Elbow and Forearm Disorders
PTA 104 Orthopedic Dysfunctions

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

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Elbow and Forearm Complex

Objectives

Describe the mechanism of injury for common conditions for the elbow and forearm
Select appropriate interventions and exercises based on the the tissue healing stage, precautions and contraindications for elbow and forearm conditions

Functional Anatomy

The elbow-forearm complex is comprised of the humeroulnar, humeroradial, and radioulnar joints. The majority of joint stability comes from the humeroulnar joint. Upper extremity mobilty for agility, reaching, and manipulating objects required functional range of motion within this complex.

Functional range of motion (ROM) is 30-130 degrees at the elbow and a combined 100 degree in the forearm, equally distributed

Anatomy and Kinesiology Review Videos(Approximately 8 minutes, and 4 minutes respectively)

Ligaments

The ligaments and joint capsule are primary sources of joint stability

medial collateral ligament - also called ulnar collateral ligament, is a complex of three ligaments that form a fan: anterior, posterior, and transfer. It's role is to protect against valgus forces throughout the range of motion
lateral collateral ligament - also called radial collateral ligament, intersects with the annular ligament, which provides stability against varus stresses
annular ligament - stabilizes and controls the position of the radius with respect to the ulna and the humerus during elbow and forearm activities

The interossesus membrane provides stability between the radius and ulna during pronation and supination motions

Videos for Varus and Valgus Tests (Approximately 4 minutes)

Muscles, bones, and motions

Check your muscles that flex and extend the elbow, and pronate and supinate the forearm.

Components of an Elbow PT Exam

Christina narrates a Elbow PT Exam

Observation and Inspection

Posture (carrying angle, scapula position)

Functional use of arm during gait and ADLs

Soft tissue: atrophy, symmetry, swelling

Skin

Joint testing: hypomobility and hypermobility

AROM/PROM and overpressures

Accessory joint motion (distraction, medial-lateral and dorsal-ventral glides)

Mobilization with Movement

Manual Muscle Testing

Motor Function and Control

Muscle length

Palpation

Neuromuscular tests (light touch, DTRs, upper limb tension tests)

Special tests

median nerve (pinch grip, pronator syndrome, Tinel's)

valgus extension overload

thoracic outlet syndrome

pulses (brachial)

cervical screen (C5-T2 pathologies can refer to the elbow)

Review of images (if available)

Common Soft and Connective Tissue Conditions

Strains and Ruptures

Muscle strains of elbow flexors and elbow extensors can evolve over time with overuse, or can present suddenly with sudden forces to the joint. Tendons can rupture completely, which produces signficant bruising and a sudden loss of elbow strength and elbow and forearm function. Athough distal biceps and tricep tendon ruptures are rare, overuse and improper lifting techniques may result in rupture and loss of elbow function.

A PTA should be mindful of providing the appropriate exercise interventions, specifically when adding resistance or weight to the distal end.

Medial Epicondylitis - Medical elbow tendinopathy

Monica Bonvicini, Hammering out (an old argument).jpg

onset is associated with faulty mechanics (e.g., with throwing, golfing, swimming) and with repetitive use (e.g. with hand tools)
repeated microtrauma to medial flexors and pronator tendon leads to tendon overload and failure
primary muscle involved: flexor carpi radialis, pronator teres; some involvement of palmaris, flexor carpi radialis, and flexor ulnaris

Video approximately 2 minutes

Lateral Epicondylitis - Lateral Elbow Tendinopathy

7% of all sports injuries (most common injury in elbow and forearm)
presents most often in age 35-50
tendon degeneration due to microtrauma from hyperpronation
high risk for chronic pain and dysfunction due to soft tissue changes from repetitive overuse/chronic inflammation
can be a misdiagnosis: some evidence of referred cervical pain, peripheral nerve entrapment, bony changes or myofascial pain syndromes presenting with similar pain patterns

Videos approximately 4 minutes

Triceps Tendinitis

rare
sudden severe strain (javelin, tennis, volleyball)
may evolve into a "snapping triceps" over posterior medial aspect of elbow due to subluxation or dislocation of portion of triceps and/or ulnar nerve
incidence can be associated with decreased triceps flexibility

