PTA 130Fundamentals of

Treatment IElbow & Forearm

Lesson Objectives

Identify key anatomical muscles and structures of the elbow and forearm

Identify common tissue injuries, conditions and surgical interventions

Introduce interventions for common injuries, conditions, and surgical procedures

Identify soft tissue specific mobilizations Identify flexibility, strengthening, functional,

and stabilization exercises

Anatomy Review - Muscles

Primary muscles involved in the following movements:◦Elbow flexion-

Brachialis, Biceps Brachii, Brachioradialis◦Elbow extension-

Triceps brachii, Anconeus◦Forearm pronation-

Pronator teres, Pronator quadratus◦Forearm supination-

Supinator, Biceps Brachii, Brachioradialis

Anatomy Review – Bones

The elbow joint is made up of:◦Distal end of the humerus◦Ulna◦Radius

Four joints involved in elbow and forearm function: ◦Humeroulnar◦Humeroradial◦Proximal radioulnar◦Distal radioulnar

Anatomy Review - Ligaments

The elbow joint has a lax joint capsuleThe elbow joint is supported by two major

ligaments◦Medial (ulnar) collateral

Provides support against valgus stresses◦Lateral (radial) collateral

Provides support against varus forces

Brachialis

Triceps Brachii

Pronator Teres

Elbow and Forearm Characteristics

Function is to position the handMost muscles crossing the elbow are two-

joint muscles◦Examples?

Biceps and triceps co-contract to provide weight-bearing stability to elbow

Elbow instability occurs primarily due to tears of the medial collateral ligament

Relationship of Wrist and Hand Muscles to the Elbow

The epicondyles of the humerus are attachment points for many of the muscles that act on the wrist and hand

The muscles provide stability at the elbow, but don’t contribute to motion at the elbow

Wrist Flexor Muscles◦Originate on the medial epicondyle

Wrist Extensor Muscles◦Originate on the lateral epidondyle

Kinematic Considerations

The elbow and forearm create coupled and patterned movement◦Elbow flexion with forearm supination

Biceps brachii and supinator Lift and carry functions

◦Elbow extension with forearm pronation Triceps brachii and pronator teres Push out and push down

Kinetic Considerations

The elbow is inherently stabile to support lifting and carrying ability◦When the elbow becomes injured, it is one of

the most difficult joints to restore full ROM◦When overloaded, the joint inflames and will

dramatically decrease ability to handle force

Forces at the Elbow

Lifting weights with elbow extended: ◦more stress anteriorly

Lifting weights with elbow flexed: ◦more stress posteriorly

Forces at the Elbow

Reducing Joint Forces

Lighter weights or cuffs attached to mid-forearm

Greatest compression forces in push-up position◦Widening hand position decreases force

Low-resistance, high-rep exercises are most appropriate early in rehabilitation program

Referred Pain and Nerve Injury

C5, C6, T1 and T2 nerve roots cross the elbow- ◦Symptoms are not usually isolated in the elbow

Nerve Disorders◦Ulnar nerve-

Compression at the cubital tunnel◦Radial nerve-

Entrapment of the deep branch under extensor carpi radialis brevis, or with radial head fracture

◦Median nerve- Entrapment between the ulnar and humeral heads of the

pronator teres muscle

Elbow Joint Hypomobility

Typically caused by: ◦Rheumatoid arthritis and/or Juvenile

Rheumatoid Arthritis◦Degenerative Joint Disease◦Trauma◦Dislocation◦Fractures◦Immobilization

Joint Hypomobility:Common Impairments

Acute Stage◦Joint effusion◦Muscle guarding◦Pain

Subacute and Chronic Stages◦Capsular pattern is typically present

Elbow flexion is more restricted than extension◦Decreased joint play

Common Functional Limitations

Difficulty turning a key, doorknob, or jar lids

Pain or difficulty with pushing and/or pulling activities

Difficulty performing ADL’sLimited reachInability to carry objects with an extended

armDifficulty pushing self up from a chair

Joint Hypomobility:Nonoperative Management

Protection phase◦Patient education◦Reduce effects of inflammation◦Maintain soft tissue and joint mobility◦Maintain integrity and function of related areas

