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Academy of Orthopaedic Physical erapy, APTA.

https://t.me/med1917

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

The Elbow Complex:

https://t.me/med1917

Evidence-Informed Physical

Therapy Patient Management

Independent Study

Course 31.2.6

Mark Dutton, PT

OrthoRecovery Specialists

Pittsburgh, Pennsylvania

The Elbow Complex:

https://t.me/med1917

Evidence-Informed Physical

Therapy Patient Management

Guy G. Simoneau, PT, PhD, FAPTA—Editor

Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor

Cover Illustration by Joseph Kinstler

Dear Colleagues,

I am pleased to welcome you to e Elbow Complex: Evidence-Informed Physical erapy Patient Management monograph written by Mark Dutton, PT. is work is part of the Academy of Orthopaedic Physical erapy Independent Study Course series 31.2, Current

Concepts of Orthopaedic Physical erapy, 5th Edition.

Mark Dutton received his bachelor of science degree in physical therapy from the University of Pittsburgh. During his career he has worked in a variety of physical therapy settings including inpatient, home health, extended care, and outpatient facilities. Mark was the Regional Director for the Allegheny Health System, Pittsburgh for approximately 20 years. As an author, Mark has authored numerous physical therapy textbooks covering orthopaedics, patient skills, and the National Physical erapy Examination (NPTE). Mark is currently working as a consultant for OrthoRecovery Specialists.

Consistent with the other monographs in this series, the author rst describes the anatomy and kinesiology of the elbow complex. Although of a simple outward appearance, the complexity of this anatomy and kinesiology should not be underestimated, especially when dealing with traumatic injuries. Subsequently, common examination procedures are described along with their clinical accuracy. e author then discusses common muscular, articular, and neurological injuries aecting the elbow. Both traumatic and non-traumatic conditions are included along with nonoperative and surgical management when indicated. e monograph concludes with clinical scenarios to provide additional clinical context to the information provided.

My sincere thanks to the author for his contribution to the Current Concepts series.

Sincerely,

Guy Simoneau, PT, PhD, FAPTA Editor

2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Oce 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965

TABLE OF CONTENTS

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ACRONYM LIST ................................................................................................................................................................................................................5

ABSTRACT

..........................................................................................................................................................................................................................7

LEARNING OBJECTIVES ..............................................................................................................................................................................................7

INTRODUCTION .............................................................................................................................................................................................................7

CLINICAL ANATOMY, KINESIOLOGY, AND BIOMECHANICS ...................................................................................................................7

CLINICAL EXAMINATION AND DECISION-MAKING PROCEDURES ....................................................................................................8

History .......................................................................................................................................................................................... 9

Systems Review ............................................................................................................................................................................. 9

Observation and Palpation ............................................................................................................................................................ 9

Range of Motion ......................................................................................................................................................................... 10

Resistive Testing .......................................................................................................................................................................... 10

Passive Joint Mobility Testing ...................................................................................................................................................... 11

Special Tests ................................................................................................................................................................................ 11

Decision-making ......................................................................................................................................................................... 11

Conclusion.................................................................................................................................................................................. 14

COMMONLY ENCOUNTERED CONDITIONS OF THE ELBOW AND FOREARM

.......................................................................... 14

Elbow Tendon Pathologies .......................................................................................................................................................... 15

Lateral elbow tendinopathy .................................................................................................................................................. 15

Medial elbow tendinopathy.................................................................................................................................................. 19

Bicipital tendinopathy.......................................................................................................................................................... 20

Distal biceps tear .................................................................................................................................................................. 21

Distal triceps tear ................................................................................................................................................................. 22

Olecranon Bursitis ...................................................................................................................................................................... 23

Compressive Neuropathies .......................................................................................................................................................... 23

Elbow Instability ......................................................................................................................................................................... 26

Valgus instability .................................................................................................................................................................. 26

Posterolateral rotatory instability .......................................................................................................................................... 27

