KIN 188 – Prevention KIN 188 – Prevention and Care of Athletic and Care of Athletic

InjuriesInjuries

Elbow Evaluation and InjuriesElbow Evaluation and Injuries

AnatomyAnatomy

Bony AnatomyBony Anatomy

► HumerusHumerus Medial/lateral epicondyles, Medial/lateral epicondyles,

capitellum, trochleacapitellum, trochlea

► UlnaUlna Semilunar notch (coranoid Semilunar notch (coranoid

process – anterior, process – anterior, olecranon process – olecranon process – posterior)posterior)

► RadiusRadius Radial head, radial Radial head, radial

tuberosity (insertion of tuberosity (insertion of biceps brachii)biceps brachii)

Ligamentous AnatomyLigamentous Anatomy

► Ulnohumeral jointUlnohumeral joint Flexion/extension Flexion/extension

motionsmotions Medial/lateral collateral Medial/lateral collateral

ligamentsligaments

► Radiohumeral jointRadiohumeral joint Pronation/supination Pronation/supination

motionsmotions

► Radioulnar joint Radioulnar joint (proximal)(proximal) Pronation/supination Pronation/supination

motionsmotions Annular ligamentAnnular ligament

Muscular AnatomyMuscular Anatomy

►Muscles acting on elbowMuscles acting on elbow Anterior/flexorsAnterior/flexors

►Biceps brachii, brachialis, brachioradialisBiceps brachii, brachialis, brachioradialis

Posterior/extensorsPosterior/extensors►Triceps brachii, anconeusTriceps brachii, anconeus

►Muscles acting on forearm, wrist, hand and Muscles acting on forearm, wrist, hand and fingersfingers Flexor/pronator group from medial epicondyleFlexor/pronator group from medial epicondyle Extensor/supinator group from lateral epicondyleExtensor/supinator group from lateral epicondyle

EvaluationEvaluation

HistoryHistory

► Mechanism of injury/etiologyMechanism of injury/etiology Direct trauma (contusion, fracture, bursitis)Direct trauma (contusion, fracture, bursitis) Hyperextension (posterior dislocation, ligamentous Hyperextension (posterior dislocation, ligamentous

injury, biceps brachii tendon rupture)injury, biceps brachii tendon rupture) Valgus force application (MCL injury)Valgus force application (MCL injury) Varus force application (LCL/annular ligament Varus force application (LCL/annular ligament

injury)injury) Repetitive stresses (tendonitis, epicondylitis, Repetitive stresses (tendonitis, epicondylitis,

bursitis)bursitis) Fall on outstretched arm (fracture, dislocation, Fall on outstretched arm (fracture, dislocation,

ligamentous injury)ligamentous injury)

HistoryHistory

►Unusual sounds/sensationsUnusual sounds/sensations Feeling of “giving way” of elbow with Feeling of “giving way” of elbow with

throwing motionthrowing motion ““Pop” or “snap” often associated with Pop” or “snap” often associated with

ligament or tendon ruptureligament or tendon rupture

►History of previous injury/surgeryHistory of previous injury/surgery

HistoryHistory

► Change in activityChange in activity Intensity, duration, frequency, biomechanics/technique, Intensity, duration, frequency, biomechanics/technique,

equipmentequipment

► Acute/gradual onset of symptomsAcute/gradual onset of symptoms Macrotraumatic vs. microtruamaticMacrotraumatic vs. microtruamatic

► Characterize painCharacterize pain Location (point with 1 finger)Location (point with 1 finger) Dull, sharp, burning, throbbing, etc.Dull, sharp, burning, throbbing, etc. Rate on scale (1-10)Rate on scale (1-10) What increases or decreases?What increases or decreases?

► Treatment, medication, evaluation to dateTreatment, medication, evaluation to date

Inspection/ObservationInspection/Observation

► ALWAYSALWAYS compare bilaterally compare bilaterally► Obvious deformityObvious deformity

Cubitus valgum (“carrying angle”)Cubitus valgum (“carrying angle”)► Should be present, normal is ~11-16 degrees)Should be present, normal is ~11-16 degrees)

Cubitus varum (“gunstock deformity”)Cubitus varum (“gunstock deformity”) Cubitus recurvatum (“hyperextension”)Cubitus recurvatum (“hyperextension”) Bony alignment (medial/lateral epicondyles, olecranon Bony alignment (medial/lateral epicondyles, olecranon

process)process)► Straight line in extension, isosceles triangle in flexionStraight line in extension, isosceles triangle in flexion

► BleedingBleeding► Discoloration/ecchymosisDiscoloration/ecchymosis► SwellingSwelling

Immediate vs. gradual, amountImmediate vs. gradual, amount► ScarsScars

Inspection/ObservationInspection/Observation

PalpationPalpation

► AnteriorAnterior Biceps brachii tendon, brachioradialis, flexor/pronator groupBiceps brachii tendon, brachioradialis, flexor/pronator group

