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Elbow Disorders
Kim Kraft, PT, DPT, CHT
St Louis, MOApril 27-29, 2018
AgendaEvaluation/Special TestsEvaluation/Special Tests
Elbow PathologyElbow Pathology
• Ligamentous Injury
• Lateral Collateral Ligament Complex
• Medial Collateral Ligament Complex
• Dislocations
• Fractures
• Elbow trauma
• Total elbow replacement
• Tendinous
Elbow Evaluation
Elbow Exam1. History
2. Visually inspect the front, side and back of both elbows to compare symmetry
3. Look for edema, ecchymosis, bony misalignment
4. Normal carrying angle is slight valgus
5. Ask patient to extend/flex and sup/pro bilaterally
6. Take PROM if AROM is incomplete
7. Resisted Tests
8. Special Tests
9. Palpate for temperature and tenderness
Outcomes Measures
Name
American Shoulder and Elbow Surgeons Form
Disabilities of Arm, Shoulder, and Hand
Elbow Self‐Assessment Score
Oxford Elbow Score
Patient Rated Elbow Evaluation
QuickDASH
• Examiner places one hand on medial elbow, the other on distal radial wrist and applies medial force to wrist
• Two positions: full extension and up to 30 degrees flexion
• Positive if painful or more lax than contralateral
• Charalambus & Stanley 2008
Varus Stress TestRadial (Lateral) Collateral Ligament
Kraft
Gravity Assisted Varus Stress Test
Kraft
Bend/straighten elbow in sitting or standingPositive if painful, popping, or grindingRamirez et al 2015
Push Up SignPosterolateral Rotary Instability (PLRI)
• Supinated forearm, elbow flexed 90 degrees, hands wider than shoulders
• Positive: apprehension, muscle guarding, dislocation
• Regan et al 2006
Kraft
This is the best I can supinate!
Stand Up Test/ Chair SignPosterolateral Rotary Instability (PLRI)
• Forearms supinated, elbows flexed 90 degrees and weight bearing as the patient pushes up from chair
• Positive: Apprehension, pain or instability
• Regan et all 2006Kraft
But my hands can’t point backward!
Lateral Pivot Shift
• Elbow in extension; examiner applies axial extension and valgus force to the elbow
• Positive: apprehension, dislocation
• O’Driscoll et al 1991• Charalambus &
Stanley 2008Kraft
Valgus Stress TestUlnar (Medial) Collateral Ligament
• Forearm pronation* disclaimer
• Apply valgus in 2 positions 0 and slightly flexed 5-30 degrees
• Azar et al 2000
• Also, moving Valgus test Kraft
Moving Valgus Stress Test
• ER humerus at 90 abduction
• Examiner places a constant valgus stress on the elbow as it is moved 90-30 at the elbow
• Rahman et all 2008
Milking Test
• Which ligament?• Elbow flexed 70
degrees; forearm supinated
• Clinician applies valgus force by applying force to the thumb
• Safran 2004 Kraft
Hook TestDistal Biceps Integrity• Try it!• Palpate distal
biceps tendon in the elbow crease
• If tendon is found, the test is negative
• O’Driscoll et al 2007
Kraft
Squeeze TestDistal Biceps• Try it on a buddy!• Squeeze belly of
biceps
• Watch for slightflexion or elbow with pressure
• Ruland et al 2007
Bicep Squeeze
Marik
Cubital Tunnel Tests
Marik
Test Sensitivity/Specificity
Wartenberg’s sign: Abduction SF
?
Palpation Ulnar Groove ?
Tinel’s Sensitivity 54‐70%Specificity 98%
Elbow Flexion Sensitivity 75%Specificity 98%
Pressure Provocative Test(30 seconds compression ulnar nerve with sustained elbow flexion)
Sensitivity 46‐91%Specificity 99%
Scratch Collapse Sensitivity 69%Specificity 99%
Froment’s Sign ?