Varus posteromedial rotatory instability ............................................................................................................................... 29

Posterior Elbow Impingement ..................................................................................................................................................... 30

Little League Elbow .................................................................................................................................................................... 30

Osteochondritis Dissecans ........................................................................................................................................................... 31

Heterotopic Ossication ............................................................................................................................................................. 31

Elbow Dislocations and Fractures ................................................................................................................................................ 32

Elbow dislocations ............................................................................................................................................................... 32

Radial head dislocation ........................................................................................................................................................ 32

Olecranon fracture ............................................................................................................................................................... 33

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Coronoid fracture ................................................................................................................................................................ 33

Medial epicondyle fracture ................................................................................................................................................... 34

Lateral epicondyle fracture ................................................................................................................................................... 34

Compartment Syndromes ........................................................................................................................................................... 35

Acute compartment syndrome ............................................................................................................................................. 35

Chronic (exertional) compartment syndrome....................................................................................................................... 35

Complex Regional Pain Syndrome .............................................................................................................................................. 36

Osteoarthritis of the Elbow .........................................................................................................................................................36

Joint Arthroplasty ....................................................................................................................................................................... 37

Elbow Stiness ............................................................................................................................................................................ 37

OUTCOME MEASURES AND SCALES.................................................................................................................................................................38

CASE SCENARIOS ........................................................................................................................................................................................................ 38

Case Scenario 1 ........................................................................................................................................................................... 38

Case Scenario 2 ........................................................................................................................................................................... 39

Case Scenario 3 ........................................................................................................................................................................... 40

Case Scenario 4 ........................................................................................................................................................................... 41

APPENDICES .................................................................................................................................................................................................................. 43

Appendix A. Osteology of the Elbow and Forearm ......................................................................................................................43

Appendix B. Joints of the Elbow Complex .................................................................................................................................. 44

Appendix C. Elbow Motions and their Clinical Signicance ....................................................................................................... 45

Appendix D. Major Stabilizing Structures of the Elbow Complex ............................................................................................... 46

Appendix E. Major Muscles of the Elbow and Forearm ............................................................................................................... 48

Appendix F. Peripheral Nerves Crossing the Elbow: Potential Involvement and Signs and Symptoms .........................................50

Appendix G. e Patient Rated Tennis Elbow Evaluation (PRTEE) ............................................................................................ 52

Appendix H. Outcome Measures for the Elbow .......................................................................................................................... 54

REFERENCES..................................................................................................................................................................................................................58

Opinions expressed by the author are his own and do not necessarily reect the view of the

Academy of Orthopaedic Physical erapy. e author declares no conict of interest.

If we have inadvertently overlooked any, we would be willing to correct the situation at the rst opportunity.

Course content is not intended for use by participants outside the scope of their license or regulations.

e publishers have made every eort to trace the copyright holders for borrowed material.

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

ACRONYM LIST

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AAROM: active-assisted range of motion ACS: acute compartment syndrome ADLs: activities of daily living AROM: active range of motion AUCL: anterior ulnar collateral ligament BMAC: bone marrow aspirate concentrate CNS: central nervous system CRPS: complex regional pain syndrome CT: computed tomography DRUJ: distal radioulnar joint ECRB: extensor carpi radialis brevis ECRL: extensor carpi radialis longus ED: extensor digitorum FCR: exor carpi radialis FCU: exor carpi ulnaris FDS: exor digitorum supercialis HO: heterotopic ossication LET: lateral elbow tendinopathy LR: likelihood ratio LUCL lateral ulnar collateral ligament MDC: minimal detectable change MET: medial elbow tendinopathy MRI: magnetic resonance imaging MWM: mobilization with movement NPV: negative predictive value NSAIDs: nonsteroidal anti-inammatory drugs OATS osteochondral autologous transplantation surgery OCD: osteochondritis dissecans ORIF: open reduction internal xation PL: palmaris longus PLRI: posterolateral rotatory instability POLICE: protection, optimal loading, ice, compression, elevation PPV: positive predictive value PROM: passive range of motion PRP: platelet-rich plasma PRTEE: Patient-Rated Tennis Elbow Evaluation PRUJ: proximal radioulnar joint RCL: radial collateral ligament ROM: range of motion TEA: total elbow arthroplasty TFM: transverse friction massage UCL: ulnar collateral ligament US: ultrasound

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The Elbow Complex:

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Evidence-Informed Physical Therapy Patient Management

disorders of the elbow and forearm.

