Selected Techniques for Evaluation and Treatment of the Elbow

1
Selected Techniques for Evaluation and Treatment
of the Elbow

• Lynne Sturgill PT, DPT,OCS

2
Introduction

• Elbow
• HUJ
• HRJ
• Sup RUJ
• Coupled with Inf RUJ
• Pathology
• Trauma
• Overuse
• Clear cervical spine!

3
Age-Related Disorders

• lt 8 Nursemaids Elbow
• lt10 Panners Disease
• 9-12 Little League Elbow
• 15-20 Osteochondritis Dissecans
• 35-60 Tennis Elbow
• gt 60 OA

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History

• Pain
• Paresthesia
• Loss of strength
• Loss of sensation
• Loss of ROM
• Locking of joint
• Sports

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Observation/Inspection

• Swelling

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Observation/Inspection

• Normal Carrying Angle
• Males 10-15 deg
• Females 15-20 deg
• Should be symmetrical side to side (except for
  pitchers!)
• Cubitus Valgus
• Greater than normal angle

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Observation/Inspection

• Cubitus varus
• gunstock deformity
• Decreased carrying angle

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Evaluation

• ROM testing
• Ext/flex 0-150 degrees
• Sup/pron 0-80/90 degrees
• Last 10-15 degrees from radiocarpal jt
• Hyperext should be symmetrical
• normal up to 10 degrees in females
• ADLs
• 30-130 degrees 0-50 degrees pronation/supination

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Evaluation

• ROM testing
• End Feels
• Flex soft tissue approx
• Ext bone to bone
• Forearm pron/sup firm or tissue stretch
• Capsular Patterns
• HUJ limitation of flex gt ext
• HRJ flexgtext gtsupgtpron ( only if severe)
• Proximal RUJ sup, pron limitation
• Distal RUJ pron/sup painful at end ROM

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Evaluation

• Muscle Testing
• Resisted Isometrics
• Flex/ext
• Pron/sup
• Wrist flex/ext/UD/RD
• Flex/ext of fingers 2-5
• MMT
• Differentiate between ECRL/ECRB
• Grip Strength
• dynamometer

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Ulnar Collateral Ligament

• ACL of the Elbow
• Anterior band
• 1 restraint to valgus stress
• Palpate w/ elbow flexed 50-70 deg
• May contribute to limiting full ext
• Posterior band
• Oblique band

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Ulnar Collateral Ligament

• Valgus stability
• At 90 deg
• UCL 54
• osseous 36
• capsule 10
• Extension equal distribution

13
Radial Collateral Ligament

• Primary stabilizer against varus and
  postero-lateral instability
• Varus Stability
• 90 deg
• RCL 9
• Humeroulnar 75
• Capsule 13
• Instability uncommon unless dislocation

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Quick Screen UCL Tests

• Good Hands
• Milking Manuever
• Provocative tests
• Self-imposed valgus stress
• Unable to get a true sense of ligamentous laxity
  since not testing end feel
• Look for reproduction of pain

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Ligamentous Tests

• Valgus Stress Test
• Supine,sitting,prone
• Elbow slightly flexed to 20-30 deg
• Shoulder in ER
• 1 hand at elbow 1 hand above wrist
• ADD or valgus force applied at elbow
• Palpate joint line
• Assess end feel
• test pain and/or laxity

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Ligamentous Tests

• Varus Stress Test
• Supine, sitting
• elbow slightly flexed to 20-30 deg, IR shoulder
• 1 hand at elbow 1 hand above wrist
• ABD or varus force applied at elbow
• Assess end feel
• test pain and/or laxity

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Valgus Extension Overload Test

• Sitting or supine
• PT places patient arm in full extension, then
  applies valgus stress
• or apply valgus stress while moving into
  extension
• test posterior or posterior medial elbow pain

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Tests for Lateral Epicondylitis

• Cozens Test
• Patient asked to make a fist, pronate forearm,
  extend and RD wrist
• PT resists wrist ext and/or RD
• pain _at_ lateral epicondyle

