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cise.95 A randomized controlled trial of eccentric vs concentric
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exercises in 120 individuals with chronic LET determined that
eccentric exercises reduced pain and increased muscle strength
more eectively than concentric exercises.
95
Other techniques
•
Electrophysical agents (ultrasound, iontophoresis, or pulsed
electromagnetic eld treatment): ere is little to no evidence
to support the use of these interventions.
96
• Shockwave therapy: Unlikely to be more eective than placebo at improving pain, and less eective than injected corticosteroids.
96
• Low-level laser therapy: May be benecial at improving pain
in the short term when compared with placebo.
96
Management and exercise progression
In the acute stage, the POLICE principles (protect, optimize load, ice, compress, elevate) are recommended; whereas,
in the later stages, the attention is focused more on optimizing
tissue stresses and performing a biomechanical assessment of
the upper kinetic chain to identify any abnormal mechanical
forces or movement dysfunctions that could be creating excessive loading of the involved tendon.
97
is focus can include
addressing any impairments in the cervical spine and ensuring
that normal scapular muscle strength and function are present.
Along with addressing more remote contributing factors,
a stretching and strengthening program is recommended using
the following progression:
Stretches for:
• Wrist extension–exion (while progressively increasing the
elbow position from a exed to an extended position to perform the wrist exercises);
• Elbow extension–exion;
• Forearm supination–pronation (while progressively increas-
ing the elbow position from a exed to an extended position).
Emphasis on concentric–eccentric strengthening with a focus
on:
• Wrist extension–exion;
• Forearm pronation–supination;
• Elbow exion-extension.
Gradual re-initiation of previously painful movements.
As with any exercise progression, the clinician should avoid
the approach of always instructing 3 sets of 10 repetitions because each case is dierent in terms of the stage of healing and
patient tolerance. Instead, the frequency and intensity of exercises should be gradually increased while letting the symptoms
during and after the session determine the speed of progression.
Corticosteroid injections
A short course of corticosteroid injections has been historically the most common intervention for LET to relieve pain
and reduce inammation, but recent evidence suggests that
while injections provide high success rates within the rst 6 to
8 weeks, they also result in high pain recurrence rates and protracted recovery in the long-term.
97-99
A potential issue with nonoperative management is scar
tissue formation, which creates a tendon that lacks its normal
biomechanical properties and mechanical strength. Some novel therapies are on the horizon, including platelet-rich plasma
(PRP) injection, bone marrow aspirate concentrate (BMAC),
and collagen-producing cell injections that are designed to re-
82
generate tendon and regain function in patients with LET.
Surgical interventions
Lateral epicondylar release is reserved for those patients
whose symptoms and functional limitations do not resolve
with a nonoperative approach. As no specic surgical procedure is superior to another, the choice of technique (open vs
arthroscopic) often is based on surgeon experience and ease of
the procedure. However, due to the small number of studies,
large heterogeneity in interventions across trials, small sample
sizes, and poor reporting of outcomes, evidence is insucient to
100
support or refute the eectiveness of surgery for LET.
If surgery is performed, the immediate goals for a typical postoperative rehabilitation protocol are to decrease pain and inammation, improve or regain ROM, and minimize initial muscular
atrophy while monitoring for any signs of wound infection. In
the rst 7 days after the surgery, gentle pain-free AROM of the
shoulder (shrugs and scapular retraction), wrist (exion only),
and ngers are initiated together with AAROM into wrist extension with the elbow exed to 90°, PROM into elbow exion
and extension, and PROM for pronation and supination. At
approximately 2 weeks, the AAROM/PROM exercises are progressed to AROM with the goal of having 80% of normal elbow ROM after 3 weeks. At this point, submaximal isometrics
(light gripping) are started together with pain-free antigravity
wrist exion and extension and forearm supination and pronation motions. Once the patient can perform 30 repetitions
of these activities without pain, a 1-pound (0.5 kg) weight or
light resistance elastic band is added, with all exercises being
performed with the elbow exed to 90° and resting on a table or
the patient’s thigh. Also, slight overpressure into elbow extension is applied 3 to 4 times daily. Joint mobilizations are usually introduced by the third week. Once cleared by the surgeon,
the rehabilitation can be progressed using patient tolerance as
a guide until full elbow, forearm, and wrist ROM and strength
have been achieved, which typically occurs approximately 8 to
12 weeks post-surgery.
Medial elbow tendinopathy
Medial elbow tendinopathy, commonly referred to as golf-
er elbow, primarily involves the tendons of the common exor
origin, specically the FCR and pronator teres, with occasional
involvement of the PL, FCU, and FDS. Although the mecha-
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19
nism for MET can involve direct trauma, it is more likely to be
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caused by overuse or repetitive stress, and, as with LET, MET
occurs in both athletes and individuals with work occupations
that require repetitive wrist exion and forearm pronation. e
3 commonly cited reasons for the breakdown of normal tendon
behavior at the medial elbow are fatigue of the exor-pronator
tissues in response to repetitive stress, a sudden change in the
levels of stress, and failure of the UCL to suciently stabilize
the elbow against valgus forces.
