Elbow Disorders

Kim Kraft, PT, DPT, CHT

St Louis, MOApril 27-29, 2018

AgendaEvaluation/Special TestsEvaluation/Special Tests

Elbow PathologyElbow Pathology

• Ligamentous Injury

• Lateral Collateral Ligament Complex

• Medial Collateral Ligament Complex

• Dislocations

• Fractures

• Elbow trauma

• Total elbow replacement

• Tendinous

Elbow Evaluation

Elbow Exam1. History

2. Visually inspect the front, side and back of both elbows to compare symmetry

3. Look for edema, ecchymosis, bony misalignment

4. Normal carrying angle is slight valgus

5. Ask patient to extend/flex and sup/pro bilaterally

6. Take PROM if AROM is incomplete

7. Resisted Tests

8. Special Tests

9. Palpate for temperature and tenderness

Outcomes Measures

Name

American Shoulder and Elbow Surgeons Form 

Disabilities of Arm, Shoulder, and Hand

Elbow Self‐Assessment Score

Oxford Elbow Score

Patient Rated Elbow Evaluation

QuickDASH

• Examiner places one hand on medial elbow, the other on distal radial wrist and applies medial force to wrist

• Two positions: full extension and up to 30 degrees flexion

• Positive if painful or more lax than contralateral

• Charalambus & Stanley 2008

Varus Stress TestRadial (Lateral) Collateral Ligament

Kraft

Gravity Assisted Varus Stress Test

Kraft

Bend/straighten elbow in sitting or standingPositive if painful, popping, or grindingRamirez et al 2015

Push Up SignPosterolateral Rotary Instability (PLRI)

• Supinated forearm, elbow flexed 90 degrees, hands wider than shoulders

• Positive: apprehension, muscle guarding, dislocation

• Regan et al 2006

Kraft

This is the best I can supinate!

Stand Up Test/ Chair SignPosterolateral Rotary Instability (PLRI)

• Forearms supinated, elbows flexed 90 degrees and weight bearing as the patient pushes up from chair

• Positive: Apprehension, pain or instability

• Regan et all 2006Kraft

But my hands can’t point backward!

Lateral Pivot Shift

• Elbow in extension; examiner applies axial extension and valgus force to the elbow

• Positive: apprehension, dislocation

• O’Driscoll et al 1991• Charalambus &

Stanley 2008Kraft

Valgus Stress TestUlnar (Medial) Collateral Ligament

• Forearm pronation* disclaimer

• Apply valgus in 2 positions 0 and slightly flexed 5-30 degrees

• Azar et al 2000

• Also, moving Valgus test Kraft

Moving Valgus Stress Test

• ER humerus at 90 abduction

• Examiner places a constant valgus stress on the elbow as it is moved 90-30 at the elbow

• Rahman et all 2008

Milking Test

• Which ligament?• Elbow flexed 70

degrees; forearm supinated

• Clinician applies valgus force by applying force to the thumb

• Safran 2004 Kraft

Hook TestDistal Biceps Integrity• Try it!• Palpate distal

biceps tendon in the elbow crease

• If tendon is found, the test is negative

• O’Driscoll et al 2007

Kraft

Squeeze TestDistal Biceps• Try it on a buddy!• Squeeze belly of

biceps

• Watch for slightflexion or elbow with pressure

• Ruland et al 2007

Bicep Squeeze

Marik

Cubital Tunnel Tests

Marik

Test Sensitivity/Specificity

Wartenberg’s sign: Abduction SF

?

Palpation Ulnar Groove ?

Tinel’s Sensitivity 54‐70%Specificity 98%

Elbow Flexion  Sensitivity 75%Specificity 98%

Pressure Provocative Test(30 seconds compression ulnar nerve with sustained elbow flexion)

Sensitivity 46‐91%Specificity 99%

Scratch Collapse Sensitivity 69%Specificity 99%

Froment’s Sign ?