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Tests for Lateral Epicondylitis

• Mills Test
• Patient asked to make a fist, pronate forearm
  flex and UD wrist and extend elbow
• Test can be done passively
• pain _at_ lateral epicondyle

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Tests for Lateral Epicondylitis

• Third Finger Resistance Test
• Resist extension of the third digit of the hand
  distal to the PIP joint
• pain _at_ lateral epicondyle

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Test for Medial Epicondylitis

• Golfers Elbow Test
• Patient asked to make a fist, supinate forearm
  extend wrist and extend elbow
• test reproduction of pain _at_ medial epicondyle

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Tests for Ulnar Nerve Dysfunction

• Tinels Sign
• Tap ulnar nerve as it lies in groove between
  olecranon process and medial epicondyle
• Tap 4-6X
• tingling distally in ulnar n distribution

Novak et al sens .70 specif .98 Kingery et
al sens .68 specif .76
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Tests for Ulnar Nerve Dysfunction

• Wartenbergs Sign
• Patient sits with hand resting palm down on
  table. PT passively spreads fingers apart and
  asks pt to actively bring fingers together
• test if pt unable to bring 5th digit towards
  4th secondary to interossei weakness

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Tests for Ulnar Nerve Dysfunction

• Elbow Flexion Test
• Patient is asked to fully flex elbow with wrist
  in extension and hold for 60 seconds
• test tingling/paresthesia in ulnar n
  distribution distally
• cubital tunnel syndrome

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Joint Play Assessment

• Test in OPP
• HUJ 70 deg flex, 10 deg sup
• HRJ elbow ext, max sup
• Prox RUJ 70 deg flex, 35 deg sup
• Distal RUJ 10 deg sup, wrist neutral with
  slight UD
• Hypo, hyper, normal ?

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Joint Mobilization

• Start in OPP progress into restricted ROM
• Grade 1 distraction 1st?
• Techniques may be altered !
• Put hands on patient Is this comfortable?
• Stabilization impt! Keep hands close together
• Belts to stabilize humerus

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Evaluation and Treatment of Selected Elbow
Pathologies

• Overuse Injuries
• Ligamentous Injuries
• Complications of Elbow Injury
• Nerve Entrapments

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Lateral EpicondylitisTennis Elbow

• Pathology
• Overuse injury to common extensor tendon
• Classic case involvement of ECRB origin
• Not typical inflamm response tendinosis
• Incidence
• 35-50 yo
• Female gt male
• Dominant gt nondominant
• Non-athletegt athlete
• Associated with many sports

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Lateral Epicondylitis

• Etiology
• Overload/overuse
• Work contribution
• Direct trauma
• Substitution syndrome
• Tennis?
• Racquet weight
• Grip
• String tension
• Poor backhand mechanics

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Lateral Epicondylitis

• Subjective
• C/o pain at lateral elbow
• Gradual insidious onset
• Weakness and pain with carrying items in hand
• Gripping activities may exacerbate
• Injection?

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Lateral Epicondylitis

• Clinical Findings
• Localized tenderness to epicondyle
• Resisted isometric wrist ext resisted
  supination, RD, ext of 2nd and 3rd fingers
• Decreased and painful grip
• Pain with passive wrist flex with elbow ext /-
  UD
• Cozens, Mills, 3rd Finger Resistance Tests ?
• Clear cervical spine
• Evaluate shoulder ER strength
• Joint problem?
• HRJ, sup RUJ

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Lateral Epicondylitis Treatment

• Relief of pain
• PRICEMM protection, rest, ice, compression
  modalities, meds
• Ionto, US, noxious
• Promotion of healing
• strengthening (eccentric?)
• stretching
• TFM
  Nirschl et al

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Lateral Epicondylitis Treatment

• Control of force loads
• Bracing, taping
• Improved fitting of equipment
• Control of intensity/duration of activity
• Improved ergonomics or technique
• Promotion of general fitness/conditioning
  
  
  Nirschl et al

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Lateral Epicondylitis Treatment

• Joint mobilization/manipulation
• lateral gapping/gliding HUJ
• posterior/anterior glide of Prox RUJ

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Lateral Epicondylitis Failed Treatment?