101,102
Currently, no diagnostic accuracy data support the use of
physical examination tests designed to help in the diagnosis of
MET (Table 1). e typical clinical presentation for MET is
medial-sided elbow pain and tenderness, specically over the
exor-pronator origin, slightly distal and anterior to the medial
epicondyle, exacerbated by daily activities. Also, in the general population, the symptoms worsen with either resisted wrist
exion, resisted pronation, or passive wrist extension combined
103
with passive forearm supination and elbow extension.
row-
ing athletes may be particularly symptomatic during the late
104
cocking or early acceleration phases of the pitching motion.
In addition to MET, the dierential diagnosis process for
medial elbow pain must include (but is not limited to) UCL
injury or insuciency, medial elbow intra-articular pathology,
ulnar nerve entrapment or neuritis, shoulder injury, cervical
spine nerve root impingement, and thoracic outlet syndrome.
Because pathologies of the medial elbow may exist con-
105
currently,
an accurate diagnosis requires a thorough understanding of the anatomic, epidemiologic, and pathophysiologic
factors. Although out of the scope of practice of most physical
therapists, real-time sonoelastography, which can assess both
the tendon’s elastographic grade and strain ratio, is a valuable
106
supplementary tool in the diagnosis of MET.
e treatment approach for MET is similar to that of LET
except that the strengthening component focuses on the exor-pronator muscles once the acute symptomatology is allevi-
105
Although eccentric training of the wrist extensors has
ated.
been documented to be eective in treating chronic LET, the
evidence for the same approach for MET is less clear. However, 1 small study (20 participants) reported that the outcome
measures for chronic MET was markedly improved with the
addition of an eccentric wrist exor exercise program to stan-
107
dard physical therapy.
Elastic taping may be a useful treatment adjunct.
90-92
MWM
technique, similar to that used with LET, can be
108
A
trialed. e patient is asked to perform the identied painful
task while the therapist provides a medially directed glide to the
elbow (Figure 10). e MWM is typically repeated for 6 to 10
repetitions per visit and then repeated over several follow-up
sessions.
Platelet-rich plasma injection, BMAC, and collagen-producing cell injection, while still in the early stages of validation,
have all been found to boost tendon regeneration and help regain function in patients with MET, as they do for LET.
82
Figure 10.
Medial Glide of the Humeroulnar Joint
e clinician wraps the ngers around the proximal
third of the patient’s forearm with one hand while
stabilizing the patient’s humerus with the other. e
clinician then glides the ulna medially on the xed
humerus along the joint line’s mediolateral plane.
Although various techniques have been described for the
surgical treatment of recalcitrant MET, no single technique has
yet to be proven most eective. As with LET, most surgeons
specify postoperative protocols, which often are based on time
frames rather than objective criteria.
Bicipital tendinopathy
Bicipital tendinopathy at the elbow occurs at the radial tuberosity and typically is due to repetitive hyperextension of the
elbow with the forearm pronated or repetitive exion combined
with stressful pronation-supination, especially among athletic
individuals aged over 35. Understanding the anatomy and function of the biceps brachii muscle (Appendix E) is essential for
diagnosing biceps tendinopathy. As with other tendinopathies,
a degenerative process predominates over an inammatory process, following the acute phase.
Information from the subjective and physical examination
is often enough to make a diagnosis of bicipital tendinopathy.
e patient usually complains of elbow or forearm pain, especially over the radial tuberosity. e physical examination of
the distal lesion conrms tenderness over the bicipital insertion
at the radial tuberosity. e pain can often be reproduced with
109
resisted elbow exion and forearm supination.
Injection of a local anesthetic may help further dierentiate
the origin of the pain. Plain radiography, ultrasonography, and
magnetic resonance imaging (MRI) also can aid in the diagnosis.
Rehabilitation of distal biceps tendinopathy for the throw-
110
ing athlete, which leads to good results,
involves 4 phases: (1)
20
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rest, (2) stretching exercises for the scapular muscles, rotator
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cu, and posterior glenohumeral joint capsule, (3) eccentric
strengthening of the elbow exors and forearm supinators, and
110
(4) a progressive return to a throwing program.
e rehabilitation process for the non-athlete follows a similar course
but with a greater emphasis on work-related and functional demands.
e evidence for the benet of eccentric exercises for distal
biceps tendinopathy is scant compared with that for other areas
of the body. e authors of a single case study of a 41-year-old
male patient with a 2-month duration of right antecubital space
pain, reported that after eccentric exercise training for 12 sessions (3 visits over 4 weeks), the patient reported a decrease in
pain, and he exhibited an increase in right forearm supination
and elbow exion strength while also displaying clinically sig-
111
nicant improvement in his QuickDASH scores.
Surgery, including removing any structures causing primary and secondary impingement and repair of the biceps tendon
if necessary, is considered if nonoperative measures fail after 3
months. A biceps tenodesis may be considered in serious tears
or rupture.
110
Distal biceps tear
While an injury to the distal biceps occurs less frequently
than one to the proximal biceps, a rupture of the distal biceps
tendon can have signicant functional repercussions, especially
with activities requiring power throughout forearm supination
112
and elbow exion.