► MedialMedial Medial epicondyle, ulna, medial collateral ligament, ulnar Medial epicondyle, ulna, medial collateral ligament, ulnar

nervenerve

► LateralLateral Lateral epicondyle, radial head, capitellum, lateral collateral Lateral epicondyle, radial head, capitellum, lateral collateral

ligament, annular ligamentligament, annular ligament

► PosteriorPosterior Olecranon process, olecranon fossa, triceps brachii tendon, Olecranon process, olecranon fossa, triceps brachii tendon,

anconeus, extensor/supinator groupanconeus, extensor/supinator group

Special TestsSpecial Tests

► ROMROM Active – patient/athlete moves jointActive – patient/athlete moves joint Passive – clinician moves joint, evaluates end feelPassive – clinician moves joint, evaluates end feel Resistive – proximal stabilization and distal Resistive – proximal stabilization and distal

application of resistance (“break” test vs. application of resistance (“break” test vs. resistance through ROM)resistance through ROM)

► NeurovascularNeurovascular

► Special testsSpecial tests

Range of MotionRange of Motion

► FlexionFlexion 150 degrees is normal150 degrees is normal Biceps brachii, brachialis, Biceps brachii, brachialis,

brachioradialisbrachioradialis

► ExtensionExtension 0 degrees is normal (~10 0 degrees is normal (~10

degrees hyperextension degrees hyperextension OK)OK)

Triceps brachii and Triceps brachii and anconeusanconeus

Range of MotionRange of Motion

► PronationPronation 85-90 degrees normal85-90 degrees normal Pronator teres, Pronator teres,

pronator quadratuspronator quadratus

► SupinationSupination 85-90 degrees normal85-90 degrees normal Supinator, biceps Supinator, biceps

brachiibrachii

NeurovascularNeurovascular

►Neurological evalationNeurological evalation Nerve root level and peripheral nerve sensory Nerve root level and peripheral nerve sensory

and motor distributions from cervical and motor distributions from cervical spine/brachial plexusspine/brachial plexus

► Vascular evaluationVascular evaluation Skin temperature/colorSkin temperature/color Capillary refillCapillary refill Axillary pulseAxillary pulse Brachial pulse (on arm and at elbow)Brachial pulse (on arm and at elbow) Radial pulseRadial pulse

Special TestsSpecial Tests

►Valgus stress test – medial collateral Valgus stress test – medial collateral ligamentligament

►Varus stress test – lateral collateral Varus stress test – lateral collateral ligamentligament

►Tennis elbow test – lateral Tennis elbow test – lateral epicondylitisepicondylitis

InjuriesInjuries

Ligamentous InjuriesLigamentous Injuries

►Medial collateral ligament injuryMedial collateral ligament injury May occur secondary to trauma (valgus force May occur secondary to trauma (valgus force

application) or present as chronic instability application) or present as chronic instability secondary to repetitive overhead activitiessecondary to repetitive overhead activities

In competitive athletes, grade III injuries typically In competitive athletes, grade III injuries typically treated surgically (“Tommy John” procedure)treated surgically (“Tommy John” procedure)

► Lateral collateral ligament injuryLateral collateral ligament injury Not common – almost always treated Not common – almost always treated

conservativelyconservatively Usually secondary to varus force applicationUsually secondary to varus force application May also injure annular ligament and affect May also injure annular ligament and affect

radioulnar jointradioulnar joint

EpicondylitisEpicondylitis

►Medial epicondylitisMedial epicondylitis ““Golfer’s elbow” or “little leaguer’s elbow”Golfer’s elbow” or “little leaguer’s elbow” Overuse of flexor/pronator muscles – may Overuse of flexor/pronator muscles – may

have avulsion fracturehave avulsion fracture

►Lateral epicondylitisLateral epicondylitis ““Tennis elbow”Tennis elbow” Overuse of extensor/supinator musclesOveruse of extensor/supinator muscles

Cubital Tunnel SyndromeCubital Tunnel Syndrome

►General term given General term given to ulnar nerve injury to ulnar nerve injury or irritationor irritation

►May be contused May be contused via direct trauma, via direct trauma, compressed by compressed by flexor/pronator flexor/pronator mass, and/or sublux mass, and/or sublux from cubital tunnelfrom cubital tunnel

Elbow DislocationsElbow Dislocations

► PosteriorPosterior Most common directionMost common direction Typically associated with Typically associated with

hyperextension hyperextension mechanismmechanism

Significant risk of Significant risk of neurovascular injury in neurovascular injury in addition to ligamentous addition to ligamentous injuryinjury

► AnteriorAnterior Rare occurencesRare occurences

Elbow DislocationsElbow Dislocations

FracturesFractures

►HumerusHumerus Supracondylar fractureSupracondylar fracture

►UlnaUlna Coronoid/olecranon process fractureCoronoid/olecranon process fracture

►RadiusRadius Radial head fracturesRadial head fractures

FracturesFractures

Olecranon BursitisOlecranon Bursitis

► Typically due to direct Typically due to direct traumatrauma

► Usually easily treated Usually easily treated with rest, modalities with rest, modalities compression, and compression, and NSAIDsNSAIDs

► If persists, may be If persists, may be aspirated – risk of aspirated – risk of infectioninfection