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The Elbow Denisha Fergusson, ATC, LAT Primary Lab Instructor Florida International University Acute Care and Injury Prevention Ligaments of the elbow Elbow Injuries Subject to injury due to… Broad range of motion Weak lateral bone structure Exposure of soft tissue Many sports place excessive stress on joint Locking motion of some activities Throwing motion Elbow Injuries: Contusion MOI = direct blow or repetitive blows Vulnerable area due to lack of padding Signs and Symptoms Rapid swelling due to irritation of bursa or synovial membrane Management RICE immediately, for at least 24 hours If severe, refer for X-ray to rule out fracture Elbow Injuries: Olecranon Bursitis MOI = direct blow Superficial location: extremely susceptible to injury Signs and Symptoms Pain, swelling, and point tenderness Swelling will appear almost spontaneously without the pain and heat Elbow Injuries: Olecranon Bursitis Management Acute: compression for at least 1 hour Chronic: requires superficial therapy primarily involving compression If swelling fails to resolve, aspiration may be necessary May be padded to return to competition Elbow Injuries: Muscle Strains MOI = overstretching or too forceful a contraction Falling on outstretched arm Repeated microtears may cause chronic injury • Rupture of distal biceps is most common Elbow Injuries: Muscle Strains Signs and Symptoms Pain with AROM and RROM Point tenderness in muscle, tendon, or lower part of muscle belly Management PRICE Sling in severe cases Follow-up treatment • Modalities, ROM and PRE exercises If severe loss of function, refer for X-ray to rule out avulsion or epiphyseal fracture Elbow Injuries: Ulnar Collateral Ligament Injuries MOI = valgus force from repetitive trauma Secondary injuries may include… Ulnar nerve inflammation Wrist flexor tendonitis Joint instability Elbow Injuries: UCL Injuries Signs and Symptoms Pain along medial aspect of elbow Point tenderness over UCL Associated paresthesia (Reason:?) Elbow Injuries: UCL Injuries Management Conservative treatment • PRICE and NSAID’s ROM and PRE exercises as pain decreases Analysis of the throwing motion (if applicable) Surgical intervention may be necessary • Tommy John Procedure • Throwing athlete may be able to return to activity approximately 22-26 weeks post surgery Elbow Injuries: Lateral Epicondylitis (Tennis Elbow) MOI = repetitive microtrauma to insertion of wrist extensor muscles Elbow Injuries: Lateral Epicondylitis (Tennis Elbow) Signs and Symptoms Aching pain at lateral epicondyle after activity Decreased elbow ROM Pain with AROM and RROM wrist extension Pain and weakness in wrist and hand develop Elbow Injuries: Lateral Epicondylitis (Tennis Elbow) Management PRICE NSAID’s and analgesics Mobilization and stretching in pain free ranges Deep friction massage Hand grasping while in supination • Avoid pronation motions Use of neoprene sleeve Mechanics and skills training in order to avoid recurrence of injury Elbow Injuries: Medial Epicondylitis MOI = repeated forceful wrist flexion and extreme valgus torque on the elbow May involve common flexor tendons Can be associated with ulnar nerve neuropathy Elbow Injuries: Medial Epicondylitis Signs and Symptoms Pain with AROM and RROM wrist flexion Point tenderness and mild swelling at medial epicondyle Elbow Injuries: Medial Epicondylitis Management PRICE NSAID's and analgesics Sling in severe cases • Severe cases may require splinting and complete rest for 7-10 days Cryotherapy, Ultrasound Curvilinear brace • Below elbow to reduce stress at the elbow joint Elbow Injuries: Little League Elbow MOI = repetitive microtraumas that occur from throwing motion (Not due to the type of pitch) Elbow Injuries: Little League Elbow Linked to: Accelerated apophyseal growth and delayed medial epicondyle epiphysis growth Traction apophysitis with possible fragmentation of medial epicondylar apophysis Avulsion fracture at medial epicondyle or radial head Osteochondrosis of humeral capitellum Non-union stress fracture of olecranon epiphysis Elbow Injuries: Little League Elbow Signs and Symptoms Onset is slow Slight flexion contracture Tight anterior joint capsule Weakness in triceps “Locking” or “Catching” sensation Decreased ROM • Especially forearm pronation and supination Elbow Injuries: Little League Elbow Management PRICE NSAID’s and analgesics Stop throwing until… • Pain resolved • Full ROM is regained Gentle ROM exercises Gentle triceps strengthening exercises Analysis of throwing motion Elbow Injuries: Osteochondritis Dissecans MOI = Repetitive microtrauma Injurious movements include elbow rotation and extension • Excessive valgus stresses causes compression of the radial head, which adds shearing forces at the radiocapitular joint • Impairment of blood supply may result, which causes degeneration of articular cartilage creating loose bodies Elbow Injuries: Osteochondritis Dissecans Panner’s disease Occurs in children (age <10) Osteochondrosis of capitellum due to localized avascular necrosis Elbow Injuries: Osteochondritis Dissecans Signs and Symptoms Sudden pain at radiohumeral joint Swelling, creptitus Decreased ROM (full extension) • ROM usually returns in a few days • Grating with pronation and supination Locking of the joint X-ray • May show loose bodies in joint Elbow Injuries: Osteochondritis Dissecans Management Activity restriction for 6-12 weeks NSAID’s Splint and cast applied in severe cases of deterioration If repeated locking of the elbow joint occurs, loose bodies are removed surgically Elbow Injuries: Cubital Tunnel Syndrome MOI = narrowing of cubital canal or irregularity of cubital tunnel Pronounced cubital valgus may cause deep friction contributing to injury Ulnar nerve injury may result Elbow Injuries: Cubital Tunnel Syndrome Signs and Symptoms Pain on medial aspect of elbow • Pain may be referred proximally or distally Point tenderness in cubital tunnel Pain with hyperflexion Intermittent paresthesia in 4th and 5th fingers Elbow Injuries: Cubital Tunnel Syndrome Management Rest, immobilization for 2 weeks NSAID’s Splinting, surgical decompression or transposition of subluxating nerve may be necessary Avoid hyperflexion and valgus stresses Elbow Injuries: Dislocation MOI = fall on outstretched hand with elbow extended or severe twist while elbow flexed High incidence in sports Dislocation may be posterior, anterior, or lateral Elbow Dislocation Elbow Injuries: Dislocation Signs and Symptoms Swelling, severe pain, disability Median and radial nerves may be compromised Blood vessels may be compromised Often a radial head fracture is involved Elbow Injuries: Dislocation Management Immobilize and ice immediately Refer for reduction immediately Rehabilitation includes • Heat and PROM exercises to regain full ROM • ROM and PRE exercises should be initiated by athlete Elbow Injuries: Fractures MOI = fall on flexed elbow or direct blow May occur in one or more of bones in elbow joint Signs and Symptoms May not result in visual deformity Hemorrhaging, swelling, muscle spasm Elbow Injuries: Fractures Management Monitor neurovascular status Non-surgical treatment • Appropriate for stable fractures • Immobilize with cast or removable splint for 6-8 weeks Surgical treatment • Used to stabilize unstable fractures in adults • ROM exercises initiated early to prevent frozen elbow Elbow Injuries: Volkmann’s Contracture MOI = impaired circulation or ischemia Associate with humeral supracondylar fractures Compromises the brachial artery and inhibits circulation to forearm May be loss of motor and sensory function • Classic case involves median nerve Elbow Injuries: Volkmann’s Contracture Signs and Symptoms Pain in forearm which increases with PROM finger extension Cessation of brachial and radial pulses Coldness in arm Decreased ROM Management Monitor neurovascular integrity