Elbow and Forearm Disorders
PTA 104 Orthopedic Dysfunctions

tennis-elbow.jpg

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.

Contact howardc@lanecc.edu for permissions

 

Elbow and Forearm Complex

Objectives

 

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

Reading Tips

Skim p. 407-414. This should be review from PTA 133/133L. Do note Key Point on 409 about ADL ROM

 

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

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

These should be review from Anatomy and Physiology and Kinesiology

 

Components of an Elbow PT Exam

Podcast of 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)

Check the sidebar for links to resources regarding elbow conditions

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.

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

Medial Epicondylitis

ans7_golfer_elbow.jpg Monica Bonvicini, Hammering out (an old argument).jpg

Video approximately 2 minutes

 

Lateral Epicondylitis

Videos approximately 4 minutes

Triceps Tendinitis

Medial Collateral Ligament Injuries

Valgus Overload Triad

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:

 Toggle open/close quiz question

 Toggle open/close quiz question

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

Internal Derangement

Subluxation of the Radial Head

Trauma

 

 

Elbow Replacement

elbow prosthesis.jpg

Indicated with severe elbow pain and/or marked instability; most commonly seen in patients with RA

Three Potential Complications after Total Elbow Arthroplasty

  1. Joint instability
  2. Triceps insufficiency
  3. Implant loosening
    1. PTAs are expected to be able to recognize and communication signs and symptoms of hardware complications

 Hyperlink to Crossword Activity 

General Interventions Non Operative Conditions

 

Protection

Controlled Motion

Return to Function

 

Range of motion

Passive or gravity assisted; includes shoulder and wrist/hand

Progressive flexion, extension, pronation and supination; may include stabilization for supination and pronation

Transition to stretching for ROM maintenance

 

Soft tissue integrity

Immobilize with sling or splint; support with Kinesiotaping or rigid taping

Gentle soft tissue mobilization with progression to transverse friction massage

 

 

Joint mobilizations

None or Grade I-II for pain relief only

Passive accessory mobilizations, may progress to Grade III depending on stability

Mobilization with movement techniques

 

Pain management

Ice, physical agents, bracing and taping

 

 

 

Stretching

Gravity and/or weight assisted

NO STRETCHING IF HISTORY OF DISLOCATION or post-op

PNF stretching, contract relax,

EASY INTO RESISTANCE IF HISTORY OF DISLOCATION

Independent with stretching program

 

Therex

Submaximal isometrics; gravity-assisted or assisted motion in mid-ranges

Multidirectional isometrics; active range against gravity for open chain wrist, forearm and elbow motions; initiate partial weight bearing exercises and progressively load to patient tolerance

Scapular and cervical stabilization as needed

Progressive strengthing with resistance with arm position at side, extended forward, and overhead/push/pull; throwing, and swinging training for return to sport

 

Body mechanics

Modify or decrease gripping; scapula setting activities and chin tucks if wearing sling to decrease postural strain

Observe patient movements in self-identified functional limitations; integrate activity breaks during day to prevent overuse

 

Assess work station or home activities as needed to prevent overuse and/or recurrence

 

Rehab Considerations Following Trauma

Close care and attention must be taken to restore as much mobility as possible, but to avoid placing excessive pressure on healing structure. Close proximity of the ulnar and radial nerves to articulating surfaces and fracture areas can put patients at risk for dysethesias and nerve dysfunction. There are risks for compartment syndrome and related ischemic disorders following elbow and forearm trauma, which should be carefully monitored.

Following dislocation, patients are often constrained by a hinged brace. Motion is submaximal isometrics, assisted shoulder motions to prevent strain to elbow, and wrist and hand conditioning, followed by progressive ROM in a partial range (15-90 degrees). Due to dislocation and reinjury risk, stretching is introduced after strengthening, to prevent adding laxity to the healing joint.

End of Lesson