Medial Collateral Ligament Injuries

Valgus Overload Triad

serious injury in the overhead athlete (baseball, javelin, racquet) involving the posterior medial joint capsule, the ulnar nerve, and the ulnar ligament (MCL)
may also result from traumatic valgus strain during fall on outstretched hand
ligament tears, tendon avulsions, tendinitis and bony changes may result
in children, overload forces can result in asymmetric growth changes and disruption (e.g. stress fracture) to the growth plate (Little Leaguer's Elbow)

Summary of Common Soft and Connective Tissue Conditions

Diagnosis	Common Description	Involved Structures	Contributing Factors	Signs and Symptoms
Medial epicondylitis	Golfer's Elbow	Wrist flexors (common flexor tendon) and forearm pronators	Poor mechanics with sports and repetitive grip	Pain with resisted wrist flexion and forearm pronation; pain with passive wrist extension and supination; pain on medial epicondyle
Lateral epicondylitis	Tennis Elbow	Wrist extensors (ext. carpi radialis brevis origin) forearm supinators	Overloading with sport and leisure activities involving grip and pronated grip	Pain with resisted wrist extension with elbow extension; pain with grip, pain in lateral epicondyle
Triceps tendinitis	Posterior Tennis Elbow	Triceps insertion; ulnar nerve	sudden strain to triceps in full arm extension	Pain with resisted elbow extension; snapping sensation with elbow flex/ext on posterior medial elbow
Valgus Overload Triad		MCL, post-med joint capsule, ulnar nerve	trauma; overuse in athletics	Pain and instability with valgus testing
(Epiphyseal Injury)	Little Leaguer's Elbow	Accelerated growth of medial epicondyle; ulnar hypertrophy	Overuse in throwing with strain to growth plate region in proximal forearm	Pain and tenderness with loss of full extension
Olecranon bursitis	Student's Elbow	Olecranon bursa, may include ulnar nerve	Mild, repetitive pressure; weight bearing on elbows	Swelling on posterior aspect cyst-like appearance, may include point tenderness in affected area

Treatment:

Protect: immobilization, rest, ice, modalities, submaximal isometrics, cross fiber massage. Splinting and/or use of a sling often follows acute injury to prevent loading through use of the hand
Controlled motion: assisted and self-stretching, cross fiber massage, joint mobilization and MWM, resisted isometrics, progressive functional strengthening patterns
Return to function: sport and activity specific, plyometrics
Patient education to prevent recurrence with modifying lifting, hitting carrying and HEP for injury management and prevention

Common Bony and/or Articular Conditions

Osteoarthritis and rheumatoid arthritis, dislocation and history of fracture are factors which may lead to progressive loss of function and/or surgical intervention

Myositis Ossificans (MO) & Heterotopic Ossification (HO)

Bone spontaneously lays down into muscle (MO) or in surrounding areas or joint space (HO) following blunt trauma or fracture
Idiopathic onset associated with traumatic brain injury
Presents as red, hot, swollen, marked painful motion
Active and passive ROM is encouraged and may require spinting.
MASSAGE, PASSIVE STRETCHING AND RESISTIVE EXERCISES ARE CONTRAINDICATED

Internal Derangement

periodic locking of joint due to loose bodies in joint
results in loss of end-range flexion and extension which gradually resolve; repeat occurrences and predispose OA changes
in adolescents: associated with trauma (chip fracture) or osteochondrosis
in adults: cartilage fractures due to trauma and becomes a loose body (treated with joint manipulation); may need arthroscopic removal
in mid-age to elder: fragments are more numerous: may result in longer periods of limted motion

Subluxation of the Radial Head

"Nursemaid's Elbow" or "Pulled Elbow": sudden traction injury
Child is lifted up suddenly by the arm while it is held over their head in a pronated and extended position
Presents with painful inability to use arm and avoidance of supination
Generally resolves with short term immobilization

Trauma

sprain/strain to joint capsule (likelihood increases with RA)
traumatic ulnar dislocation
fracture (radial fracture is most common elbow fracture)
may result in post-immobilization capsular tightness and loss of motion, especially with closed reduction of a fracture
may result in progressive osteoarthritis or joint replacement
displaced fractures may require surgery with hardware and/or removal of bone
should be taken with stretching if there is a bony block to ROM; overstretching can lead to hypermobility

Elbow Dislocation

Elbow subluxation and dislocation can have long-standing secondary effects associated with nerve trauma and heterotopic ossification. Uncontrolled swelling can result in disability that includes the wrist and hand.

Patients are typically placed in a posterior splint for up to 2 weeks and then begin gradual ROM and strengthening of surrounding structures to progressively add stability while ROM is progressively increased.