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Chapter 23: The Elbow
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Anatomy of the Elbow
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Figure 23-1
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Figure 23-2
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Figure 23-3
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Figure 23-4 A-C
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Functional Anatomy
• Complex that allows for flexion, extension,
pronation and supination
– 145 degrees of flexion and 90 degrees of
supination and pronation
• Bony limitations, ligamentous support and
muscular stability at the elbow help to protect
it from overuse and traumatic injuries
• Elbow demonstrates a carrying angle due to
distal projection of humerus
– Normal in females is 10-15 degrees, males 5
degrees
• Critical link in kinetic chain of upper extremity
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Assessment of the Elbow
• History
– Past history
– Mechanism of injury
– When and where does it hurt?
– Motions that increase or decrease pain
– Type of, quality of, duration of, pain?
– Sounds or feelings?
– How long were you disabled?
– Swelling?
– Previous treatments?
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• Observations
– Deformities and swelling?
– Carrying angle
• Cubitus valgus versus
cubitus varus
– Flexion and extension
• Cubitus recurvatum
Figure 23-5
– Elbow at 45 degrees
• Isosceles triangle
(olecranon and epicondyles)
Figure 23-8
Figure 23-7
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•Palpation: Bony and Soft Tissue
• Humerus
• Medial and lateral
epicondyles
• Olecranon process
• Radial head
• Radius
• Ulna
• Medial and lateral
collateral ligaments
• Annular ligament
•
•
•
•
•
•
•
Biceps brachii
Brachialis
Brachioradialis
Pronator teres
Triceps
Supinator
Wrist flexors and
extensors
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• Special Tests
– Circulatory and Neurological Function
• Pulse should be taken at brachial artery and radial artery
• Skin sensation should be checked - determine presence
of nerve root compression or irritation in cervical or
shoulder region
• Tinel’s sign
– Ulnar nerve test
– Tap on ulnar nerve (in ulnar groove)
– Positive test is found when athlete complains of sensation
along the forearm and hand
– Test for Capsular Injury
• Tested after hyperextension of elbow
– Elbow is flexed to 45 degrees, wrist is fully flexed and
extended
– If joint pain is severe, moderate/severe sprain or fracture
should be suspected (chronic injury may present same)
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– Valgus/Varus Stress Test
• Assess injury to the medial and lateral
collateral ligaments, respectively
• Looking for gapping or complaint of pain
Figure 23-10
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– Medial and Lateral Epicondylitis Tests
• Elbow flexed to 45 degrees and wrist extension
or flexion is resisted
• Pain at lateral or medial epicondyle,
respectively indicates a positive test
– Pinch Grip Test
• Pinch thumb and index finger together
• Inability to touch fingers together indicates
entrapment of anterior interosseous nerve
between heads of pronator muscle
– Pronator Teres Syndrome Test
• Forearm pronation is resisted
• Increased pain proximally over pronator teres
indicates a positive test
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Figure 23-11 & 12
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Functional Evaluation
• Pain and weakness are
evaluated through
AROM, PROM and
RROM
– Flexion, extension,
pronation and
supination
– ROM of pronation and
supination are
particularly noted
Figure 23-13 & 14
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Recognition and Management
of Injuries to the Elbow
• Subject to injury due to broad range of
motion, weak lateral bone structure, and
relative exposure to soft tissue damage
• Many activities place excessive stress
on joint
• Locking motion of some activities, use
of implements, and involvement in
throwing motion make elbow extremely
susceptible
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• Contusion
– Etiology
• Vulnerable area due to lack of padding
• Result of direct blow or repetitive blows
– Signs and Symptoms
• Swelling (rapidly after irritation of bursa or
synovial membrane)
– Management
• Treat w/ RICE immediately for at least 24 hours
• If severe, refer for X-ray to determine presence
of fracture
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• Olecranon Bursitis
– Etiology
• Superficial location
makes it extremely
susceptible to injury
(acute or chronic) -direct blow
– Signs and
Symptoms
• Pain, swelling, and
point tenderness
• Swelling will appear
almost
spontaneously and
w/out usual pain and
heat
Figure 23-17
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– Management
• In acute conditions, compression for at least 1
hour
• Chronic cases require superficial therapy
primarily involving compression
• If swelling fails to resolve, aspiration may be
necessary
• Can be padded in order to return to competition
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• Muscle Strains
– Etiology
• MOI is excessive resistive motion (falling on
outstretched arm), repeated microtears that cause
chronic injury
• Rupture of distal biceps is most common muscle
rupture of the upper extremity
– Signs and Symptoms
• Active or resistive motion produces pain; point
tenderness in muscle, tendon, or lower part of muscle
belly
– Management
• RICE and sling in severe cases
• Follow-up w/ cryotherapy, ultrasound and exercise
• If severe loss of function encountered - should be
referred for X-ray (rule out avulsion or epiphyseal fx)
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• Ulnar Collateral Ligament Injuries
– Etiology
• Injured as the result of a valgus force from repetitive
trauma
• Can also result in ulnar nerve inflammation, or wrist flexor
tendinitis; overuse flexor/pronator strain, ligamentous
sprains; elbow flexion contractures or increased instability
– Signs and Symptoms
• Pain along medial aspect of elbow; tenderness over MCL
• Associated paresthesia, positive Tinel’s sign
• Pain w/ valgus stress test at 20 degrees; possible endpoint laxity
• X-ray may show hypertrophy of humeral condyle,
posteromedial aspect of olecranon, marginal osteophytes;
calcification w/in MCL; loose bodies in posterior
compartment
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• Ulnar Collateral Ligament Injuries
(cont.)