Cheng et al 2005, Novak at al 1994
Cozens (resistance)
Mills (stretch)
Lateral Tendinopathy Tests
Marik
Grip Strength: Elbow Flexed vs Elbow Extended
Kraft
Maudsley’s 3rd Finger Resistance• Base of the third
metacarpal is the insertion of the ECRB
• Positive: pain and/or weakness
• Nirschl & Ashman 1992
Kraft
• Painful palpation• Area of shear, poor
perfusion
• Versus radial tunnel
• Placement of Counter Force Brace
Marik
Palpation Lateral Epicondyle
Handshake
• Patient elbow extended
• Wrist neutral
• Positive: reproduction of pain
• Kraushaar & Nirschl 1999
Fractures
• Olecranon
• Radial Head
• Coronoid
Instability
• Lateral Collateral Ligament Injury
• PLRI
•Medial Collateral Ligament Injury
• Complex Instability (Fracture)
Tendinopathy
• Lateral
•Medial
• Bicipital
Other Pathologies/
Complications
• Osteochondritis Desiccans
• RA/OA/TEA
• Olecranon Bursitis
Elbow Diagnoses
Fractures
Elbow Fractures
Associated with traumatic event• Clear onset• Probable edema• Acute pain• Tender to palpation• X-ray confirms diagnosis
Types• Olecranon• Radial Head• Coronoid
Elbow Fractures
Stiffness is a major concern after elbow fractures (ESPECIALLY intraarticular) Early motion is important.
A/AAROM until healed, usually 6 weeks• Nondisplaced fractures start motion right away• Surgical reduction: initiation of ROM depends on
stability of the fixation • Progress to PROM and static progressive splinting
if needed once fracture is healed
Complications include: instability, non-union, post-traumatic arthrosis, heterotopic ossificans
Olecranon Fracture
• Geriatric Injury• Mechanism: Posterior fall
• Wire Fixation Most Common• Almost 99% of the time, wires/hardware
removed ultimately• ?Ulnar nerve entrapment in scar or callus
Olecranon FracturesConservative Care
0‐3 weeks
• Post Op long arm Bulky
3‐6 weeks
• Long arm splint
• AROM elbow 0‐90, forearm, wrist
• Compression
6‐7 weeks
• Unrestricted AROM
• Splinted between exercises and at night
Diagnosis and Treatment Manual 2001
Olecranon FracturesPost-Op
0‐2 weeks
• In post‐op Bulky Long Arm
2‐6 weeks
• AROM; initially just 0‐90 degrees
• Possible static progressive orthosis
6 weeks post‐op
•May begin PROM depending on films
8 weeks
• Progressive splinting
Diagnosis and Treatment Manual 2001
Radial Head Fractures
• Mechanism: ProFOOSH, direct blow/lateral force, hyperflexion
• Usually non-displaced/Type 1= conservative care
• Mason-Johnston Classification• Type 1: Non displaced• Type 2: Displaced• Type 3: Comminuted (smashed)• Type 4: Fracture/dislocation
• Replacement Criteria• Types 2-4 or LCL injury at the same time
• Development of lamellar bone in non-osseous tissue; characterized by progressive loss of ROM
• Associated with head injury, burns, other ossifying disorders (ankylosing spondylitis, for example)
Radial Head Fracture Heterotopic Ossification
Literature Review
1. Radial head fx
2. Distal DRUJ dislocation
3. Disruption of interosseous membrane
DRUJ may be pinned (supination) for 6 weeks to allow IM to heal
(Radial head excision is contraindicated ; proximal migration of radius due to insufficiency
of IM; may have radial head replacement)
Essex-Lopresti Fracture
Coronoid Fractures…Terrible TRIAD!