8. Apply research outcomes and outcome measures to develop rehabilitation programs for the elbow and forearm.

Mark Dutton, PT OrthoRecovery Specialists Pittsburgh, Pennsylvania

ABSTRACT

is monograph outlines the most current examination techniques and the contemporary nonoperative and surgical interventions for the most common pathologic conditions of the elbow region encountered by the physical therapist, using the latest evidence-based information. e complex combination of clinical expertise with the best available clinical evidence facilitates appropriate decisions for patient management in medicine. Clinical expertise enables the correct selection of those examination procedures with the highest diagnostic accuracy, followed by an accurate interpretation of all the clinical ndings to decide patient management. Pain is a typical patient complaint, and the study of pain has recently uncovered some noteworthy information about its interpretation. Similarly, recent research into tendon pathology has changed our traditional treatment approaches. Finally, there is an increased emphasis on enhancing patient/client satisfaction, improving eciency, and removing unproven treatment techniques; this has led to greater attention to consistent measurement and reporting of clinical outcomes. To conclude, 4 diverse case scenarios are presented with questions and answers about the best approach to patient management.

Key Words: humeroulnar joint, humeroradial joint, radioulnar joint

LEARNING OBJECTIVES

Upon the completion of this monograph, the course participant will be able to:

1. Understand and describe the clinical anatomy and biome-

chanics of the elbow and forearm and how they interrelate.

Describe how the relationships of the many anatomical structures help determine the various pathokinesiologic diagnoses of the elbow and forearm.

3. Apply an evidence-based approach for the examination of

the elbow and forearm.

Summarize the multiple causes of elbow dysfunction.

5. Dierentiate the various elbow and forearm pathologies

during the physical examination and their respective impact on the patient’s impairment and functional limitations.

6. Describe the clinical outcomes of the commonly treated el-

bow and forearm pathologies and the importance of kinetic chain consideration.

7. Develop an understanding of the scientic basis for the non-

operative and surgical management of the more common

INTRODUCTION

Although this monograph focuses on the elbow joint complex, any examination and treatment of the elbow should include consideration of the cervical and thoracic spine, the shoulder, and the wrist and hand. Like the knee, the elbow is an anatomically intricate joint situated centrally along its kinetic chain and is a common symptom location. Symptoms may arise from local structures or be referred to the elbow from remote locations or structures. Elbow symptoms historically have been overtreated by using a generic approach that does not address the underlying causes.

Unlike the knee in the lower kinetic chain, the elbow is not a weight-bearing joint and, therefore, its signicant functions dier. To perform all its roles eciently and allow independent function in daily activities, including during the physical demands of work and recreation, the elbow requires mobility, stability, and strength while remaining unhindered by pain. Traditionally, the 3 primary functions listed for the elbow complex are positioning the hand in space, providing the power to accomplish lifting activities, and stabilizing the upper extremity kinetic chain for power and detailed work activities. However, perhaps the elbow’s most crucial function is that it allows us to feed ourselves by enabling the hand to reach the mouth.