Cheng et al 2005, Novak at al 1994

Cozens (resistance)

Mills (stretch)

Lateral Tendinopathy Tests

Marik

Grip Strength: Elbow Flexed vs Elbow Extended

Kraft

Maudsley’s 3rd Finger Resistance• Base of the third

metacarpal is the insertion of the ECRB

• Positive: pain and/or weakness

• Nirschl & Ashman 1992

Kraft

• Painful palpation• Area of shear, poor

perfusion

• Versus radial tunnel

• Placement of Counter Force Brace

Marik

Palpation Lateral Epicondyle

Handshake

• Patient elbow extended

• Wrist neutral

• Positive: reproduction of pain

• Kraushaar & Nirschl 1999

Fractures

• Olecranon

• Radial Head

• Coronoid

Instability

• Lateral Collateral Ligament Injury

• PLRI

•Medial Collateral Ligament Injury 

• Complex Instability (Fracture)

Tendinopathy

• Lateral

•Medial

• Bicipital

Other Pathologies/

Complications

• Osteochondritis Desiccans

• RA/OA/TEA

• Olecranon Bursitis

Elbow Diagnoses

Fractures

Elbow Fractures

Associated with traumatic event• Clear onset• Probable edema• Acute pain• Tender to palpation• X-ray confirms diagnosis

Types• Olecranon• Radial Head• Coronoid

Elbow Fractures

Stiffness is a major concern after elbow fractures (ESPECIALLY intraarticular) Early motion is important.

A/AAROM until healed, usually 6 weeks• Nondisplaced fractures start motion right away• Surgical reduction: initiation of ROM depends on

stability of the fixation • Progress to PROM and static progressive splinting

if needed once fracture is healed

Complications include: instability, non-union, post-traumatic arthrosis, heterotopic ossificans

Olecranon Fracture

• Geriatric Injury• Mechanism: Posterior fall

• Wire Fixation Most Common• Almost 99% of the time, wires/hardware

removed ultimately• ?Ulnar nerve entrapment in scar or callus

Olecranon FracturesConservative Care

0‐3 weeks

• Post Op long arm Bulky 

3‐6 weeks

• Long arm splint

• AROM elbow 0‐90, forearm, wrist

• Compression

6‐7 weeks

• Unrestricted AROM

• Splinted between exercises and at night

Diagnosis and Treatment Manual 2001

Olecranon FracturesPost-Op

0‐2 weeks

• In post‐op Bulky Long Arm

2‐6 weeks

• AROM; initially just 0‐90 degrees

• Possible static progressive orthosis

6 weeks post‐op

•May begin PROM depending on films

8 weeks

• Progressive splinting

Diagnosis and Treatment Manual 2001

Radial Head Fractures

• Mechanism: ProFOOSH, direct blow/lateral force, hyperflexion

• Usually non-displaced/Type 1= conservative care

• Mason-Johnston Classification• Type 1: Non displaced• Type 2: Displaced• Type 3: Comminuted (smashed)• Type 4: Fracture/dislocation

• Replacement Criteria• Types 2-4 or LCL injury at the same time

• Development of lamellar bone in non-osseous tissue; characterized by progressive loss of ROM

• Associated with head injury, burns, other ossifying disorders (ankylosing spondylitis, for example)

Radial Head Fracture Heterotopic Ossification

Literature Review

1. Radial head fx

2. Distal DRUJ dislocation

3. Disruption of interosseous membrane

DRUJ may be pinned (supination) for 6 weeks to allow IM to heal

(Radial head excision is contraindicated ; proximal migration of radius due to insufficiency

of IM; may have radial head replacement)

Essex-Lopresti Fracture

Coronoid Fractures…Terrible TRIAD!

• Posterior dislocation of ulnohumeral joint

• Coronoid fracture

• LCL rupture

Surgery: Anterior capsule repair, radial head replacement (or fixation), Lateral Collateral Ligament repair

Avoid: varus stress to elbow during healing (shoulder AB, IR)

Literature ReviewPatient selection: no indication for radial or coronoid fracture fixation, no intraarticular fragments, has 60 pro and sup, stable ulnohumeral joint up to 45 degrees

11-140 degrees; DASH around 5 after 30.6 month follow up of 10 patients

Instability

Static Elbow StabilityResistance to: Structure 0⁰ Elbow Extension 90⁰ Elbow Flexion

Valgus stress Medial (Ulnar) Collateral Ligament

31% 54%

Anterior Capsule 38% 10%

Bony Articulation 31% 36%

Varus Stress Lateral (Radial) Collateral Ligament

14% 9%

Anterior Capsule 32% 13%

Bony Articulation 55% 75%

Distraction Anterior Capsule 70% Minimal

Medial (Ulnar)Collateral Ligament

5% Primary

Morrey 2005, Morrey 1983

Dynamic Elbow Stability

• brachialis, biceps brachii, pronator teres, FCR, FCU, palmaris longus, Humeral head of FDS