• Posterior dislocation of ulnohumeral joint
• Coronoid fracture
• LCL rupture
Surgery: Anterior capsule repair, radial head replacement (or fixation), Lateral Collateral Ligament repair
Avoid: varus stress to elbow during healing (shoulder AB, IR)
Literature ReviewPatient selection: no indication for radial or coronoid fracture fixation, no intraarticular fragments, has 60 pro and sup, stable ulnohumeral joint up to 45 degrees
11-140 degrees; DASH around 5 after 30.6 month follow up of 10 patients
Instability
Static Elbow StabilityResistance to: Structure 0⁰ Elbow Extension 90⁰ Elbow Flexion
Valgus stress Medial (Ulnar) Collateral Ligament
31% 54%
Anterior Capsule 38% 10%
Bony Articulation 31% 36%
Varus Stress Lateral (Radial) Collateral Ligament
14% 9%
Anterior Capsule 32% 13%
Bony Articulation 55% 75%
Distraction Anterior Capsule 70% Minimal
Medial (Ulnar)Collateral Ligament
5% Primary
Morrey 2005, Morrey 1983
Dynamic Elbow Stability
• brachialis, biceps brachii, pronator teres, FCR, FCU, palmaris longus, Humeral head of FDS
Ulnar Side:
• brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis
Radial Side:
• triceps
Posterior:
Muscles crossing the elbow add compression, some medial/lateral support, can be used to add stability to an unstable elbow
Elbow Ligament Injuries
Described as simple or complex• Simple = no associated fracture• Complex = concurrent fracture
Post-reduction considerations• Elbow may be stable in a limited range of motion or
specific positions• Elbows get stiff quickly when not moving through full
range of motion• Dynamic stability provided through compressive forces
of muscles crossing elbow allows early AROM
(Eygendaal 2011, Haan 2011)
Figure 1
Instability Rehab Principles
Overhead supine AA flexion / protected
extension –forearm supination
Forearm rotation at 90° flexion
Overhead supine AA flexion / protected
extension –forearm pronation
SternLiterature Review
Lateral (Radial) Collateral Ligament Injury
Mechanism of injury • Generally Traumatic• Fall on outstretched hand (FOOSH)• Forced twisting of the arm with varus
(lateral) forces• Repeated Varus stress: example
malunion as child, Gunstock deformity (decreased carrying angle), crutch users
• Treatment for Lateral Tendinopathy, radial head fracturesDynamic Varus SupportsCommon extensor origin, capsule/annular ligament
Pixabay
Lateral Collateral Ligament Injury Considerations
Position of Stability: Pronation and Flexion
Pronation stabilizes the LCL through E/F arc.
Flexion and Pronation increases the contact between the Capitellum and Radial Head
Testing: Varus stress test with the ligaments in a LAX position – testing LCL should be done in supination where it will be most unstable…treatment will be done in PRONATION for stability
Treatment Principle: Avoid positions of shoulder AB and IR which cause varus stress to the elbow AND avoid supination
Armstrong 2000, Dunning 2001
1. Splint 90° flexion, pronatedPrefabricated vs. Custom LAS
2. AROM extension/flexion; extension limited to 60° initially and gradually increased
3. Forearm rotation from pronation to neutral only for 6 weeks (no supination)
4. Immobilization period varies from 2 to 12 wks;
5. Gradually resume supination6. Return to sport at 6 to 9 mo post-op
AliMed
Lateral Collateral LigamentRehab Principles
Posterolateral Rotatory Instability (PLRI)
• Can result from a FOOSH with forearm supinated
• Leads to ulna (moving with radius due to annular ligament) externally rotating away from trochlea Radsource:
http://www.radsource.us/clinic/0901
• C/o clicking, snapping, clunking, locking, “giving way”
• Usually occurs with slight elbow flexion and partial supination
• May have history of elbow sprain• Progressive condition with increasing loss of
function due to elbow instability• Requires LCL reconstruction• Clinical Tests: Pivot shift, push up sign, chair
sign, press up maneuver
PLRI Symptoms LCL SurgeryRepair Vs. Reconstruction • Not all tears are repaired; sometimes they are left
to heal on their own
• This can lead to chronic instability
• Ligament repair can occur if surgery is performed within 2-3 weeks of injury
• Ligament reconstruction is chosen if injury is more than 3 weeks old
• Palmaris longus is usually used for reconstruction
• Great outcomes with reconstruction; usually open repair (not arthroscopic)
LCL Reconstruction
Sanchez et al
Mechanism: Traumatic/clear onset/”pop” and pain
vsGradual progressive (Thrower’s elbow)
Testing: (pronated) Valgus Stress Test, Moving valgus, Milking maneuver
Little League ElbowOnset may be vague, characterized by failure to perform at less than normal ability:
Decreased accuracyDecreased velocityDecreased endurance
Medial (Ulnar) Collateral Ligament Injuries
Medial (Ulnar) Collateral Ligament InjuryConsiderations
• Dynamic support from flexor/pronator group• Can be associated with radial head fracture or lateral
HU/Olecranon degeneration (by compression)• If no specific “pop” or rupture is noted, conservative
management consisting of strengthening the muscles surrounding the joint is pursued.
