ELBOW disorders

DPT, 7th SEMESTER

Dr. Aftab Ahmed Mirza Baig, PhD

MS(Advanced Physiotherapy), PhD (Health, Physical Education and Sports Sciences)
Associate Professor, Department of Physical Therapy, Faculty of Health Sciences, Iqra University,
North Campus
Learning objectives

• Introduction to elbow
• Subjective and objective examination
• Common injuries to elbow
• Ulnohumeral(trochlear) Joint:
• Resting Position: 70 deg elbow flexion, 10 deg supination
• Close packed position: extension with supination
• Capsular pattern: Flexion, extension

• Radiohumeral Joint:
• Resting Position: full extension and full supination
• Close packed position: elbow flexed to 90 deg, forearm supinated to
5 deg.
• Capsular pattern: flexion, extension, supination, pronation
• Ligaments:
• Ulnar collateral ligament (primary restraint to valgus instability)
• Radial collateral ligament (primary restraint to posterolateral
instability)

• Cubital tunnel
• Superior Radioulnar Joint
• Resting Position: 35 deg supination, 70 deg elbow flexion
• Close packed position: 5 deg supination
• Capsular pattern: equal limitation of supination and pronation
• Annular Ligament
• Middle radioulnar articulation: interosseous membrane (it prevents
proximal displacement of the radius on the ulna, e.g. in pushing
movements)
• Oblique cord (pulling movts.)

• Patient History
• Observation
• Carrying angle (Males: 5 to 10 deg, females:10 to 15 deg)
• Cubitus valgus: carrying angle more than 15 deg)
• Cubitus varus: less than 5 to 10 deg
• Gun stock deformity
• Normal functional position
• Goose egg
• Triangle sign (isosceles triangle)
• EXAMINATION:
• Hyperextension
• Loss of elbow extension is sensitive indicator of intra-articular pathology.
It is the first movement lost after injury to the elbow and the first
regained with healing.
• 75 deg of supination and pronation occurs in the forearm articulation
and the remaining 15 deg is the result of wrist action.
• Most ADLs are performed at between 30 deg and 130 deg of flexion and
between 50 deg of pronation and 50deg of supination.
Lateral Tendon Injuries (Tennis
Elbow)
• Peak age: 40 to 50years.
• It involves primarily the extensor carpi radialis brevis and
occasionally the extensor digitorum, extensor carpi radialis longus,
and more rarely the extensor carpi ulnaris.
Grade 1 Grade 2 Grade 3

Generalized elbow soreness with Working or playing through the Simple activities of daily living
activity, which is most often ignored. soreness may increase pain, which become more painful and difficult
A vicious cycle of irritation, becomes localized at the lateral (i.e. shaking hands and turning a
inflammation, pain, weakness, and condyle or radial head and persists door knob). Continued activity leads
inadequate healing is initiated and after activity. The lateral aspect of to secondary problems such as
gains full expression in subsequent the joint below may become swollen rotator cuff or low back pain as
grades of injury. and warm and tender to touch. Pain other joints attempts to
will interfere with work or athletic compensate. If ignored, arthritic
activity. As the condition persists, changes in the proximal radial or
pain may radiate down the forearm humeral ulnar joint may occur.
to the wrist and may extend upward
into the upper arm and shoulder.
Medial Tendon Injury (Medial Tennis
Elbow Or Golfer’s Elbow)
• It may occur in tennis (faulty forehand stroke), throwing (acceleration
phase), swimming (faulty pull-through), golf (“hitting from the top”),
and occupations such as carpentry that involve repetitive hammering
or screwing.
• Repeated microtrauma to the flexor-pronator musculature at its
insertion onto the medial epicondyle can cause medial tennis elbow
or golfer’s elbow.
• It involves primarily the pronator teres and flexor carpi radialis and
occassionally the palmaris longus, flexor carpi ulnaris, and flexor
digitorum superficialis.
• Provacation occurs with resisted wrist flexion and forearm pronation,
passive wrist extension, and supination.
• More common in those who has strong hand grip and repeated
adduction movement of the elbow.
Posterior Tendon Injuries (Posterior
Tennis Elbow)
• Tendinitis of the triceps at its attachment to the olecranon is rare.
• It typically follows sudden severe strain to the triceps tendon as the
arm is fully extended and can result from throwing a javelin or from a
twisted serve in competitive tennis players.
• Pain is provoked on resisted elbow extension.
• Snapping: subluxation or dislocation of a portion of the triceps
mechanism or subluxation or dislocation of the ulnar nerve.
Examination and Management