Ulnar Side:

• brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis

Radial Side:

• triceps

Posterior:

Muscles crossing the elbow add compression, some medial/lateral support, can be used to add stability to an unstable elbow

Elbow Ligament Injuries

Described as simple or complex• Simple = no associated fracture• Complex = concurrent fracture

Post-reduction considerations• Elbow may be stable in a limited range of motion or

specific positions• Elbows get stiff quickly when not moving through full

range of motion• Dynamic stability provided through compressive forces

of muscles crossing elbow allows early AROM

(Eygendaal 2011, Haan 2011)

Figure 1

Instability Rehab Principles

Overhead supine AA flexion / protected 

extension –forearm supination

Forearm rotation at 90° flexion

Overhead supine AA flexion / protected 

extension –forearm pronation

SternLiterature Review

Lateral (Radial) Collateral Ligament Injury

Mechanism of injury • Generally Traumatic• Fall on outstretched hand (FOOSH)• Forced twisting of the arm with varus

(lateral) forces• Repeated Varus stress: example

malunion as child, Gunstock deformity (decreased carrying angle), crutch users

• Treatment for Lateral Tendinopathy, radial head fracturesDynamic Varus SupportsCommon extensor origin, capsule/annular ligament

Pixabay

Lateral Collateral Ligament Injury Considerations

Position of Stability: Pronation and Flexion

Pronation stabilizes the LCL through E/F arc.

Flexion and Pronation increases the contact between the Capitellum and Radial Head

Testing: Varus stress test with the ligaments in a LAX position – testing LCL should be done in supination where it will be most unstable…treatment will be done in PRONATION for stability

Treatment Principle: Avoid positions of shoulder AB and IR which cause varus stress to the elbow AND avoid supination

Armstrong 2000, Dunning 2001

1. Splint 90° flexion, pronatedPrefabricated vs. Custom LAS

2. AROM extension/flexion; extension limited to 60° initially and gradually increased

3. Forearm rotation from pronation to neutral only for 6 weeks (no supination)

4. Immobilization period varies from 2 to 12 wks;

5. Gradually resume supination6. Return to sport at 6 to 9 mo post-op

AliMed

Lateral Collateral LigamentRehab Principles

Posterolateral Rotatory Instability (PLRI)

• Can result from a FOOSH with forearm supinated

• Leads to ulna (moving with radius due to annular ligament) externally rotating away from trochlea Radsource:

http://www.radsource.us/clinic/0901

• C/o clicking, snapping, clunking, locking, “giving way”

• Usually occurs with slight elbow flexion and partial supination

• May have history of elbow sprain• Progressive condition with increasing loss of

function due to elbow instability• Requires LCL reconstruction• Clinical Tests: Pivot shift, push up sign, chair

sign, press up maneuver

PLRI Symptoms LCL SurgeryRepair Vs. Reconstruction • Not all tears are repaired; sometimes they are left

to heal on their own

• This can lead to chronic instability

• Ligament repair can occur if surgery is performed within 2-3 weeks of injury

• Ligament reconstruction is chosen if injury is more than 3 weeks old

• Palmaris longus is usually used for reconstruction

• Great outcomes with reconstruction; usually open repair (not arthroscopic)

LCL Reconstruction

Sanchez et al

Mechanism: Traumatic/clear onset/”pop” and pain

vsGradual progressive (Thrower’s elbow)

Testing: (pronated) Valgus Stress Test, Moving valgus, Milking maneuver

Little League ElbowOnset may be vague, characterized by failure to perform at less than normal ability:

Decreased accuracyDecreased velocityDecreased endurance

Medial (Ulnar) Collateral Ligament Injuries

Medial (Ulnar) Collateral Ligament InjuryConsiderations

• Dynamic support from flexor/pronator group• Can be associated with radial head fracture or lateral

HU/Olecranon degeneration (by compression)• If no specific “pop” or rupture is noted, conservative

management consisting of strengthening the muscles surrounding the joint is pursued.

• If surgery is required, ligament repair may be possible in nonprofessional athletes

• Most professional athletes require ligament reconstruction, aka “Tommy John” , Docking procedures.