For example, strength decits in elbow
exion and forearm supination after a distal biceps tendon rupture have been estimated at 30% to 40%, with even greater
113
decits for endurance.
But, exact losses are dicult to determine because comparisons must be made with either a patient’s
opposite side or with age-matched controls.
e distal biceps tendon can be avulsed completely or par-
tially either at the musculotendinous junction or at the radial
114
tuberosity, the latter of which is more common.
Avulsions of
the biceps tendon at the elbow, which typically involve a sudden
uncontrolled large eccentric load of the biceps with the elbow
in 90° of exion, occur almost exclusively in males, with the
most common scenario being a rupture of the dominant elbow
115
of a muscular male in his fth decade of life.
e diering
trajectories followed by the short (medial in the arm) and the
long (lateral in the arm) head of the biceps result in the biceps
brachii musculotendinous unit making a 90º external rotation
116-118
twist from origin to insertion.
While seemingly arbitrary,
biomechanically, this creates a higher moment arm of the short
head of the biceps with the forearm in neutral and pronated
position (and likely contributes more to elbow exion), whereas
the long head of the biceps has a higher moment arm in supi-
116-118
nation.
Traditionally, distal biceps tendon tears have been categorized as partial (insertional or intra-substance) or complete; acute if less than 4 weeks old, or chronic if more than
116,118
4 weeks.
Early and accurate diagnosis is essential because
a delayed diagnosis may preclude primary repair and lead to
chronic weakness.
common and likely under-diagnosed.
112
Partial distal biceps tendon tears are less
117
e diagnosis of a
complete distal biceps tendon tear can often be established
based on patient history (reports of a sudden pop at the time
of injury) and physical examination alone. For example, the
physical examination typically reveals marked ecchymosis in
the distal arm and proximal forearm soon after injury; this is
usually accompanied by a attening of the distal contour of
the arm created by the proximal retraction of the biceps, which
creates a noticeable dierence in the crease-to-biceps distance
between the elbow exion crease and the round biceps muscle
belly when compared with the opposite arm.
119
Manual muscle
testing may reveal some weakness in elbow exion but mostly
forearm supination, depending on the patient’s strength. e
hook test, devised by O’Driscoll et al,
120
can help in the diagnosis. is simple test involves asking the patient to actively supinate the forearm with the elbow exed to 90°.
120
If the distal biceps tendon is intact, the clinician can hook their nger around
its cord-like structure but cannot if the biceps is torn because
the distal brachialis is at.
120
Despite its simplicity, the hook
test was found to have 100% sensitivity, specicity, and positive
and negative predictive values, which exceeded the values found
with MRI.
120
Alternatively, the biceps squeeze test (Table 1),
which is analogous to the ompson test for the Achilles ten-
121
don,
can be performed by squeezing the biceps brachii when
the elbow is exed 90° to elicit forearm supination if the distal
tendon is intact.
46
e test designers found a sensitivity of 96%,
and all of the patients who underwent operative repair of the
tendon had a negative squeeze test postoperatively.
46
Finally, a
slightly more involved test, the biceps crease interval test, can
be used.
122
e biceps crease interval is dened as the distance
between the elbow’s antecubital crease and the cusp of the distal
descent of the biceps muscle: the point at which the distal curve
of the biceps begins to turn most sharply toward the antecubital
fossa. e biceps crease interval test, which is considered positive if the interval is greater than 6 cm, 2 standard deviations
above the norm (mean ± standard deviation: 4.8 cm ± 0.6 cm),
was determined to have a sensitivity of 92% and a specicity of
100%, with a PPV of 100% and NPV of 71%.
122
If further conrmation is required, ultrasound (US) imaging and MRI should be used because plain radiographs are
usually normal.
e chosen course of treatment often depends on the patient and the extent of the tear. For a partial distal biceps tendon
tear, most recommend a trial of nonoperative treatment, including activity modications, use of NSAIDs, and physical therapy, with surgical considerations if debilitating symptoms persist
for 3 to 6 months.
123,124
In contrast, while some individuals may
maintain adequate function after nonoperative treatment of a
complete distal biceps tendon rupture, clinical and biomechanical studies suggest that most will benet from surgical repair or
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21
reconstruction.
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112
However, for a patient with a complete tear
but with low physical demands, nonoperative treatment may be
considered, provided the patient understands the potential for
117
residual weakness, particularly in forearm supination.
Most tears are best treated by primary repair if an operative
course is chosen, using either single- or double-incision tech-
117
niques.
Various xation techniques can be used to provide
dierent levels of stability without negatively impacting clinical
117
outcomes.
