swelling) may be present Pain and weakness with throwing/ overhand motion Diagnosis Valgus Stress Test MRI

37. UCL Sprain Treatment: Conservative RICE (Rest, Ice, Compression, Elevation) NSAIDs No overhand motion for 4 to 6 weeks for partial tears Treatment: Aggressive Athletes and doctors are now opting for reconstructive surgery for partial and full tears due to its high success rate. reconstructive surgery Commonly known as “Tommy John Surgery”

38. Lab 1.Valgus and Varus Stress Tests 2.Goniometry 3.Pre-wrap tendinosis strapping 4.TENS unit demonstration

39. Tommy John Epidemic in MLB? In Little Leaguers 30 for 30 Shorts

40. Quiz Review Quiz on Friday 1/16. 10 Questions with 15 terms listed in the word bank Some terms will not be used. No term will be used more than once.

41. What you should know: What type of joint is the elbow? What is the primary elbow flexor and extensor muscles? Which muscle group originates from the medial epicondyle of the humerus? How about the lateral epicondyle? What is lateral epicondylitis also know as?

42. What you should know: What is “Tommy John Surgery” used to repair? Common MOI for an elbow dislocation? Know chronic vs. acute. What is a bursa?

43. What you should know: Which injury is this?