1. PTA 130 Fundamentals of Treatment I
Elbow & Forearm

2. 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

3. 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

4. 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

5. 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

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

8. 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.

9. 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

10. 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

11. 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

12. 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

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

14. Forces at the Elbow

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Total Elbow Arthroplasty

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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 weeks
Elbow Dislocation

37. Posterior Dislocation of Elbow

38. 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

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

40. 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)

41. “Pulled” Elbow Syndrome Radial Head Subluxation

42. Exercise Interventions for the Elbow and Forearm

43. 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

44. Supination Self Stretch with Weight

45. Supination Self-Stretch

46. Pronator Self-Stretch

47. Assisted Elbow Flexion-Extension Stretches

48. 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

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

50. Supination/Pronation Strengthening

51. Elbow Flexion Strengthening

52. Elbow Extension Strengthening
(continued)

53. Elbow Extension Strengthening

54. 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

55. Orthopedic Special Tests

56. 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

57. 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

58. 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

59. 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

60. Questions?