• Site of pain:
• lateral tennis elbow: lateral humeral epicondyle, often referred into
the C7 segment, down the posterior forearm into the dorsum of the
hand, and perhaps into the ring and long fingers.
• Medial tennis elbow: over the medial epicondyle, rarely referred to
the ulnar aspect of the forearm.
• Posterior tennis elbow: over the posterior compartment of the
elbow.
• Gradual onset of pain
• Grasping activities aggravates lateral tennis elbow, medial tennis
elbow is worsened by repeated wrist flexion and gripping.
• Active and Passive movements
• Resisted Isometric movements: resisted wrist extension (with the
elbow extended)= lateral tennis elbow
• Resisted wrist flexion reproduces pain in medial tennis elbow.
• Resisted elbow extension with the elbow in flexion and the forearm
fully supinated is a key test for posterior tennis elbow.
• Joint play movements should be full and painless.
• Tenderness at the epicondyles.
• Goals:
• To restore normal, painless use of the involved extremity.
• To restore normal strength and extensibility of the musculotendinous
unit.
• To encourage proper maturation of scar tissue and collagen formation,
and to allow extensibility and the ability of the tendon to attenuate
tensile stresses.
Treatment:
Acute and Chronic
• PRICE
• Splint
• Avoid grasping, pinching and fine finger movts.
• Deep transverse friction massage
Medial Tension Overload Syndromes

• MEDIAL COLLATERAL LIGAMENT INJURIES (VALGUS OVERLOAD

TRIAD)
• The syndrome includes problems relating to the posterior medial
joint capsule, the ulnar nerve, and medial collateral ligament of the
elbow.
• MCL =common site of injury in overhead athlete. e.g. in baseball,
javelin, hitting and racquet sports.
• Traumatic valgus thrust while the arm is outstretched.
• It is common to many pathologic entities.
• Tension stress= ulna & humerus= spur formation= compression of the
ulnar nerve=elbow flexion contracture or potentially increase stability
of the elbow.
• History: gradual onset of symptoms. First tendinitis symptoms.
• Popping sensation, relieved by rest.
• Overtime medial elbow pain may be accompanied by ulnar nerve
irritability or posterior elbow pain cause by olecranon impingement.
• Observation:
• Swelling=soft tissue injury
• AROM AND PROM: decrease elbow extension and supination owing
to flexor and pronator contractors.
• JPM: valgus laxity.
• Resisted movts.: pain in resisted forearm pronation and making a fist.
• Point tenderness over MCL.
• Ulnar nerve hypersensitivity in the groove and possible subluxation.
• Tenderness at medial epicondyle.
• Special tests
• Management:
• Pain reduction
• Maintaining and regaining ROM of flexors and pronators.
• Proximal control of the scapula and rotator cuff m/s. Fatigue of the shoulder
musculature is thought to affect arm angle during throwing, increasing the load
to the medial elbow.
• Strengthening both concentrically and eccentrically the pronators and supinators.
Grip ex.
• Strengthening of flexors especially flexor carpi ulnaris and flexor digitorum
superficialis.
• In advance cases: surgical stabilization of the MCL instability and posterior media
bony impingement.
Cubital Tunnel Syndrome

• It is used to identify a specific anatomic site for entrapment of the ulnar

nerve, the most common site of entrapment of the ulnar nerve at the elbow.
• Ulnar nerve can be compromised by any swelling that occurs within the
tunnel, with inflammatory changes that result in the thickening of the fascial
sheath, and because of constriction by the aponeurosis of the flexor carpi
ulnaris.
• Due to prolonged flexion of the elbow.
• Can be damaged by single traumatic episode, by repeated trauma, by
previous trauma that has resulted in a cubitus valgus deformity that gradually
stretches the nerve, or by overuse of the elbow, resulting in entrapment.
• Ligamentous laxity, hyperflexed elbow posturing, recurrent sublaxation or
dislocation of the nerve out of the ulnar groove, tethering of the nerve at the
arcade of Struthers, muscle hypertrophy, tumors, ganglions, or restrictions of
the nerve by adhesions in the cubital tunnel may result in nerve compression.
• Physical examination: symptoms are mainly sensory.
• Wasting of hypothenar eminence and of the adductor m/s of the
thumb.(clawing of the little and ring finger). The lack of ability to
adduct the little finger may be the first sign of ulnar n/v compression.
• Grip and thumb-index finger pinch weakness.
• Positive elbow flexion test.
• Positive tinel’s sign
• ULTT for ulnar nerve may be positive.
• EMG
Management

• Conservative treatment
• Soft elbow pads are helpful.
• Exercises to increase flexibility of the forearm muscles and functional
activities are introduced slowly.
• Appropriate neck and shoulder girdle postures are considered
throughout the therapy program.
• Nerve gliding
• Soft tissue manipulations
• Avoidance of hyperflexion and valgus stress.
• Dynamic stability drills: specifically Pronator teres and wrist flexor
m/s
• Surgical Management
“If you are willing to learn, no one can help you. If you are determined
to learn, no one can stop you.” — Anonymous

Thanks!