pta 130 fundamentals of treatment i elbow & forearm
TRANSCRIPT
Lesson Objectives
Identify key anatomical muscles and structures of the elbow and forearm
Identify common tissue injuries, conditions and surgical interventions
Introduce interventions for common injuries, conditions, and surgical procedures
Identify soft tissue specific mobilizations Identify flexibility, strengthening, functional,
and stabilization exercises
Anatomy Review - Muscles
Primary muscles involved in the following movements:◦Elbow flexion-
Brachialis, Biceps Brachii, Brachioradialis◦Elbow extension-
Triceps brachii, Anconeus◦Forearm pronation-
Pronator teres, Pronator quadratus◦Forearm supination-
Supinator, Biceps Brachii, Brachioradialis
Anatomy Review – Bones
The elbow joint is made up of:◦Distal end of the humerus◦Ulna◦Radius
Four joints involved in elbow and forearm function: ◦Humeroulnar◦Humeroradial◦Proximal radioulnar◦Distal radioulnar
Anatomy Review - Ligaments
The elbow joint has a lax joint capsuleThe elbow joint is supported by two major
ligaments◦Medial (ulnar) collateral
Provides support against valgus stresses◦Lateral (radial) collateral
Provides support against varus forces
Elbow and Forearm Characteristics
Function is to position the handMost muscles crossing the elbow are two-
joint muscles◦Examples?
Biceps and triceps co-contract to provide weight-bearing stability to elbow
Elbow instability occurs primarily due to tears of the medial collateral ligament
Relationship of Wrist and Hand Muscles to the Elbow
The epicondyles of the humerus are attachment points for many of the muscles that act on the wrist and hand
The muscles provide stability at the elbow, but don’t contribute to motion at the elbow
Wrist Flexor Muscles◦Originate on the medial epicondyle
Wrist Extensor Muscles◦Originate on the lateral epidondyle
Kinematic Considerations
The elbow and forearm create coupled and patterned movement◦Elbow flexion with forearm supination
Biceps brachii and supinator Lift and carry functions
◦Elbow extension with forearm pronation Triceps brachii and pronator teres Push out and push down
Kinetic Considerations
The elbow is inherently stabile to support lifting and carrying ability◦When the elbow becomes injured, it is one of
the most difficult joints to restore full ROM◦When overloaded, the joint inflames and will
dramatically decrease ability to handle force
Forces at the Elbow
Lifting weights with elbow extended: ◦more stress anteriorly
Lifting weights with elbow flexed: ◦more stress posteriorly
Reducing Joint Forces
Lighter weights or cuffs attached to mid-forearm
Greatest compression forces in push-up position◦Widening hand position decreases force
Low-resistance, high-rep exercises are most appropriate early in rehabilitation program
Referred Pain and Nerve Injury
C5, C6, T1 and T2 nerve roots cross the elbow- ◦Symptoms are not usually isolated in the elbow
Nerve Disorders◦Ulnar nerve-
Compression at the cubital tunnel◦Radial nerve-
Entrapment of the deep branch under extensor carpi radialis brevis, or with radial head fracture
◦Median nerve- Entrapment between the ulnar and humeral heads of the
pronator teres muscle
Elbow Joint Hypomobility
Typically caused by: ◦Rheumatoid arthritis and/or Juvenile
Rheumatoid Arthritis◦Degenerative Joint Disease◦Trauma◦Dislocation◦Fractures◦Immobilization
Joint Hypomobility:Common Impairments
Acute Stage◦Joint effusion◦Muscle guarding◦Pain
Subacute and Chronic Stages◦Capsular pattern is typically present
Elbow flexion is more restricted than extension◦Decreased joint play
Common Functional Limitations
Difficulty turning a key, doorknob, or jar lids
Pain or difficulty with pushing and/or pulling activities
Difficulty performing ADL’sLimited reachInability to carry objects with an extended
armDifficulty pushing self up from a chair
Joint Hypomobility:Nonoperative Management
Protection phase◦Patient education◦Reduce effects of inflammation◦Maintain soft tissue and joint mobility◦Maintain integrity and function of related areas
Controlled motion phase◦Increase soft tissue and joint mobility◦Improve joint tracking of the elbow◦Improve muscle performance and functional
abilities
Joint Hypomobility:Nonoperative Management
Return to function phase◦Improve muscle performance
Activities should replicate the demands of ADL’s Modification of activities to reduce stress on joint
◦Restore functional mobility of joints and soft tissues Joint mobilizations Aggressive stretching techniques
Joint Surgery and Postoperative Management
Surgical intervention is often necessary for management of severe fractures or dislocations
In adults, the most common fracture in the elbow region is a fracture of the head and neck of the radius◦ Typically occurs when falling onto an outstretched hand
Long standing arthritis may also need to be managed through surgery
The goals of surgery are: ◦ Relief of pain◦ Restoration of bony alignment and joint stability◦ Sufficient strength and ROM to allow for functional mobility
Joint Surgery and Postoperative Management
