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

Elbow and Forearm Disorders