– Management
• Conservative treatment begins w/ RICE and
NSAID’s
• W/ resolution, strengthening should be
performed; analysis of the throwing motion (if
applicable)
• Surgical intervention may be necessary
(Tommy John procedure)
– Involves reconstruction using palmaris longus
autograft and occasionally transposition of the ulnar
nerve
– Throwing athlete can return to activity 22-26 weeks
post surgery with full-recovery taking 18-24 months
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• Lateral Epicondylitis (Tennis Elbow)
– Etiology
• Repetitive microtrauma to insertion of extensor
muscles of lateral epicondyle
• Tendinosis with degeneration of tendon without
inflammation
– Signs and Symptoms
• Aching pain in region of lateral epicondyle after
activity
• Pain worsens and weakness in wrist and hand
develop
• Elbow has decreased ROM; pain w/ resistive
wrist extension
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• Lateral Epicondylitis
(continued)
– Management
• RICE, NSAID’s and
analgesics
• ROM exercises and PRE,
deep friction massage, hand
grasping while in supination,
avoidance of pronation
motions
• Mobilization and stretching in
pain free ranges
• Use of a counter force or
neoprene sleeve
• Mechanics and skills training in
Figure 23-19
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• Medial Epicondylitis
– Etiology
• Repeated forceful flexion of wrist and extreme
valgus torque of elbow
• May involve pronator teres, flexor carpi radialis
and ulnaris, and palmaris longus tendons
• Can be associated with ulnar nerve neuropathy
– Signs and Symptoms
• Pain produced w/ forceful flexion or extension
• Point tenderness and mild swelling
• Passive movement of wrist seldom elicits pain,
but active movement does
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– Management
• Sling, rest, cryotherapy or heat through
ultrasound
• Analgesic and NSAID's
• Curvilinear brace below elbow to reduce elbow
stressing
• Severe cases may require splinting and
complete rest for 7-10 days
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• Elbow Osteochondritis Dissecans
– Etiology
• Impairment of blood supply to anterior surface
resulting in degeneration of articular cartilage,
creating loose bodies
• Repetitive microtrauma in movements of elbow
rotation, extension, valgus stress causing
compression of the radial head and shearing of the
radiocapitellar joint
• Seen in young athletes involved in throwing motion
• Panner’s disease in incidents of children age <10
– Osteochondrosis of capitellum due to localized
avascular necrosis
– Signs and Symptoms
• Sudden pain, locking; range usually returns in a few
days
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– Signs and Symptoms (continued)
• Swelling, pain at radiohumeral joint, crepitus,
decreased ROM (full extension); grating w/
pronation and supination
• X-ray may show flattening and crater of
capitulum w/ loose bodies
– Management
• Activity restriction for 6-12 weeks; NSAID’s
• Splint and cast applied for cases of extensive
deterioration
• If repeated locking occurs, loose bodies are
removed surgically
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• Little League Elbow
– Etiology
• Caused by repetitive microtraumas that occur
from throwing (not type of pitch)
• May result in numerous disorders of growth in
the pitching elbow
• Linked to:
– Accelerated apophyseal growth region and delay in
medial epicondyle growth plate
– Traction apophysitis with possible fragmentation of
medial epicondylar apophysis
– Avulsion of medial epicondyle or radial head
– Osteochondrosis of humeral capitellum
– Non-union stress fracture of olecranon epiphysis
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• Little League Elbow (continued)
– Signs and Symptoms
• Onset is slow; slight flexion contracture,
including tight anterior joint capsule and
weakness in triceps
• Patient may complain of locking or catching
sensation
• Decreased ROM of forearm pronation and
supination
– Management
• RICE, NSAID’s and analgesics
• Throwing stops until pain resolved and full
ROM is regained
• Gentle stretching and triceps strengthening
• Throwing under supervision w/ good technique
to prevent recurrence
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• Cubital Tunnel Syndrome
– Etiology
• Pronounced cubital valgus may cause deep
friction problem
• Ulnar nerve dislocation
• Traction injury from valgus force, irregularities
w/ tunnel, subluxation of ulnar nerve due to lax
impingement, or progressive compression of
ligament on the nerve
– Signs and Symptoms
• Pain medially which may be referred proximally
or distally
• Tenderness in cubital tunnel on palpation and
hyperflexion
• Intermittent paresthesia in 4th and 5th fingers
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• Cubital Tunnel Syndrome (continued)
– Management
• Rest, immobilization for 2 weeks w/ NSAID’s
• Splinting or surgical decompression or
transposition of subluxating nerve may be
necessary
• Patient must avoid hyperflexion and valgus
stresses
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• Dislocation of the Elbow
– Etiology
• Caused by fall on outstretched hand w/ elbow
extended or severe twist while flexed
• Bones can be displaced backward, forward, or
laterally
• Distinguishable from fracture because lateral and
medial epicondyles are normally aligned w/ shaft
of humerus
– Signs and Symptoms
• Swelling, severe pain, disability
• Complications w/ median and radial nerves and