• Rule out Radial Tunnel Syndrome
• Rule out cervical spine
• Surgical consult ?

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Radial Tunnel Syndrome

• PIN compressed in Arcade of Frohse
• Increased symptoms with sup/pron
• Night pain
• Paresthesias/pain in hand and lateral forearm
• Test flex elbow to 90 deg, fully pronate
  forearm, resist supination
• Resisted extension of middle finger ?

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Radial Tunnel Syndrome

• Radial nerve neural tension test ()
• Palp radial head gt LE
• Decreased radial head mobility
• Can occur with lateral epicondylitis
• Treatment
• Conservative 3-6 months
• Rest, NSAIDS, Neurontin/Lyrica, splinting
• Modalities
• Neural glides
• Radial head mobs
• Surgical decompression last resort
• Usually worse with PT

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Guided by the Evidence ?

• Literature does not support many of the
  recommended physical treatments for lateral
  epicondylitis
• Injection short term benefits lt 6 weeks
  decreased pain, increased function
• Lack of evidence for ECSWT

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Guided by the Evidence ?

• Some support for
• Brace superior early on for ability of ADLs
• At 26, 52 weeks no difference
• Struijs et al
• Radial head mobilizations distinctive component
  responsible for improved outcomes
• Drechsler et al 1997
• Taping increased grip strength by 24
• Vicenzino, et al 2003

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Guided by the Evidence ?

• Autologous blood injections
• Patients with sxs at least 3 months some failed
  corticosteroid injection
• 2ml blood from opp arm mixed with lidocaine
• Injected ECRB
• 79 0/10 pain within 3 weeks f/u 9.5 months
• ? Inflamm from local tissue irritation or from
  some factors in blood
• Edwards et al 2003

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Medial EpicondylitisGolfers Elbow

• Pathology
• Tendinosis of FCR and pronator teres
• Secondary pathology to UCL sprain ?
• Incidence
• Less common than tennis elbow
• 40-60 yo men women
• 75 dominant elbow
• Recent increase in young throwers
• Seen with golf, tennis, racquetball,
  handball,baseball

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Medial Epicondylitis

• History
• Insidious onset medial elbow pain typically
  local
• Can have ulnar n symptoms
• Clinical Findings
• Tender common flexor origin
• Pain with resisted isometric wrist flex,
  pronation
• Resisted RD, UD, finger flex ?
• Golfers elbow test
• Ulnar nerve neural tension test ()
• Treatment
• Similar to lateral epicondylitis

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Little League Elbow

• Usually seen in 9-12 yo throwers
• Overuse injury repeated stress to medial
  epicondyle and or injury to growth plate
• Clinical findings tenderness, swelling,
  decreased elbow ext, valgus stress test
• Dx confirmed with x-ray
• Rx relative rest, pain management, education!

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Ulnar Collateral Ligament Injury

• Pathomechanics
• UCL primary stabilizer of elbow
• Severe instability occurs even if only ant band
  ruptures
• Valgus force on extended elbow during
  acceleration phase of throwing
• Chronic vs Acute

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Ulnar Collateral Ligament Injury

• Acute
• Pt reports audible pop followed by pain
• Ant and medial elbow pain
• Capsular pattern ?
• Valgus stress pain/laxity
• Pain with palpation of UCL
• Complete tear ant band of UCL
• Surgery?