Certain chronic tears can be surgically addressed
with a primary repair if the tendon tissue can be identied;
otherwise, autograft or allograft reconstruction can be contem-
117
plated, with both techniques reporting good outcomes.
e
ROM parameters typically are determined intra‐operatively
with bracing implemented post‐operatively to protect the soft
tissue repair. If the surgery involved repairing a retracted distal
biceps tendon, the surgeon typically limits extension ROM initially and then allows progress to full elbow extension over 4 to
6 weeks based on the amount of tension present in the repaired
tendon. As always, the postoperative rehabilitation protocol depends on the surgical technique performed and the surgeon’s
preferences. An evidence-based approach for postoperative rehabilitation does not currently exist. However, the principles
remain the same - each phase of the rehabilitation process must
be tailored to the individual patient’s needs and restrictions, and
112
progression must be carefully supervised.
the following outline can be used as a guideline
With that in mind,
112
:
• Early recovery (weeks 0 to 6): Focus is on pain and eusion
reduction, protection of the surgical repair, and optimizing
the tissue healing environment. Typically, a splint/brace is
used to immobilize the elbow at 90° of exion and in full
supination and is worn at all times (except for hygiene or
physical therapy sessions). During home exercise sessions, the
brace is unlocked to allow passive exion ROM from 30° to
full exion. e extension setting is reduced gradually by the
clinician (approximately 10° per week) to match whatever
passive, tension-free extension is achieved during the physical
therapy sessions. No active elbow exion or forearm supination is permitted initially (gravity‐assisted exion and extension may begin 2 weeks post‐operatively). Shoulder, hand,
and wrist ROM and gripping exercises should begin immediately. Cardiovascular exercises involving the lower extremities
(eg, treadmill) can be introduced as early as week 1 post‐operatively. Progression to the next phase can occur when there
is no persistent or recurrent pain and/or swelling.
Intermediate recovery (weeks 6 to 12): Isometric triceps ex-
•
ercises (patient seated and isometrically pressing the forearm
into a table) may begin at 6 weeks postoperatively, with concentric exercises of the triceps beginning at week 8, together
with the strengthening of the shoulder girdle, and the wrist
exors and extensors.
• Late recovery (weeks 12 to 16): Continued progression of
previous exercises. Also, biceps isometrics are initiated, fol-
lowed by light biceps concentric exercises (biceps curls, hammer biceps curls, and reverse biceps curls) at week 16.
Final stage (week 16+): Biceps strengthening is advanced to
•
include side curls (arms at 90° of abduction and 90° of exion, with palms facing upward). Upon attaining full upper
extremity strength, return to sport or work activities may be
assessed on a sport/work‐specic basis. No specic test for
return to sport/work following distal biceps repair exists; instead, the clinician must assess the quality and strength of
movements specic to the preferred sport/work activities.
Distal triceps tear
A distal triceps tendon rupture is relatively rare, accounting
125
for less than 1% of all upper limb tendon injuries.
e injury
usually happens when a deceleration force occurs during elbow
extension or with an uncoordinated contraction of the triceps
muscle while eccentrically resisting an elbow exion force.
ese injuries can be dicult to diagnose and are frequent-
ly missed, potentially resulting in considerable function loss.
126
As with the biceps tendon rupture, the physical ndings depend
on whether the tear or avulsion is partial or complete, but the
most common ndings include an inability to extend the arm
overhead against gravity and a loss of overall elbow extension
strength. A tendon defect may be present if the tear is com-
127
plete.
Platelet-rich plasma is an emerging non‐surgical interven-
128
tion for tendon and ligament pathology.
e evidence surrounding the use of PRP in orthopedics and sports medicine
is still in its infancy, and the results have been variable, but the
application of PRP has been shown to be eective in improving
overall outcomes for individuals who are refractory to nonoperative treatment measures and who elect to avoid more invasive
surgical interventions.
128
e traditional nonoperative approach for a partial tear involves immobilization for about 3 weeks, followed by a gradual
progression of ROM and strengthening exercises. A primary
repair tends to be the treatment of choice for acute complete
ruptures. Although other surgical repair techniques have been
described, evidence is lacking on the optimal reconstructive
technique and no guide exists for physical therapists on post-
126
operative rehabilitation.
e postoperative rehabilitation protocol will depend on the surgical technique performed and the
surgeon’s preferences, with each phase tailored to the individual
patient’s needs and restrictions. e following outline can be
126
used as a guideline
:
• Immediately post-operative: Following surgery, the patient’s
elbow is usually cast at 45° of exion, and the patient is advised not to use the arm for any weight-bearing activities.
However, to help establish pain-free ROM and minimize the
eects of immobilization, patients typically are instructed to
perform wrist extension and exion exercises using a light
dumbbell, and shoulder pendulum exercises.
22
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• Approximately 2 to 6 weeks post-surgery: e patient is usu-
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ally provided with an elbow ROM brace, locked at 0° to 90°,
while also receiving instructions to avoid passive exion beyond 90° when out of the brace, and to avoid any resisted
elbow extension. However, active-assisted elbow extension is
permitted with the shoulder at 90° of abduction. e patient
also receives instructions on exercises to perform while in
the brace, including active supination and pronation, active
elbow exion, and light isometric elbow exion. Elbow extensor strengthening exercises and elastic resistance shoulder
rotation exercises are also initiated.
•
Approximately 6 to 12 weeks post-surgery: e elbow brace’s
ROM settings are gradually increased until the patient is allowed to move the elbow through its full ROM. At this point,
the focus of the rehabilitation switches to strengthening and
kinetic chain exercises while monitoring any reduced vascularity to the tendon repair.