CLINICAL ANATOMY, KINESIOLOGY, AND BIOMECHANICS

is monograph assumes a working knowledge of the basic anatomy of the elbow and forearm region, including the origins and insertions of the various muscles and tendons. us, this monograph presents only a brief overview of the elbow complex’s anatomy and biomechanics to highlight the more significant points.

e elbow is a trochoginglymoid (combination hinge and pivot) joint. It consists of articulations between the humerus, ulna, and radius (Figure 1). e osteology (Figure 2) of this region is outlined in Appendix A. stability is attributed to the conguration of the bones. especially true for varus-directed stress applied while the elbow is in full extension.

e elbow complex is composed of 3 distinct articulations within a shared capsule: the humeroulnar joint and the humeroradial joint that form the elbow; the proximal radioulnar joint (PRUJ), located near the elbow, which is an articulation between the head of the radius and the radial notch of the ulna; and the distal radioulnar joint (DRUJ), located near the wrist, which is an articulation between the ulnar notch of the radius and the ulnar head. ese latter 2 joints have a symbiotic relationship (Appendix B). bow complex is formed by the trochlea of the humerus and the

Fifty percent of the elbow’s

e hinge component of the el-

is is

Figure 1.

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e Left Elbow Joint Complex

I, Humerus; II, Ulna; III, Radius; A, Medial epicondyle; B, Coronoid fossa; C, Radial fossa; D, Trochlea; E, Capitulum; F, Lateral epicondyle; G, Tip of olecranon process; H, Longitudinal crest; J, Fovea; K, Annular ligament; L, Radial tuberosity.

Figure 2.

Osteology of the Ulna

trochlear notch of the proximal ulna as well as by the radial head and the capitulum (Appendix A). e shapes of the articulat-

4-7

ing surfaces (Appendix C)

are important to remember when

assessing joint mobility and when applying joint mobilizations.

e 3 joints of the elbow increase the mobility of the hand

in space by shortening or lengthening the upper kinetic chain, and through rotation of the forearm. e primary motions of this joint complex include exion-extension, which occurs primarily at the humeroulnar joint, and pronation-supination, which occurs at the humeroradial and PRUJ, assisted by the DRUJ (Appendix C).

Unlike the glenohumeral joint, the elbow complex is in-

herently strong and stable because of the interrelationship of its articular surfaces, the joint capsule, and numerous ligamentous constraints (Appendix D).

7-11

Operating parsimoniously, the nervous system tends to ac-

tivate the fewest muscles or muscle bers possible to control a given joint action. us, physical tasks with a high-level of force demand are performed primarily by those muscles and tendons that cross more than 1 joint (eg, the long head of the triceps and the long head of the biceps), whereas the 1-joint components of those muscles perform tasks with a low-level force demand. A summary of the muscles acting on the elbow, and their nerve

1,7,12-14

supply, is outlined in Appendix E.

e prime movers for elbow exion are the brachialis, bra-

chioradialis, and biceps, with the pronator teres serving as a secondary exor. e triceps and anconeus perform elbow extension. Unlike the elbow exors, which are served by 3 dierent peripheral nerves, the elbow extensors have only a single peripheral nerve supply, perhaps reecting the exors’ more critical functional role. Forearm supination is performed primarily by the supinator and biceps muscles, while forearm pronation is completed primarily by the pronator teres and pronator quadratus, assisted by the exor carpi radialis (FCR) and the palmaris longus (PL), if it is present.

e nerve supply to the elbow structures and forearm is

provided by the nerve roots of C5 to C8, which form several peripheral nerves (the radial, musculocutaneous, median, and ulnar nerves). A brief description of these peripheral nerves and their potential entrapment sites in the upper extremity is outlined in Appendix F, with more details provided later in the text.

e elbow’s vascular supply is provided by the brachi-

al artery, the radial and ulnar arteries, the middle and radial collateral arteries, and the superior and inferior ulnar collateral

arteries.

A, Coronoid process; B, Olecranon process; C, Supinator crest; D, Radial notch; E, Longitudinal crest of the trochlear notch.

CLINICAL EXAMINATION AND DECISION-MAKING PROCEDURES

It is not within this monograph’s scope to provide a de-

tailed description of how to perform a thorough clinical examination of the elbow complex, so only a broad overview of the more salient points is discussed.

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

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