Controlled motion phase◦Increase soft tissue and joint mobility◦Improve joint tracking of the elbow◦Improve muscle performance and functional

abilities

Joint Hypomobility:Nonoperative Management

Return to function phase◦Improve muscle performance

Activities should replicate the demands of ADL’s Modification of activities to reduce stress on joint

◦Restore functional mobility of joints and soft tissues Joint mobilizations Aggressive stretching techniques

Joint Surgery and Postoperative Management

Surgical intervention is often necessary for management of severe fractures or dislocations

In adults, the most common fracture in the elbow region is a fracture of the head and neck of the radius◦ Typically occurs when falling onto an outstretched hand

Long standing arthritis may also need to be managed through surgery

The goals of surgery are: ◦ Relief of pain◦ Restoration of bony alignment and joint stability◦ Sufficient strength and ROM to allow for functional mobility

Joint Surgery and Postoperative Management

Surgical Options for Displaced Fractures of the Radial Head ◦ORIF◦Arthroscopic Reduction and Internal Fixation◦Excision of the radial head

Joint Surgery and Postoperative Management – Excision of Radial Head

Maximum Protection Phase◦Immobilization◦Pain Control◦Edema Control◦AROM exercises for shoulder, wrist, and hand◦PROM and/or AAROM exercises for the elbow

when permitted AROM exercises are allowed within a week after

exercises are initiated◦Submaximal isometrics when permitted

Joint Surgery and Postoperative Management –Excision of Radial Head

Moderate and Minimum Protection Phases◦Begins when wound has healed and AROM of the

elbow is relatively pain free◦ Increase ROM

Gentle stretching Mobilizations once the joint capsule is well healed

(typically 6 weeks postoperatively)◦ Improve functional strength and muscular

endurance Low-load resistance exercises with high repetitions Use of affected UE for light ADL’s

Joint Surgery and Postoperative Management - TEA

Indications for Total Elbow Arthroplasty◦Severe joint pain◦Articular destruction of the humeroulnar and

humeroradial joints◦RA is one of the most common pathologies

leading to a TEA◦Significant instability of the elbow joint◦Failed radial head resection

Joint Surgery and Postoperative Management - TEA

Maximum Protection Phase (0-4 weeks)◦Immobilization – position varies◦Control of pain, inflammation, and edema◦Early AAROM exercises◦Maintain mobility of the shoulder, wrist, and

hand◦Regain motion of the elbow and forearm◦Minimize atrophy of UE musculature

Joint Surgery and Postoperative Management - TEA

Moderate and Minimum Protection Phase◦Improve elbow ROM

Low-intensity manual self-stretching◦Regain strength and endurance of elbow

musculature Isometrics Light ADL’s UBE Open-chain resistance exercises

◦Use operated arm for gradually demanding functional activities

Total Elbow Arthroplasty

Myositis Ossificans

Also known as heterotopic or ectopic bone formation-◦The formation of bone in atypical locations of the body

Etiology of symptoms◦Most often develops in the brachialis muscle or joint

capsule◦Caused by trauma, radial head fracture, etc

Management◦Active, pain-free ROM◦Massage, passive stretching, and resistive exercise

are CONTRAINDICATED

Overuse Syndromes - Epicondylitis

Lateral epicondylitis- Tennis Elbow◦Pain in the common wrist extensor tendons◦What activities are typically associated with

this diagnosis?

Medial epicondylitis- Golfer’s Elbow◦Pain in the common wrist flexor tendons◦What activities are typically associated with

this diagnosis?

