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Upper Arm, Elbow, and Forearm Conditions Anatomy Anatomy Cont’d… 3 articulations (single capsule) – Humeroulnar (elbow joint) – Humeroradial – Proximal radioulnar Carrying angle – Angle between humerus and ulna (arm in anatomic position) – 10-15° angle – Greater in females Anatomy Cont’d… Ligaments – Ulnar (medial) collateral – Radial (lateral) collateral – Annular Anatomy Cont’d… Bursae – Several small – Olecranon bursa Superficial Anatomy Cont’d… Anatomy Cont’d… Anatomy Cont’d… Nerves – Musculocutaneous – Median – Ulnar – Radial Anatomy Cont’d… Muscles – Flexors (at the humeroradial and humeroulnar joints) Brachialis; biceps; brachioradialis Effectiveness depends on supination/pronation position – Extensors (at the humeroradial and humeroulnar joints) Triceps; anconeus – Pronation and supination (at the proximal radioulnar joint) Pronator quadratus; pronator teres; supinator; biceps Kinematics Non–weight bearing but still sustains significant loads Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises Injury Prevention Protective equipment – Pads – Braces Physical conditioning – Flexibility and strength – Focus on entire arm Proper skill technique – Throwing – Falling Contusions Susceptible due to: – Lack of padding – General vulnerability S&S – Rapid swelling – can limit ROM Chronic blows – Development of ectopic bone Tackler’s exostosis – Painful periostitis and fibrositis may develop Management: standard acute; NSAIDs Olecranon Bursitis Acute and chronic – Mechanism Fall on a flexed elbow Constantly leaning on elbow Repetitive pressure and friction – S&S Tender, swollen, relatively painless Rupture – goose egg visible 50% history of abrupt onset; 50% insidious onset over a few weeks Motion limited at extreme of flexion – tension increases over bursa – Management: standard acute; NSAIDs; possible aspiration Sprain Mechanism – FOOSH - Fall on outstretched hand (hyperextension injury) – Valgus or varus force – More common; repetitive forces irritate and tear ligaments, especially UCL Ulnar nerve may also be affected S&S – Localized pain – Point tenderness – Instability with stress test Management: standard acute Dislocation Proximal radial head – Adolescents: often associated with immature annular ligament – Due to: longitudinal traction of an extended and pronated upper extremity – Inability to pronate and supinate pain free warrants immediate physician referral – Immobilization for 3-6 weeks in flexion is usually necessary Dislocation Ulnar dislocation – Younger than 20 years old – Mechanism: Hyperextension Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral – Associated conditions fractures of the medial epicondyle, radial head, coronoid process, and olecranon process disruption of the anterior capsule tearing of the brachialis muscle injury to the ulnar collateral ligament Dislocation Cont’d… – S&S Snapping or cracking sensation Severe pain, rapid swelling Total loss of function Obvious deformity Arm held in flexion, with forearm appearing shortened Olecranon and radial head palpable posteriorly Slight indentation in triceps visible just proximal to olecranon Nerve palsy – Management: immediate immobilization in vacuum splint; activation of EMS Strains Flexors and pronator teres – Repetitive tensile stresses Extensor – Decelerating type injury S&S – Typical muscle strain S&S – Self-limiting Management: standard acute Triceps Brachii Rupture Mechanism: – Direct blow to posterior elbow – Uncoordinated triceps contraction during a fall 80% involve olecranon avulsion fracture S&S – Pain and swelling in distal attachment – Palpable defect in the triceps tendon or a stepoff deformity of the olecranon – Active extension weak – partial tear; nonexistent – total rupture Management: standard acute; immobilize in sling; immediate physician referral Overuse Conditions Medial epicondylitis (aka – Little League Elbow) – Due to repeated valgus forces during acceleration phase of throwing motion – Commonly involved tendons: pronator teres and flexor carpi radialis – S&S Swelling, ecchymosis, and point tenderness at humeroulnar joint or over the flexor/pronator origin Severe pain; aggravated by: Resisted wrist flexion and pronation Valgus stress applied at 15-20° of elbow flexion Ulnar nerve involved – tingling and numbness – Management: ice; NSAIDs; sling immobilization for 2-3 weeks with wrist in slight flexion; therapeutic exercise Overuse Conditions Cont’d… Lateral epicondylitis (aka – Tennis Elbow) – Due to eccentric loading of extensor muscles (especially extensor carpi radialis brevis) during deceleration phase of throwing motion or tennis stroke – Contributing factors – S&S Pain anterior or just distal to lateral epicondyle; may radiate into forearm extensors during and after activity Repetition produces pain that becomes more severe and ↑ with resisted wrist extension – Management: ice; NSAIDs; rest; support Overuse Conditions Cont’d… Ulnar nerve Entrapment – Vulnerable to compression and tension – S&S Shocking sensation (medial elbow), radiating as if “hitting their funny bone.” + Tinel sign – ulnar groove (tingling and numbness of medial forearm into ring and little finger) Pain not present, ROM is not limited Grip strength may be weak Fractures Olecranon – Direct blow – Triceps tension pulls bone fragment superiorly – Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention Ulna (forearm fracture) – Direct blow – Also known as “nightstick” fracture Assessment History Observation/inspection – Carrying angle – Position of function Palpation Physical examination tests Assessment Cont’d… AROM – – – – – – Elbow flexion Elbow extension Supination Pronation Wrist flexion Wrist extension AROM AAROM PROM RROM ROM (cont.) Special Tests Ligamentous instability – Valgus stress – Varus stress **Test at multiple angles Special Tests Common extensor tendinitis (lateral epicondylitis) – Resisted extension and radial deviation of wrist – Passive stretching of wrist extensors – Resisted extension of extensor digitorum communis in middle finger with wrist extended Common flexor tendinitis (medial epicondylitis) Special Tests (cont.) Tinel’s sign for ulnar neuritis Rehabilitation (cont.) Restoration motion of – Use of opposite hand to supply load – UBE Rehabilitation (cont.) Restoration of proprioception and balance – Closed-chain exercises Muscular strength, endurance, and power – Open-chain exercises – PNF-resisted exercises Cardiovascular fitness