Elbow disorders

Dr.Atef A. Nadier, PhD

Lecture of Orthopedic Physical Therapy,PUA
Spring 2023
 Content
Anatomy of
elbow.

Olecranon Bursitis. Myositis Ossificans.

Lateral Elbow Osteochondritis

epicondylitis. Dissecans
Anatomy of the elbow
The elbow is composed of three distinct articulations:
• The humeroulnar joint, the humeroradial joint, and the proximal
radioulnar joint.
Anatomy of the elbow
• Posterior view • Lateral view
Anatomy Of The Elbow
• The humeroradial (radiocapitellar) joint is a uniaxial hinge joint
formed between the spherical capitellum of the humerus and the
concave fovea of the radial head.
• The resting, or open-packed, position of the humeroradial joint is
extension and forearm supination.
• The closepacked position is approximately 90 degrees of elbow
flexion and 5 degrees of supination.
Anatomy of the elbow
• HUMERO-ULNAR JOINT: Is a uniaxial hinge joint formed between the
incongruent saddle-shaped joint surfaces of the spool-shaped
trochlea of the humerus and the trochlear notch of the proximal ulna.
• The resting or open-packed position for the humeroulnar joint is 70
degrees of flexion with 10 degrees of forearm supination.
• The close-packed position is full extension and maximum forearm
supination.
Anatomy of the elbow
The carrying angle:
• Carrying angle is a small degree of cubitus
valgus formed between the axis of a
radially deviated forearm and the axis of
the humerus.
• It helps the arms to swing without hitting
the hips while walking.
• In full flexion these axes become aligned.
• The carrying angle is approximately 11–14
degrees in males and 13–16 degrees in
females.
Anatomy of the elbow
Ligaments:
• Joint capsule surrounds joint.(The capsule is thin but strong and is
reinforced medially and laterally by ligaments).
• Ulnar collateral .
• Radial collateral .
• Annular ligament.
Anatomy of the elbow
• N.B:50% of elbow stability is the result of the joint capsule, MCL, and
the LCL.
• The remaining 50% is associated with the bony structure of the joint.
Anatomy of the elbow
BURSAE:
• The olecranon bursa.
• The bicipitoradial bursa: Separates the biceps tendon from the radial
tuberosity.
• The subcutaneous medial epicondylar bursa.
• The subcutaneous lateral epicondylar bursa.
Anatomy of the elbow
Muscles:
• Biceps Brachii:
Via its long head, acts as a
shoulder flexor,
Elbow flexion from supination,
supination of the forearm
commonly when 90 flexion.
Anatomy of the elbow
Muscles:
• Brachialis:
Flex the elbow (from pronation or
supination ).
-It is the most powerful flexor of the
elbow when the forearm is pronated.
• Brachioradialis: act as a shunt muscle,
overcoming centrifugal forces acting on
the elbow, and adding power to increase
the speed of flexion.
• It is the most powerful flexor of the
elbow when the forearm is in nutral.
Anatomy of the elbow
Extensors of the elbow:
• Triceps brachii:
• Long head
• Lateral head
• Medial head
Myositis Ossificans (MO)
It is a reactive process with proliferation of
fibroblast, cartilage and bone within a muscle
and is usually seen after trauma.
Heterotopic bone formation in the muscletendon
unit, capsule, or ligamentous structures.
Myositis Ossificans (MO)
• Most often develops in the brachialis
muscle or joint capsule post a
comminuted fracture of the radial
head, supracondylar or a tear of the
brachialis tendon.
• Aggressive stretching of the elbow
flexors after injury and a period of
immobilization also acommon cause.
Myositis Ossificans
Clinical:
Passive extension is more limited than flexion.
 Resisted elbow flexion at mid-range causes pain in the brachialis muscle.
Tenderness at distal brachialis.
Heterotopic bone formation is laid down in muscle between individual muscle
fibers or around the joint capsule within a 2- to 4-week period.
In most cases, the heterotopic bone, is largely reabsorbed over several months,
and motion usually returns to near normal.
Myositis Ossificans
Management:
• Analgesics.
• Ice.
• Rest in a splint, removed only during active pain-free ADL.
• Rest should continue until the bony mass matures and then resorbs.
• Massage, passive stretching, and resistive exercise are
contraindicated if the brachialis muscle is implicated after trauma.
Myositis Ossificans
Management:
• Iontophoresis with acetic.
• Ultrasound .
• Extra corporeal shock wave therapy.(Low evidence)
• Surgical excision (rare) when failled conservative mangement and still
function limitation .
Lateral Epicondylitis
• Epicondylitis: Overuse of the medial and lateral musculotendinous
structures causing microscopic tears and inflammation.
• N.P: Tendinosis or tendinopathy refers to degenerative changes in the
collagen tissue without signs of inflammation.
Lateral epicondylitis:
• Overuse of the lateral musculotendinous structures causing
microscopic tears and inflammation.
• The most common cause of epicondylalgia is excessive repetitive use
or eccentric strain of the wrist or forearm muscles.
• The result is microdamage and partial tears, usually near the
musculotendinous junction.
• Initially there may be signs of inflammation followed by the