•
Approximately 12 weeks post-surgery: e patient can return to normal activities or sporting pursuits (as appropriate)
based on the quality and strength of the movements specic
to the planned activity.
Olecranon Bursitis
e olecranon bursa, a synovial membrane, is located supercially and immediately posterior to the elbow’s olecranon
bone. is location and its limited vascularity increase its potential to be injured easily through direct trauma or irritated
through sustained pressure or vibration. Indeed, the olecranon bursa is one of the most frequently aected bursae in the
129
body.
As a result of the multiple etiologies, olecranon bursitis can present with reasonable frequency, and, although many
interventions have been documented, a single, evidence-based,
standardized treatment pathway has not been established.
129
Until it is, the clinician must use current methods that have
shown promise.
Olecranon bursitis, which is characterized by an abnormal
increase in the volume of uid within the bursal cavity, occurs
in 3 main types:
• Aseptic: is type results from injury from direct trauma or
sustained pressure or vibration over the bursa. If the patient
is experiencing signicant pain or discomfort with elbow
movements, a sling reduces these symptoms. Aspiration to
analyze the uid content to help rule out infection or gout
should be performed only when the diagnosis is uncertain or
130
to relieve symptoms in refractory cases.
Otherwise, a sim-
ple approach using ice, compression bandaging, and NSAIDs
131
normally will suce.
However, if the bursitis recurs or develops an infection that does not respond to antibiotics, it
will require evaluation for surgical excision.
• Septic: A bursa can become infected if it is inltrated by a
132,133
fungal, mycobacterial, or bacterial organism.
Redness,
heat, and exquisite tenderness suggest infection. Prompt rec-
ognition is essential to minimize recovery time and prevent
the spread of infection. Distinguishing between septic and
aseptic olecranon bursitis can be dicult even with bursal
aspirate analysis because the physical and laboratory data
134
overlap.
• Chronic: is type is associated with either prolonged or repetitive injury to the bursa or secondary to additional comorbidities such as diabetes mellitus, gout, or pseudo-gout. If no
comorbidities are present, this type is relatively easy to treat
through patient education about activities and positions to
avoid irritating the bursa. A series of corticosteroid injections
may be warranted to manage recalcitrant chronic bursitis
once the diagnosis of infection has been excluded.
Some dierential diagnoses of olecranon bursitis are acute
fractures, rheumatoid arthritis, gout, and synovial cysts.
Compressive Neuropathies
e nervous system is a complex network of tissue that
sends electrical and chemical signals, with continuity between
its 2 subdivisions: the central and peripheral nervous systems.
It has been suggested that movement can apply dierent strain
levels to a particular nerve segment depending on the sequence
135,136
of joint movement used.
Although peripheral nerves have
viscoelastic characteristics, the nerves and their microcirculation are vulnerable to tension, friction, and compressive forces
137
anywhere along their trajectory.
e elbow region has many
vulnerable sites (Appendix F), with involvement of the radial,
ulnar, and median nerves and their branches being the most
common. As with any peripheral nerve, the potential for compression increases if the nerve is located supercially or if it passes through an area of high risk for trauma or through a narrow
bony canal. For example, due to its supercial location, the ulnar nerve can be irritated, and its normal gliding impeded, by
1
protracted elbow exion.
Also, several diseases such as diabetes mellitus, hypothyroidism, hereditary neuropathy, immune
deciency syndromes, rheumatoid arthritis, and alcoholism are
hypothesized to contribute to a peripheral nerve trunk injury.
e severity of nerve injury will be dependent on the duration, magnitude, and character of the applied forces. Various
attempts have been made to classify nerve injuries, but the clas-
138
sication introduced by Seddon
in 1942 is still widely used
in combination with a grading system introduced by Sunder-
139
in 1951 (Table 2).
land
140,141
Nerve injury recovery has been
documented to occur at 2 mm to 3 mm per day in the proximal segments and 1 mm to 2 mm per day in the more distal
segments through a process involving Wallerian degeneration,
axonal regeneration, and end-organ re-innervation.
141
Neural tissue responds to injury in the same way that a
ligament or tendon does, by evoking the inammatory process
cascade, resulting in pain when stressed. A neurological dysfunction due to compressive pathology at multiple sites along
a single peripheral nerve, called the double-crush syndrome,
adds to the complexity of some clinical scenarios. e term
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23
Table 2.
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Seddon
138
and Sunderland
139
Classication of Nerve Injury
Seddon Sunderland Injury
Neuropraxia Grade I Focal, but transient, segmental demyelination without Wallerian degeneration.
Axonotmesis Grade II Axon is damaged with intact endoneurium. Wallerian degeneration occurs.
Grade III Axon and endoneurium are damaged with intact perineurium. Regenerating axons may
not innervate to original end organs.
Grade IV Axon, endoneurium, and perineurium damaged with intact epineurium.
Neurotmesis Grade V Complete nerve transection. Surgical intervention is usually required.