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Ulnar Collateral Ligament Injury

• Chronic
• Vague onset of medial elbow pain
• Inability to perform _at_ 100 effort
• May present as medial epicondylitis
• Valgus stress ?
• May have ulnar n symptoms
• Harder to dx !
• Undersurface tear of anterior band between
  superficial and deep layers
• Conservative management vs surgery

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Ulnar Collateral Ligament Injury

• Conservative Management
• Acute phase
• Limit motion to 20-90 deg
• Isometrics for wrist/elbow mm can strengthen
  shoulder mm except ER
• Modalities to decrease pain/inflamm
• Sub-acute phase
• Isotonics for shoulder, elbow, wrist, hand
• RS
• Modified PNF
• Return to activity phase
• Plyometrics/interval throwing program/functional
  progression
• Biomechanical assessment

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UCL ReconstructionTommy John Surgery

• Palmaris longus tendon graft
• Graft woven through medial epicondyle and medial
  ulna in figure 8
• Ulnar n transposition?
• Restrict elbow ROM initially
• Avoid sh ER
• 12 months rehab

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Humero-radial Joint

• Gives some support against valgus stress
• ? Instability after excision of radial head

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Valgus Extension Overload

• Medial olecranon tip impinges against medial wall
  of fossa
• Result osteophyte formation on posteromedial
  olecranon, kissing lesion on fossa wall
• Seen in throwers

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Valgus Extension Overload

• S
• Posterior elbow pain during acceleration
• Gradual loss of control with early release
• O
• Tenderness over posteromedial olecranon
• Characteristic flexion contracture
• Pain with passive and active extension
• Resisted elbow extension /- ?
• Possible swelling
• Positive VEO clinical test
• Radiographs

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Osteophyte Excision
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Complications of Elbow Injury

• Myositis Ossificans
• Elbow Stiffness or Anklylosis

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Myositis Ossificans

• Pathology
• Brachialis
• Usually result of trauma or fracture
• Bone formation develops in muscle

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Myositis Ossificans

• Clinical Findings
• Hx of trauma
• Pain in anterior middle 1/3 of arm
• hyperemia, swelling, warmth
• Loss of motion
• Resisted isometric flex weak/painful?
• Palpate painful mass ?

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Myositis Ossificans

• Treatment
• NSAIDS, low-dose radiation ideal Rx ?
• May get spontaneous regression after 4-6 mo
• Surgical excision ?
• May result in permanent loss of ext gt flex
• Impt to prevent !
• Ant capsule vs mm ?
• Recommendation gentle PROM, low grade mobs,
  avoiding painful range Scalzitti 2003

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Elbow Stiffness or Anklyosis

• Why most frequent complication after elbow injury
  ?
• Little capsular laxity
• Ant capsule tends to scar down!
• Biceps spasm
• Common after fracture
• Soft tissue scarring
• Articular malalignment
• Excessive callus

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Elbow Stiffness or Anklyosis

• Treatment
• Joint mobilization
• Contract-relax
• Low-load prolonged stretching
• Soft tissue mobilization
• Dynamic splinting
• Prevention !

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Treatment to Improve Elbow Extension

• Active warm-up
• Thermal modalities with stretching
• Soft tissue mobilization
• Joint mobilization
• Contract-Relax techniques
• Passive stretching
• AROM exercises/strengthening into restriction
• Cryotherapy with low-load long duration stretching

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Treatment to Improve Elbow Extension

• Put your patient supine for ROM/stretching
• Stretching
• want long lever arm
• fulcrum under distal humerus
• biceps vs triceps strengthening?
• Home program
• Manipulation under anesthesia

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Nerve Entrapments

• Radial Tunnel Syndrome
• Cubital Tunnel Syndrome
• Anterior Interrosseous Nerve Syndrome

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Cubital Tunnel Syndrome

• S
• C/o medial elbow and forearm pain and
  paresthesias
• Weakness in hand
• O
• Abductor digiti minimi weakness
• Tinels
• Elbow flex test
• Wartenbergs sign
• Valgus instability ?
• Increased carrying angle ?

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Anterior Interosseous Nerve Syndrome

• AIN branch of median
• Entrapped as passes between 2 heads of pronator
  teres
• S Paresthesias in median n distribution
• O Weakness FPL, lateral ½ FDP, and pronator
  quadratus
• Abnormal pinch
• Pinch Sign