formation of granulation tissue and adhesions.
Lateral epicondylitis:
• This typical throwing movement can cause injuries in tennis and
baseball such as tennis elbow.
• Also when the elbow is maximally extended, so that the posterior
upper part of the ulna, i.e. the olecranon, is pressed against the back
of the upper arm and can cause impingement.
Lateral epicondylitis:
• Involvement of the extensor carpi radialis brevis (ECRB) is typical in
tennis players.
• In lateral elbow tendinosis due to other causes, e.g. industrial work, it
seems that the extensor digitorum communis is typically involved.
This also leads to a positive middle finger test.(Maudsley Test)
Lateral epicondylitis:
Clinical Features:
• Patient is active of 30-40 years.
• Pain comes on gradually, often after a period of forceful gripping and
wrist extension.
• Pain usually localized the lateral epicondyle but in severe cases pain
radiating widely to the back of forearm.
• Flexion and extension of the elbow all full and painless.
• Limited elbow extension may be present in sever cases.
• Decreased hand grip strength.
Lateral epicondylitis:
Clinical Features:
• Pain can be reproduced by passively stretching the wrist
extensors with ulnar deviation (elbow is completely
extended) or by asking the patient to extend his wrist with
radial deviation while the therapist resist this movement.
Lateral epicondylitis:
Nonoperative Management:
Rest.
A splint :Such as a cock-up splint in
which the elbow and fingers are free to
move.
Patient instruction. Instruct the patient
to avoid all aggravating activities, such
as strong or repetitive gripping actions.
Cryotherapy: Ice to help control edema
and swelling.
Lateral epicondylitis:
Nonoperative Management:
• Multiple-angle muscle setting :(low-intensity isometrics) within the pain
free range:
From sitting with the elbow flexed, forearm pronated and resting on a table, and
the wrist in extension. Begin with gentle isometric contractions with the wrist
extensors in the shortened position.
Lateral epicondylitis:
Multiple-angle muscle setting:
• Hold the contraction to the count of 6, relax, and repeat several
times; then move the wrist toward flexion and repeat the isometric
resistance).
• When full wrist flexion is obtained without pain in the lateral
epicondyle region, progress by placing the elbow in greater degrees
of extension and repeat the isometric resistance sequence to the
wrist extensors.
Lateral epicondylitis:
Nonoperative Management:
• Cross-fiber massage :Apply gentle cross-fiber massage within
tolerance at the site of the lesion.
• Neuromobilization: If increased symptoms occur with nerve tension
testing, use neuromobilization
techniques.(https://www.youtube.com/watch?v=Fv_EJV8q2E0)
Lateral epicondylitis:
Nonoperative Management:
• Mobilization with movement (MWM)
for lateral epicondylitis.
Lateral glide is applied to the proximal
forearm (A) with resistance added to
wrist extension, (B) with patient
squeezing a ball to bring in the wrist
extensors, and (C) with self-treatment.
Lateral epicondylitis:
Nonoperative Management:
• Counter force elbow strap.
to reduce the load on the musculotendinous
unit.( immediate effect).
(Constrictive band caused a significant reduction
in integrated electromyography (EMG) activity of
the extensor carpi radialis brevis and the
extensor digitorum communis ).
• Hand grasping while in supination.
• Avoid pronation motions .
Lateral epicondylitis:
Nonoperative Management:
• Eccentric training:
 First within a comfortable wrist ROM against a
low-intensity load, at a slow speed.
 Then Progress to faster speeds before
increasing the resistance.
 When resistance is increased, return to a slow
speed and then again work up to a faster speed
before increasing the resistance and so on.
Lateral epicondylitis:
Nonoperative Management:
• Plyometric exercises:( A program of high-
intensity, high-velocity exercises develops
power output, quick neuromuscular reactions,
and coordination)
• If the patient’s goals include returning to
sports,
• or occupational activities that require elbow
and forearm power.
Lateral epicondylitis:
Nonoperative Management:
(For prevention) :
• The racquet should be individually selected
with regard to playing technique.
• The appropriate size of grip circumference
should equal distance between the midline of
the palm of the hand and the tip of the middle
finger.
• The balls should be light.
• Correct playing and working techniques are
the most important preventive measures.
 Remember
 Tennis elbow is a self-healing condition with a good prognosis.
The injury persists for an average of 6 months to 2 years.
An effective tennis serve requires good core strength and core stability.
Recurring problems are seen because the resulting immobile or immature scar is
re-damaged when returning to activities before there is sufficient healing or
mobility in the surrounding tissue
Lateral epicondylitis:
Nonoperative Management:
• Shock wave treatment, which has been shown to have some effect in
some studies.
• This treatment creates a tissue injury and thus initiates the healing