140
MacKinnon and Dellon
attempted to introduce a Grade VI to denote combinations of Grade III-V injuries along a
damaged nerve, but its usage has not been widely accepted.
double-crush syndrome describes the serial compromise of axonal transport within the same nerve ber, causing a subclinical
lesion at the distal site to become symptomatic. For example,
cervical radiculopathy, manifesting as little more than neck pain
and stiness, can cause a distal focal entrapment neuropathy
at the elbow to become symptomatic. e results from a neurophysiological examination combined with nerve conduction
studies are critical in distinguishing between a single or a double lesion and determining the comparative severity of the 2
142,143
lesions.
Several factors (excluding diseases such as rheumatoid arthritis, hypothyroidism, diabetes mellitus, immune deciency
syndromes, and alcoholism) are theorized to contribute to a
lesion within a peripheral nerve trunk (Appendix F). ese include the following
144,145
:
• Entrapment: is is the most prevalent type of peripheral
neuropathy and results from direct pressure to the nerve that
is either prolonged or repetitive.
• Sustained postures: A sucient change to the spine’s natu-
ral curves can shorten the distance traveled by the peripheral
nerve trunk and lead to an eventual adaptive shortening of
these structures.
• Direct trauma: Nerve injuries can occur due to a direct blow
to the nerve or secondary to damage of an adjacent structure
such as a fracture, joint dislocation, or tendon rupture.
• Extremes of motion: Extreme movements, including those
employed by neurodynamic mobility tests, can place a traction force through a peripheral trunk, especially in less exible individuals.
e clinical ndings depend on the magnitude of the injury and the nerve type, but the fundamental sign of entrapment
neuropathies is function loss with or without paresthesia and
146
pain.
It is also possible for a nerve injury to cause pure motor
paresis, pure sensory decit, or both, depending on the injury’s
extent and location. e classical description of nerve entrapment described in the literature is the occurrence of symptoms
within a dermatomal distribution, but it must be remembered
that symptom distribution in a nondermatomal pattern is also
common. us, an entrapment neuropathy cannot be ruled
out solely based on the pattern of symptom distribution.
146
In
general, the temporal sequence of neurological manifestations is
pain and paresthesia with irritation or inammation of the sensory nerves, numbness with ablation of the sensory nerves, and
weakness and atrophy when motor nerves are involved.
e dierential diagnoses to consider when suspecting any
involvement of the upper extremity’s peripheral nerves are outlined in Table 3. Traditionally, adverse neural tension tests were
thought to be diagnostic for entrapment neuropathies; however,
heightened mechanosensitivity can occur in the absence of a
nerve lesion, and vice versa, with patients with conrmed entrapment neuropathies presenting without signs of heightened
mechanosensitivity.
146
Nonoperative intervention is usually recommended for
patients with intermittent symptoms, no changes in 2-point
discrimination, and an absence of muscle atrophy. However,
despite clinical practice guidelines recommending nonoperative treatment before surgery is considered independent of the
type of entrapment neuropathy, with the exceptions of sciatica
and carpal tunnel syndrome, there is scant evidence for such an
approach.
146
In general, the focus of nonoperative intervention
from a physical therapy perspective is to teach the patient to
avoid prolonged movements or positions that provoke symptoms and to provide padding or splinting, when necessary, to
protect the injury site. For example, the goals for splinting for
signicant injury to the major nerves are as follows:
• Median nerve: to enhance thumb opposition while also pro-
viding some assistance to nger exion
• Ulnar nerve: to prevent clawing of the hand by blocking
metacarpophalangeal joint hyperextension
24
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Table 3.
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Dierential Diagnoses to Consider when Suspecting Peripheral Nerve Involvement
Peripheral
nerve
Ulnar –
cubital tunnel
Dierential diagnoses Comments
Cervical radiculopathy
oracic outlet syndrome
syndrome
Median –
pronator
syndrome
Cubital tunnel syndrome
Cervical radiculopathy
oracic outlet syndrome
AIN syndrome
Median –
AIN syndrome
Cervical radiculopathy
Brachial neuritis
A rupture of the exor
pollicis longus
Parsonage-Turner syndrome (idiopathic brachial plexopathy or neuralgic
amyotrophy)
Radial –PIN
RTS RTS is the only nerve compression syndrome in which the signs and symp-
syndrome
Radial –RTS Lateral elbow
tendinopathy
PIN syndrome
Cubital tunnel syndrome is commonly found in throwers due to the extreme
valgus stress placed upon the elbow, or people with sustained exed elbow
positions (long-range cyclists).
Pronator syndrome can be dierentiated from carpal tunnel syndrome by
using a Tinel test at the wrist or the provocation of symptoms through
prolonged wrist exion, neither of which should produce symptoms from a
pronator syndrome.
To help rule out brachial neuritis and Parsonage-Turner syndrome, the clinician should determine whether the patient has a history of transient shoulder
pain, viral infection, or recent immunization.
toms are not based on its distribution. e main clinical feature of RTS is
a localized tenderness over the radial tunnel (some 5 cm distal to the lateral
epicondyle, anterior to the radial neck). Resisted supination of the forearm
with the elbow fully extended should also reproduce the pain. e pain can
also become more severe when increased traction is applied to the nerve by
extending the elbow, pronating the forearm, or exing the wrist.
To help dierentiate between RTS and LET, LET presents with tenderness
directly on the lateral epicondyle and pain with resisted wrist extension.