• Check out Ulnar nerve (traction)

• Protect: rest from overhead activity

• Splint: LCL injury in pronation

MCL injury in supination

Both MCL/LCL injured: in neutral rotation

• Early exercise can include these to increase joint stability:• Isometric elbow extension and flexion• Resisted wrist extension and flexion

• Strengthening- core,plus…• Dynamic Stabilizers can help!• Thrower’s Ten Program for shoulder, elbow, forearm,

and wrist

• Evaluation of throwing/serving/etc technique

Elbow Ligament Rehab Principles

Post-operative management of MCL injury• Splint in neutral rotation or supination, 90° flexion

• Active elbow extension and flexion, with full extension limited initially

• AROM digits and wrist; ok to grip

• Isometric strengthening of shoulder. No external rotation of shoulder as it creates valgus stress at elbow

• Splint D/C’d at 6 weeks

• Progress through full ROM and into Thrower’s Ten

Post-Tommy JohnLigament Injuries with Fracture and Dislocation

Galeazzi: Radial shaft fracture with dislocation of distal radial ulnar joint, IOM 

tear assumed

Essex Lopresti: Ulna shaft fracture and dislocation of the radial head, IOM 

tear assumed

Complex Ligament Injury

radiopaedia.org

Tendinopathy

Elbow TendinopathyClinical Exam• Palpation, Tension,

Resistance of: tendons in the area patient reports painful

• Always compare to contralateral, *chief complaint

Mechanism: often an event involving a sudden eccentric load to biceps while it is contracting.

Exam:• Palpate at elbow crease and just distal• Resist supination • Resist elbow flexion with forearm supinated• Hook Test, Squeeze Test – Supinate forearm,

examiner “hooks” finger under the biceps tendon on the lateral side. Positive if tendon is not felt

• Consider partial tear-terrible prognosis=painful

Biceps Tendinopathy Distal Biceps Rupture

• The Popeye• Men aged 40-60• Smokers (7.5 times more

likely)• ~30% loss of flexion strength• ~40% loss of supination

strength• Diagnosis can be confirmed

by MRI or USMarik

Distal Biceps Rehab Principles

Non-operative - Patients should expect to recover more of their flexion strength than supination strength

Rehab focus:• Pain management• AROM as able without significant pain• Strengthening when pain has resolved

• Within 2-3 weeks to avoid retraction of tendon and scarring of tendon to humerus

• If greater than 70° flexion is required for tendon to reach radial tuberosity due to retraction, a tendon graft is performed: plantaris longus, long extensor to 2/3 toes, gracilis(Vastamaki & Vastamaki, 2008) or allograft (hamstring or achilles).

• One or two incision technique. The two-incision approach is associated with higher incidence of hetertopic ossification (HO) and radioulnar synostosis.

• Complications: LABC nerve irritation, PIN irritation, HO

Distal Biceps Repair Concepts

Distal Biceps Repair(Endobutton)0‐3 weeks po

• Hinged brace elbow 80 degrees and ideally supinated

• Hand ROM

• ACE wrap for edema

3‐6 weeks po

• Flexion AROM/PROM

• Supination/pronation

• 6 x per day ROM out of the splint

• Progress hinge 15 degrees per week

• PROM at 4 weeks

6 weeks po

• Hinged brace discontinued

• Light strengthening

• (2‐4#)

• Light use until 3‐6 months po

a.k.a.

• Tennis Elbow/Golfer’s Elbow• Lateral Epicondylitis• Lateral Epicondylosis• Lateral Epicondylagia• Lateral Epicondyopathy• Lateral Epicondyle Tendinopathy (LET)

• Is not just a tendonitis• Histology studies reveal a lack of inflammatory cells

• LET is, instead, a de-conditioned status of the ECRB origin, occasionally the EDC/ECRL, Even lateral triceps, episodic

Elbow Tendinopathy

Medial Elbow Tendinopathy

Golfer’s Elbow• Involves the origin of the flexor pronator

mass

• Aggravated by activities involving wrist flexion and grip

• Usually occurs in athletes with repetitive valgus and flexion forces

• 10% of epicondylopathy

Lateral Tendinopathy Tests(Medial Tests “Reverse”)Test Positive Sign 

Grip Strength Pain reproduced or weakness

Cozen’s Test Pain reproduced

Mill’s Test Pain reproduced

Third Finger Resistance (Maudsley’s Test)