Overuse Syndromes - Epicondylitis

Treatment- Protection Phase◦Avoid provoking activities◦Immobilization- rest the muscle◦Relieve pain, swelling, and scar tissue adhesions ◦Modalities◦Cross-friction massage◦Brace/Splint◦Low-intensity isometrics◦Active ROM and resistive exercise of

shoulder/scapular muscles

Overuse Syndromes - Epicondylitis

Treatment - Controlled Motion and Return to Function Phases◦ Increase muscle flexibility

Manual stretching Self-stretching

◦Restore joint tracking of the RU Joint◦Cross-friction massage◦ Improve muscle performance and function

Isometrics, dynamic exercises, functional patterns, etc. ◦Patient education

Activity modification

Little League Elbow

Caused by excessive traction forces on medial epicondyle epiphyseal plate during acceleration

Curve and breaking pitches create the greatest forces

Treatment ◦Rest, ice, active exercises to tolerance◦No heavy weights ◦Avoid valgus stresses early in rehab◦Avoid aggressive exercises

Sprains

Hyperextension sprain- ◦Anterior capsule injury; can cause bone bruise in

olecranon regionMedial collateral ligament sprain-

◦Injures the primary stabilizing unit of elbowTreatment-

◦Cross-friction massage to adhesions is contraindicated during initial 7-10 days after injury

◦Immobilization◦Pain-free ROM

Elbow Dislocation

Most dislocations are posterior and follow sudden hyperextension and abduction

Injury is obvious due to deformityTreatment

◦Splint is worn for 2 weeks with motion beginning after first week

◦Initiate isometrics during first week◦Rehabilitation may take 16-26 weeks

Posterior Dislocation of Elbow

Elbow Arthroscopy

Usually performed for debridementTreatment

◦Sling is worn for 1-3 days◦Rehabilitation may take 8 weeks◦May initiate shoulder, wrist range-of-motion

exercises, isometrics early◦Begin with straight plane, progress to diagonal

plane◦Progression depends on patient response

Elbow Bursitis (Olecranon Bursitis)

Inflammation of the olecranon bursa

May follow a traumatic incident

Treatment: ◦Stretches◦ROM◦Ice massage◦Modalities

Nursemaid's Elbow(“Pulled” Elbow Syndrome)

A partial dislocation of the elbow joint – ◦Involves the head of radius slipping out from

the annular ligamentCommon condition in children under the

age of fiveMay occur when a child is pulled too hard

by the hand or wrist

“Pulled” Elbow Syndrome Radial Head Subluxation

Exercise Interventions for the Elbow and Forearm

Exercises for Flexibility and ROM

Manual, mechanical, and self-stretching techniques◦To increase elbow extension◦To increase elbow flexion◦To increase forearm pronation and supination

Self-stretching techniques—muscles of the medial and lateral epicondyles◦To stretch the wrist extensor muscles◦To stretch the wrist flexor muscles

Supination Self Stretch with Weight

Supination Self-Stretch

Pronator Self-Stretch

Assisted ElbowFlexion-Extension Stretches

Exercises to Develop & Improve Muscle Performance & Functional Control

Isometric exercises◦Elbow flexion, elbow extension, and forearm

pronation/supination◦Rhythmic stabilization

Dynamic strengthening and endurance exercises◦Elbow flexion, elbow extension, pronation, and

supination◦Wrist flexion and extension

Functional exercises◦PNF patterns◦Pulling, lifting, and carrying activities◦Simulated tasks and activities

Strengthening Exercises

Progression◦Isometrics◦Isotonic

Straight plane Multi-plane

◦Plyometrics◦Functional exercises◦Activity specific exercises

Supination/Pronation Strengthening

Elbow Flexion Strengthening

Elbow Extension Strengthening (continued)

Elbow Extension Strengthening

Functional and Sport Specific Activities

Warm up and cool downBegin with low level and progress to

overhead exercises ◦Use easy activities at diminished distances,

forces, and speeds◦Gradually increase one component at a time

If pain occurs, return to previous level of exercises

Orthopedic Special Tests

Ligamentous Test

Varus and Valgus Stress Testing◦Note any laxity, decreased mobility or altered

pain with testing

Tests for Epicondylitis

Lateral Epicondylitis – Cozen’s Test◦A positive test is indicated by sudden severe

pain in the area of the lateral epicondyle of the humerus

Tests for Epicondylitis

Lateral Epicondylitis – Mill’s Test◦A positive test is indicated by sudden severe

pain in the area of the lateral epicondyle of the humerus

Tests for Epicondylitis

Medial Epicondylitis◦A positive sign is indicated by pain over the

medial epicondyle of the humerus.

Questions?