To help dierentiate between RTS and PIN syndrome, there is no motor or
sensory loss in RTS, whereas, with PIN syndrome, there is a motor loss but
no sensory loss.
Abbreviations: AIN, anterior interosseous nerve; LET, lateral elbow tendinopathy; PIN, posterior interosseous nerve; RTS, radial tunnel syndrome
• Radial nerve: to provide wrist stability while also providing
some assistance to metacarpophalangeal joint extension
Any prescribed exercises must not reproduce the distal
nerve symptoms and may, therefore, initially need to be per-
• Radial nerve: metacarpophalangeal joint extension, thumb
abduction, and wrist extension
More specically, each of the common nerve compressive
neuropathies can be treated as follows:
formed in limited motion arcs. Each of the exercises prescribed
must address the potential functional loss depending on the
nerve involved:
• Cubital tunnel syndrome: A Cochrane systematic review
treatments for ulnar neuropathy found that activity modication with protection over the cubital tunnel with an elbow
• Median nerve: thumb opposition, precision grip, and strength
in the involved digits
• Ulnar nerve: key pinch, power grip, and coordination
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25
pad placed on the medial-posterior aspect,
tive extreme elbow exion, and night splinting at 40° to 60°
of elbow exion may be helpful. In severe cases, the splint
144
limiting repeti-
147
of
is worn during the day, or the elbow is cast at about 45°.
https://t.me/med1917
148
Exercises must not reproduce the distal nerve symptoms and
may, therefore, initially need to be performed in limited arcs
of motion.
•
Pronator syndrome: Rehabilitation, in cases where the nerve
compression is related to MET, involves gentle massage along
the bers to aid in breaking adhesions.
Anterior interosseous syndrome: In addition to a period of
•
rest and observation, splinting of the elbow near 90° of exion (or the position of most comfort for the patient) is often
benecial.
Posterior interosseous nerve syndrome: In addition to those
•
approaches mentioned previously, using a cock-up splint
combined with soft tissue techniques, such as active release
techniques in conjunction with neural gliding, may be bene-
149
Regular gentle stretching of the wrist extensor mus-
cial.
cles, with the elbow held in full extension, is initiated after a
spontaneous recovery.
• Radial tunnel syndrome: e intervention should focus on
education to avoid provocative positioning of the arm into
forceful extension and supination of the wrist and forearm,
with splinting used as appropriate.
Manual therapy, in the form of neurodynamic mobility
techniques, can be attempted, but it is worth remembering that
the examination of neural adhesions is by no means an exact science, and the interpretation of these tests and what constitutes
a positive test vary widely in the literature. us, the results
of these techniques must always be used in conjunction with
subjective and objective ndings from a complete neuromusculoskeletal reevaluation.
For those patients who fail to respond to nonoperative
management after 3 to 4 months and have muscle atrophy,
persistent sensory changes, or persistent symptoms, operative
intervention (eg, nerve decompression) is usually warranted.
Elbow Instability
In the presence of elbow instability, the standard preliminary physical examination of the elbow is usually unremarkable
for strength, ROM, and tenderness. Although elbow instability
has been documented for decades, the clinical tests for diagnosis
have been developed relatively recently. e following 5-item
classication system for elbow instability is useful for correct
150
diagnosis and treatment decision-making
:
1. e timing (acute, chronic, or recurrent)
2. e articulation(s) involved (humeroulnar or proximal ra-
dioulnar)
3. e direction of displacement (varus [lateral], valgus [medi-
al], anterior, or posterolateral rotatory).
4. e severity of displacement (subluxation or dislocation)
5. e presence or absence of associated fractures
e anatomical structures and the most common ndings
associated with the 2 main directions of instability are described
151
in Table 4.
e initial diagnosis of elbow instability is made
by the history and a careful physical examination. Patients
typically present with a history of recurrent painful clicking,
snapping, clunking, or locking of the elbow that occurs in the
extension portion of the arc of motion with the forearm in supination. e 2 most common tests to assess elbow joint stability
151,152
are
:
• e ulnar (medial) collateral ligament (valgus) test (Figure
11): e elbow is placed in 20° to 30° of exion with the
forearm supinated, and a valgus stress is applied. e test is
positive when no rm endpoint is perceived, greater than 10
mm of medial joint opening is noted (uoroscopically), or
the patient’s pain is reproduced. e valgus stress test is 66%
sensitive and 60% specic.
152
• e radial (lateral) collateral ligament (varus) test (Figure
12): With the patient sitting or standing, the therapist places
the patient’s elbow in slight exion (between 5° and 30°) and
then applies a varus force to the elbow. is test is considered
positive if the patient experiences pain or the clinician detects
excessive laxity compared to the contralateral side. e diagnostic accuracy of this test is currently unknown.
Another test that can help for a more specic diagnosis is
palpation of the UCL for tenderness, which has 81% to 94%
sensitivity and 22% specicity for a UCL tear.