blood vessels
• Often a radial head fracture is involved
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Elbow Dislocation
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– Management
• Cold and pressure immediately w/ sling
• Refer for reduction
• Neurological and vascular fxn must be assessed prior
to and following reduction
• Physician should reduce - immediately
• Immobilization following reduction in flexion for 3
weeks
• Hand grip and shoulder exercises should be used
while immobilized
• Following initial healing, heat and passive exercise
can be used to regain full ROM
• Massage and joint movement that are too strenuous
should be avoided before complete healing due to
high probability of myositis ossificans
• ROM and strengthening should be performed and
initiated by patient (forced stretching should be
avoided)
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• Fractures of the Elbow
– Etiology
• Fall on flexed elbow or from a direct blow
• Fracture can occur in any one or more of the
bones
• Fall on outstretched hand often fractures
humerus above condyles or between condyles
– Condylar fracture may result in gunstock deformity
• Direct blow to olecranon or radial head may
result in fracture
– Signs and Symptoms
• May not result in visual deformity
• Hemorrhaging, swelling, muscle spasm
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• Elbow Fractures
(continued)
– Management
Figure 23-22
• Decrease ROM,
neurovascular status
must be monitored
• Surgery is used to
stabilize adult unstable
fracture, followed by
early ROM exercises
• Stable fractures do not
require surgery
– Removable splints are
used for 6-8 weeks
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• Volkmann’s Contracture
– Etiology
• Associate w/ humeral supracondylar fractures,
causing muscle spasm, swelling, or bone pressure
on brachial artery, inhibiting circulation to forearm
• Can become permanent
• There may be loss of motor and sensory function
– Classic case involves median nerve
• Results from insufficient arterial perfusion and
venous stasis followed by ischemic degeneration
• Irreversible muscle damage occurs after 4-6 hours
• Edema further impairs circulation propagating
muscle necrosis
• Necrosis may lead to secondary fibrosis and
calcification
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– Signs and Symptoms
• Pain in forearm increased w/ passive
extension of fingers
• Pain is followed by
cessation of brachial
and radial pulses,
coldness in arm
• Decreased motion
– Management
• Remove elastic wraps
or casts
• Close monitoring must
occur
Figure 23-23
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• Pronator Teres Syndrome
– Etiology
• Entrapment of median nerve
– Proximal to the elbow joint
– In the pronator teres muscle as the nerve passes between the
superficial and deep heads of the muscle
• May become trapped due to edema or muscle hypertrophy
– Signs & Symptoms
• Sensory deficits – numbness, tingling, pins & needles (digits 1-4)
• Motor deficits – loss of flexion and opposition, weakness with
pronation
• Symptoms reproduced with tightly gripping and resisted pronation
– Management
• Rest, NSAID’s, TENS for pain, modified activity
• Decompression surgery if treatment is unsuccessful
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Rehabilitation of the Elbow
• General Body
Conditioning
– Must maintain preinjury fitness levels cardiovascular and
strength (lower body)
• Flexibility
– Restoring ROM is
critical in elbow rehab
– Variety of approaches
can be used as long as
they don’t force the
joint
Figure 23-24
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• Joint Mobilizations
– Loss of proper arthrokinematics following
immobilization is expected
– Joint mobilization and traction can be very
useful to increase mobility and decrease
pain through restoration of accessory
motions
Figure 23-25 A & B
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• Strengthening
– Achieved through low-resistance, high-repetition
exercises - must be pain free
– Shoulder and grip exercises should also be
performed
– Continuous passive motion units followed by
dynamic splinting is ideal following surgery
– Isometrics can be used while elbow is
immobilized
– PNF and isokinetics are useful in early and
intermediate active stages of rehab
– A graded PRE program w/ tubing, weights or
manual resistance should be included
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Strengthening Exercises
Figure 23-26
Plyometric
Exercises
Figure 23-27
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Closed Kinetic Chain
Exercises
Figure 23-28
– Closed kinetic chain activities should also be
incorporated
• Assist in both static and dynamic stability to the elbow
– Proprioceptive training should also incorporated
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• Functional Progressions
– Will enhance healing and performance
• PNF, swimming, pulley machines and rubber
tubing
• Simulate sports activities
– Should include steps
• Warm-up
• Gradual build up to activity, becoming
increasingly more difficult
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• Return to Activity
– Can re-engage in activity
when criteria has
successfully been
completed
– ROM w/in normal limits,
strength should be equal
w/ no complaint of pain
– Return should progress
with use of restrictions in
an effort to objectively
measure activity
progression
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