• If surgery is required, ligament repair may be possible in nonprofessional athletes
• Most professional athletes require ligament reconstruction, aka “Tommy John” , Docking procedures.
• Check out Ulnar nerve (traction)
• Protect: rest from overhead activity
• Splint: LCL injury in pronation
MCL injury in supination
Both MCL/LCL injured: in neutral rotation
• Early exercise can include these to increase joint stability:• Isometric elbow extension and flexion• Resisted wrist extension and flexion
• Strengthening- core,plus…• Dynamic Stabilizers can help!• Thrower’s Ten Program for shoulder, elbow, forearm,
and wrist
• Evaluation of throwing/serving/etc technique
Elbow Ligament Rehab Principles
Post-operative management of MCL injury• Splint in neutral rotation or supination, 90° flexion
• Active elbow extension and flexion, with full extension limited initially
• AROM digits and wrist; ok to grip
• Isometric strengthening of shoulder. No external rotation of shoulder as it creates valgus stress at elbow
• Splint D/C’d at 6 weeks
• Progress through full ROM and into Thrower’s Ten
Post-Tommy JohnLigament Injuries with Fracture and Dislocation
Galeazzi: Radial shaft fracture with dislocation of distal radial ulnar joint, IOM
tear assumed
Essex Lopresti: Ulna shaft fracture and dislocation of the radial head, IOM
tear assumed
Complex Ligament Injury
radiopaedia.org
Tendinopathy
Elbow TendinopathyClinical Exam• Palpation, Tension,
Resistance of: tendons in the area patient reports painful
• Always compare to contralateral, *chief complaint
Mechanism: often an event involving a sudden eccentric load to biceps while it is contracting.
Exam:• Palpate at elbow crease and just distal• Resist supination • Resist elbow flexion with forearm supinated• Hook Test, Squeeze Test – Supinate forearm,
examiner “hooks” finger under the biceps tendon on the lateral side. Positive if tendon is not felt
• Consider partial tear-terrible prognosis=painful
Biceps Tendinopathy Distal Biceps Rupture
• The Popeye• Men aged 40-60• Smokers (7.5 times more
likely)• ~30% loss of flexion strength• ~40% loss of supination
strength• Diagnosis can be confirmed
by MRI or USMarik
Distal Biceps Rehab Principles
Non-operative - Patients should expect to recover more of their flexion strength than supination strength
Rehab focus:• Pain management• AROM as able without significant pain• Strengthening when pain has resolved
• Within 2-3 weeks to avoid retraction of tendon and scarring of tendon to humerus
• If greater than 70° flexion is required for tendon to reach radial tuberosity due to retraction, a tendon graft is performed: plantaris longus, long extensor to 2/3 toes, gracilis(Vastamaki & Vastamaki, 2008) or allograft (hamstring or achilles).
• One or two incision technique. The two-incision approach is associated with higher incidence of hetertopic ossification (HO) and radioulnar synostosis.
• Complications: LABC nerve irritation, PIN irritation, HO
Distal Biceps Repair Concepts
Distal Biceps Repair(Endobutton)0‐3 weeks po
• Hinged brace elbow 80 degrees and ideally supinated
• Hand ROM
• ACE wrap for edema
3‐6 weeks po
• Flexion AROM/PROM
• Supination/pronation
• 6 x per day ROM out of the splint
• Progress hinge 15 degrees per week
• PROM at 4 weeks
6 weeks po
• Hinged brace discontinued
• Light strengthening
• (2‐4#)
• Light use until 3‐6 months po
a.k.a.