152
Several diagnostic maneuvers are designed to help detect
Valgus instability
Valgus instability arises from injuries to the UCL, specifically its anterior portion (AUCL). Damage to the UCL may
occur with microtrauma (repetitive overuse in overhead throwing athletes) or macrotrauma (dislocation), with the patient reporting a pop followed by medial elbow pain after throwing
or presenting with persistent medial elbow pain that happens
during the various phases of throwing (late cocking to early
acceleration, most commonly) combined with a progressive
151
loss of performance.
Multiple examination maneuvers have
been described to assess valgus instability, including the valgus stress test, the milking maneuver (Figure 13 and Table 1),
the moving valgus stress test (Figure 14 and Table 1), and the
modied milking maneuver. e modied milking maneuver
is performed with the shoulder adducted, maximally externally
rotated, and the elbow exed to 70° as a valgus stress is applied
152
by pulling the thumb.
Unfortunately, no diagnostic studies
have been conducted to validate this test.
e nonoperative management of acute UCL injury, which
has been shown not to increase the risk of recurrent instability,
consists of a rehabilitation program after rest and adequate pain
control, with immediate mobilization in all planes of elbow and
26
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Table 4.
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Findings with the Most Common Directional Instabilities at the Elbow
Direction of
instability
Varus (RCL) e RCL is the primary
Description Clinical ndings Comments
Patients with the posterolateral type instability
at the elbow.
e common extensor muscle origin, the
posterior lateral capsule,
and the insertion of the
capsule into the annular
ligament provide secondary restraints.
typically have vague elbow
discomfort and clicking or
clunking that is worse with
supination of the forearm.
Patients with the posteromedial type instability
typically have a history
of repetitive trauma and
reports of clicking or
popping with elbow exion
and extension.
Valgus (UCL) Of the 3 portions of
the UCL, injury to
the anterior portion
is the most signicant
concern due to its primary role in providing
stability to the elbow.
e typical presentation is
one of medial elbow pain
and a history of either trauma or overuse. Depending
on the chronicity of the
symptoms, there may be
associated tendinopathy
or another source of local
inammation. e patient
may report the elbow
feeling more unstable when
the forearm is in pronation
than when the forearm is in
supination.
Abbreviations: RCL, radial collateral ligament; UCL, ulnar collateral ligament
A pure varus mechanism of injury is uncommon
because of the anatomic design of the elbow. Varus
20
injuries typically occur in 1 of 3 ways
Elbow dislocation (a valgus directed force in
1.
:
combination with an external rotation rotatory
force).
2.
Varus elbow stress. Although not common in
everyday activities, postural deformities (cubitus
varus deformity) or signicant weight-bearing
activities through the upper extremities (crutch
ambulation) can produce excessive varus forces.
3. Iatrogenic causes (eg, post lateral epicondyle
tendinopathy surgery).
Commonly the result of excessive valgus force to
the UCL such as a fall on the outstretched hand,
or from repetitive overhead throwing.
wrist motion being important to prevent stiness.
(PROM and AAROM) are performed at the humeroulnar joint
to restore exion/extension and at the humeroradial and radioulnar joints for supination/pronation.
be prescribed to enhance comfort and to decrease valgus stress
while progressively increasing elbow extension.
ness of any manual technique is determined by the stage of healing of the aected tissues, any motion limitations, and the end
feel. e strengthening program initially focuses on sub-painful
and submaximal isometrics for the elbow exors and extensors
and the wrist exor, extensor, pronator, and supinator muscle
154
groups.
Shoulder isometrics may also be performed during
this phase, with care taken with internal and external rotation exercises. e remaining progression focuses on advancing elbow and upper extremity mobility, improving muscular
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153
Exercises
154
A dynamic brace can
155
e forceful-
strength and endurance, and reestablishing neuromuscular control of the elbow complex.
High-demand patients diagnosed with UCL insuciency
for whom nonoperative treatment has failed are candidates for
surgical reconstruction.
156
Posterolateral rotatory instability
is type of instability, which occurs secondary to a traumatic or iatrogenic injury, is the elbow’s most common recurrent type of instability. ere has been a growing belief that
the lateral ulnar collateral ligament (LUCL) (Appendix D) is
the principal stabilizer against posterolateral rotatory instability
(PLRI), with support from several anatomic studies indicating
that other lateral elbow structures must also be aected, such
as the common extensor mechanism, the RCL, and portions of
27
Figure 11.
https://t.me/med1917
Valgus Stress test for the Ulnar Collateral
Ligament
e clinician places the patient’s elbow in slight exion while monitoring the joint line and stabilizing the
patient’s distal humerus with one hand. e clinician
then applies valgus stress to the elbow with the other
hand.
Figure 13.
Milking Maneuver
After the patient’s arm is extended and externally
rotated to neutralize glenohumeral motion, the forearm is supinated, and the elbow is exed to 90°. e
clinician then applies a valgus stress to the elbow by
extending the patient’s thumb.
Figure 14.
Moving Valgus Stress Test
Figure 12.
Varus Stress Test for the Radial Collater-
al Ligament (RCL)
e RCL is tested with the elbow positioned 5–15°
short of full extension. e clinician stabilizes the humerus and adducts the ulna, producing a varus force
at the elbow.).
e clinician uses his left hand to apply a valgus force
while using the right hand to ex and extend the patient’s elbow.
28
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