process with increased circulation over a period of at least 2–3
months.
Lateral epicondylitis:
A cortisone injection( local):
• Today are considered to be a chronic tennis elbow when a long
period of training has not had the intended effect.
• During the initial 24–28 hours, increased pain may be experienced.
• A steroid injection should be followed by 1–2 weeks’ rest and should
not be repeated more than 2 times.
Lateral epicondylitis:
Surgery:
• Surgery consists of resection of damaged tissue.
• The attachment of normal tissues should be maintained and the healthy
tissues protected.
• The elbow is protected at 90° for 1 week in a counterforce elbow
immobilizer.
• Strength and endurance resistance exercises usually start 3 weeks after
surgery.
• Postoperatively, 85% experience complete pain relief and full return of
strength.
• A recurrence rate of 18–66% is reported.
Elbow Osteochondritis Dissecans
• The etiology of this condition is
probably relates to a focal
arterial injury and subsequent
bone necrosis resulting from
increased radiohumeral lateral
compression forces.
• Repetitive microtrauma is widely
accepted as the etiology.
• May be more prevalent among
adolescent overhead athletes.
Elbow Osteochondritis Dissecans
Clinical:
 Crepitation at the radiocapitellar joint with Resistive testing.
Pain with activity especially while repetitive valgus stress activites and with
supination & pronation.
Tenderness at the lateral aspect of the elbow.
Loss of extension with 15 to 20 degree flexion contracture.
Swelling at the elbow joint.
Sudden locking or catching of the elbow motion due to osteophytes and loose
bodies.
Elbow Osteochondritis Dissecans
Clinical:
• X.ray:May reveal a flattening or
focal distortion of the capitellum
and
perhaps even loose bodies.
• MRI can also confirm diagnosis,
monitor progress and assess for
potential surgical intervention,
will show any accumulation of fluid
in the area and can detect any loose
fragments.
Elbow Osteochondritis Dissecans
Treatment:
Analgesia and NSAIDs.
Biceps and triceps strength exercises.
A motion-limiting brace can be used to reduce stress.( for 6-12
weeks)
 (e.g:Hinged elbow brace).
 Most athletes who respond to conservative management may start
gentle overhead throwing at 3–4 months with return to play at
6 months.
Elbow Osteochondritis Dissecans
Surgical intervention:
• Reserved for patients who do not respond to conservative treatment,
or those with loose bodies or,
separation of the cartilage capsule.
Arthroscopic surgery will aim to:
Remove loose bodies and fragments.
Debride any necrotic bone.
Mirco-fracture the site to stimulate increased blood flow.
Elbow Osteochondritis Dissecans
Surgical intervention:
Osteochondral autograft transplantation:
• May be nedded in large, unstable lesions,
• lesions involving greater than 50 % of the articular surface,
• and lesions extending into the lateral border of the capitellum.
Elbow Osteochondritis Dissecans
Post-operative:
• CPM.
• Gentle circulation and residual joint ROM exercises can be started
(fingers, wrist and shoulder).
• At three weeks post operatively ROM and gradual strengthening may
be commenced.
• A high rate of return to sport was observed after operative
management of capitellar OCD.
Olecranon bursitis:
• The olecranon bursa is easily injured through direct trauma or can be
irritated through repetitive weight bearing through the elbows, such
as students.
Olecranon bursitis
Clinically:
Swollen, painful enlargement of the posterior aspect of the elbow.
In chronic cases, patient have chronic recurrent swelling over the
posterior aspect which is not tender .
If the swelling increase it may affect the elbow motion.
Redness and heat suggest inflammation, whereas sever tenderness
indicates trauma or infection.
Olecranon bursitis
Differential diagnoses:
• Acute fractures,
• Rheumatoid arthritis,
• Gout.
• Synovial cysts.
Olecranon bursitis
Treatment:
Ice.
Rest.
Elevation.
A sling: If the patient is experiencing significant pain.
Aspiration:In patients with marked swelling (to distinguish between
septic and nonseptic bursitis or gout).
 A splint and sling after aspiration for 1 week.
Olecranon bursitis
Treatment:
Antibiotic :For septic bursitis .
Surgical excision :An infection that does not respond to antibiotics
Corticosteroids injection: Used to manage chronic bursitis.
ROM exercices.
Differential Diagnoses For Elbow:
1-Radial Tunnel Syndrome
2-Golfer's elbow .
3-Cubital Tunnel Syndrome
4-Pronator teres syndrome .
5- Cervical radiculopathies.
6- CTS.
7-Systemic causes of elbow pain.
 REFERENCES

Carolyn Kisner, Lynn Allen Colby Therapeutic Exercise Foundations and

Tec,2020.
David J ORTHOPEDIC PHYSICAL ASSESSMENT 5ThEdition, David et al.2011.
Dutton’s Orthopaedic Examination, Evaluation and Intervention, Fourth
Edition 4th Edition,2020.
Orthopedic & Sports Clinical Practice Guidelines by JOSPT ,2017.
Sferopoulos et al .Myositis ossificans in children: A review. Eur J Orthop Surg
Traumatol (2017) 27:491–502.
Efficacy of mobilization with movement in lat.epicondylitis.J of P.T,2010.
Thank you