• Tennis Elbow/Golfer’s Elbow• Lateral Epicondylitis• Lateral Epicondylosis• Lateral Epicondylagia• Lateral Epicondyopathy• Lateral Epicondyle Tendinopathy (LET)
• Is not just a tendonitis• Histology studies reveal a lack of inflammatory cells
• LET is, instead, a de-conditioned status of the ECRB origin, occasionally the EDC/ECRL, Even lateral triceps, episodic
Elbow Tendinopathy
Medial Elbow Tendinopathy
Golfer’s Elbow• Involves the origin of the flexor pronator
mass
• Aggravated by activities involving wrist flexion and grip
• Usually occurs in athletes with repetitive valgus and flexion forces
• 10% of epicondylopathy
Lateral Tendinopathy Tests(Medial Tests “Reverse”)Test Positive Sign
Grip Strength Pain reproduced or weakness
Cozen’s Test Pain reproduced
Mill’s Test Pain reproduced
Third Finger Resistance (Maudsley’s Test)
Pain reproduced
Handshake Test Pain reproduced
• Most often 30-50 year olds• c/o pain with
• Shaking hands (grip)• Opening doors (grip with varus stress)• Taking lids off jars (grip with varus stress)
• Victims are usually not tennis players• Usually progressive pain without sudden onset• Episodic• Self limiting?• Surgical candidate after a year of suffering…long
recovery (6 months+ but good outcomes)
Lateral/Medial Tendinopathy Tendinopathy Surgery
• Outcomes very good: 88-97% success rates
• Cock up splint 2-6 weeks
• Gradual AROM
• Return to sport 4-6 months This Photo by Unknown Author is licensed under CC BY-SA
Garg et al 2010Prospective RCT. N=44.
• 2 groups• Outcomes: Mayo Elbow Performance(MEP) and
American Shoulder and Elbow Society Elbow (ASES) Assessment Form
• Data collected at baseline and 6 weeks• Statistically significant reduction in pain with wrist
splint measured by ASES
Literature Review Literature Review
• Stasinopoulos, D., & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy, 30(1), 13-19.
Evidence Informed?
• Heat/massage for temporary pain relief and perfusion• Wrist immobilizer to reduce tension on extensors• Palm up/elbow flexed use of the arm• Coach through activities/problem solve ergonomics• Anti inflammatories for acute episodes• Light exercise to recondition/reperfuse• Proximal stability (parascapular muscles)• Progress to eccentrics to strengthen non-contractile
elements• Tool assisted STM
Osteochondritis Desiccans
• Adolescent pitchers, gymnasts
• Due to repetitive loading or weightbearing
• Subchondral bone disease due to vascular compromise; cartilage becomes loose bodies
• Especially affects capitellum
Creative Commons
ArthritisOsteoarthritis (OA)
• calcification of cartilage in joint spaces, osteophytes, loose bodies
• c/o pain, stiffness, decreased ROM
Post-traumatic arthritis (PA)• c/o locking and catching
Rheumatoid arthritis (RA)• Symptoms: pain, symmetrical
edema of multiple jointsPixabay
Population• RA• Older less active adults• Highly comminuted fractures
5# life time lifting weight limit30 degree flexion or more x 4 weeks post opPronation during early ROMConsiderations
• Status of triceps (and bone stock)• Ulnar nerve – may react to prolonged elbow flexion
during post-op period• Incision – RA may take longer to heal
Total Elbow Arthroplasty
Total Elbow Arthroplasty
Questions: 1. Was the Ulnar nerve transposed?
2. How was the triceps handled?3. What are the forever limitations?
3 Types(May be inflammation, infection, or both)• Aseptic: trauma or pressure at olecranon• Septic: Cellulitis or wound nearby. Infection
can lead to osteomyelitis.• Chronic: related to Gout/pseudogout• Treatment: NSAIDS, compression/cushion
• Sometimes aspirated• Antibiotics if indicated
Olecranon Bursitis
Snapping Elbow ProblemsPlica Syndrome
Ulnar nerve• Subluxes over medial epicondyle• Usually at 90° elbow flexion
Medial head of triceps• Subluxes over medial epicondyle• Occurs during elbow extension and flexion – usually at
~110° flexion
Intra-articular loose bodies• Can be bony or cartilaginous• Elbow may “get stuck” when attempting motion• X-rays helpful if bony• Arthroscopic removal
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