Pain reproduced

Handshake Test Pain reproduced

• Most often 30-50 year olds• c/o pain with

• Shaking hands (grip)• Opening doors (grip with varus stress)• Taking lids off jars (grip with varus stress)

• Victims are usually not tennis players• Usually progressive pain without sudden onset• Episodic• Self limiting?• Surgical candidate after a year of suffering…long

recovery (6 months+ but good outcomes)

Lateral/Medial Tendinopathy Tendinopathy Surgery

• Outcomes very good: 88-97% success rates

• Cock up splint 2-6 weeks

• Gradual AROM

• Return to sport 4-6 months This Photo by Unknown Author is licensed under CC BY-SA

Garg et al 2010Prospective RCT. N=44.

• 2 groups• Outcomes: Mayo Elbow Performance(MEP) and

American Shoulder and Elbow Society Elbow (ASES) Assessment Form

• Data collected at baseline and 6 weeks• Statistically significant reduction in pain with wrist

splint measured by ASES

Literature Review Literature Review

• Stasinopoulos, D., & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy, 30(1), 13-19.

Evidence Informed?

• Heat/massage for temporary pain relief and perfusion• Wrist immobilizer to reduce tension on extensors• Palm up/elbow flexed use of the arm• Coach through activities/problem solve ergonomics• Anti inflammatories for acute episodes• Light exercise to recondition/reperfuse• Proximal stability (parascapular muscles)• Progress to eccentrics to strengthen non-contractile

elements• Tool assisted STM

Osteochondritis Desiccans

• Adolescent pitchers, gymnasts

• Due to repetitive loading or weightbearing

• Subchondral bone disease due to vascular compromise; cartilage becomes loose bodies

• Especially affects capitellum

Creative Commons

ArthritisOsteoarthritis (OA)

• calcification of cartilage in joint spaces, osteophytes, loose bodies

• c/o pain, stiffness, decreased ROM

Post-traumatic arthritis (PA)• c/o locking and catching

Rheumatoid arthritis (RA)• Symptoms: pain, symmetrical

edema of multiple jointsPixabay

Population• RA• Older less active adults• Highly comminuted fractures

5# life time lifting weight limit30 degree flexion or more x 4 weeks post opPronation during early ROMConsiderations

• Status of triceps (and bone stock)• Ulnar nerve – may react to prolonged elbow flexion

during post-op period• Incision – RA may take longer to heal

Total Elbow Arthroplasty

Total Elbow Arthroplasty

Questions: 1. Was the Ulnar nerve transposed?

2. How was the triceps handled?3. What are the forever limitations?

3 Types(May be inflammation, infection, or both)• Aseptic: trauma or pressure at olecranon• Septic: Cellulitis or wound nearby. Infection

can lead to osteomyelitis.• Chronic: related to Gout/pseudogout• Treatment: NSAIDS, compression/cushion

• Sometimes aspirated• Antibiotics if indicated

Olecranon Bursitis

Snapping Elbow ProblemsPlica Syndrome

Ulnar nerve• Subluxes over medial epicondyle• Usually at 90° elbow flexion

Medial head of triceps• Subluxes over medial epicondyle• Occurs during elbow extension and flexion – usually at

~110° flexion

Intra-articular loose bodies• Can be bony or cartilaginous• Elbow may “get stuck” when attempting motion• X-rays helpful if bony• Arthroscopic removal

References• Akin et al. Short‐term effectiveness of US treatment in patients with LET: randomized, single‐blind, control study.  TurkJRheum. 2010;25:50‐55.

• Alolabi B, et al. Rehabilitation of the medial‐ and lateral collateral ligament‐deficient elbow: an in vitro biomechanical study.  J Hand Ther. 2012; 25:363‐73.

• Armstrong AD, Dunning CE, Faber KJ, Duck TR, Johnson JA, King GJ. Rehabilitation of the medial collateral ligament‐deficient elbow: an in vitro biomechanical study. J Hand Surg Am. 2000;25(6):1051–7. 

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• Clasper J, Carr A.  Arthroscopy of the elbow for loose bodies.  Ann R Coll Surg Engl. 2001; 83:34‐36.

References

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