Surgical Options for Displaced Fractures of the Radial Head ◦ORIF◦Arthroscopic Reduction and Internal Fixation◦Excision of the radial head
Joint Surgery and Postoperative Management – Excision of Radial Head
Maximum Protection Phase◦Immobilization◦Pain Control◦Edema Control◦AROM exercises for shoulder, wrist, and hand◦PROM and/or AAROM exercises for the elbow
when permitted AROM exercises are allowed within a week after
exercises are initiated◦Submaximal isometrics when permitted
Joint Surgery and Postoperative Management –Excision of Radial Head
Moderate and Minimum Protection Phases◦Begins when wound has healed and AROM of the
elbow is relatively pain free◦ Increase ROM
Gentle stretching Mobilizations once the joint capsule is well healed
(typically 6 weeks postoperatively)◦ Improve functional strength and muscular
endurance Low-load resistance exercises with high repetitions Use of affected UE for light ADL’s
Joint Surgery and Postoperative Management - TEA
Indications for Total Elbow Arthroplasty◦Severe joint pain◦Articular destruction of the humeroulnar and
humeroradial joints◦RA is one of the most common pathologies
leading to a TEA◦Significant instability of the elbow joint◦Failed radial head resection
Joint Surgery and Postoperative Management - TEA
Maximum Protection Phase (0-4 weeks)◦Immobilization – position varies◦Control of pain, inflammation, and edema◦Early AAROM exercises◦Maintain mobility of the shoulder, wrist, and
hand◦Regain motion of the elbow and forearm◦Minimize atrophy of UE musculature
Joint Surgery and Postoperative Management - TEA
Moderate and Minimum Protection Phase◦Improve elbow ROM
Low-intensity manual self-stretching◦Regain strength and endurance of elbow
musculature Isometrics Light ADL’s UBE Open-chain resistance exercises
◦Use operated arm for gradually demanding functional activities
Myositis Ossificans
Also known as heterotopic or ectopic bone formation-◦The formation of bone in atypical locations of the body
Etiology of symptoms◦Most often develops in the brachialis muscle or joint
capsule◦Caused by trauma, radial head fracture, etc
Management◦Active, pain-free ROM◦Massage, passive stretching, and resistive exercise
are CONTRAINDICATED
Overuse Syndromes - Epicondylitis
Lateral epicondylitis- Tennis Elbow◦Pain in the common wrist extensor tendons◦What activities are typically associated with
this diagnosis?
Medial epicondylitis- Golfer’s Elbow◦Pain in the common wrist flexor tendons◦What activities are typically associated with
this diagnosis?
Overuse Syndromes - Epicondylitis
Treatment- Protection Phase◦Avoid provoking activities◦Immobilization- rest the muscle◦Relieve pain, swelling, and scar tissue adhesions ◦Modalities◦Cross-friction massage◦Brace/Splint◦Low-intensity isometrics◦Active ROM and resistive exercise of
shoulder/scapular muscles
Overuse Syndromes - Epicondylitis
Treatment - Controlled Motion and Return to Function Phases◦ Increase muscle flexibility
Manual stretching Self-stretching
◦Restore joint tracking of the RU Joint◦Cross-friction massage◦ Improve muscle performance and function
Isometrics, dynamic exercises, functional patterns, etc. ◦Patient education
Activity modification
Little League Elbow
Caused by excessive traction forces on medial epicondyle epiphyseal plate during acceleration
Curve and breaking pitches create the greatest forces
Treatment ◦Rest, ice, active exercises to tolerance◦No heavy weights ◦Avoid valgus stresses early in rehab◦Avoid aggressive exercises
Sprains
Hyperextension sprain- ◦Anterior capsule injury; can cause bone bruise in
olecranon regionMedial collateral ligament sprain-
◦Injures the primary stabilizing unit of elbowTreatment-
◦Cross-friction massage to adhesions is contraindicated during initial 7-10 days after injury
◦Immobilization◦Pain-free ROM
Elbow Dislocation
Most dislocations are posterior and follow sudden hyperextension and abduction
Injury is obvious due to deformityTreatment
◦Splint is worn for 2 weeks with motion beginning after first week
◦Initiate isometrics during first week◦Rehabilitation may take 16-26 weeks
Elbow Arthroscopy
Usually performed for debridementTreatment
◦Sling is worn for 1-3 days◦Rehabilitation may take 8 weeks◦May initiate shoulder, wrist range-of-motion
exercises, isometrics early◦Begin with straight plane, progress to diagonal
plane◦Progression depends on patient response
Elbow Bursitis (Olecranon Bursitis)
Inflammation of the olecranon bursa
May follow a traumatic incident
Treatment: ◦Stretches◦ROM◦Ice massage◦Modalities
Nursemaid's Elbow(“Pulled” Elbow Syndrome)
A partial dislocation of the elbow joint – ◦Involves the head of radius slipping out from
the annular ligamentCommon condition in children under the
age of fiveMay occur when a child is pulled too hard
by the hand or wrist
Exercises for Flexibility and ROM
Manual, mechanical, and self-stretching techniques◦To increase elbow extension◦To increase elbow flexion◦To increase forearm pronation and supination
Self-stretching techniques—muscles of the medial and lateral epicondyles◦To stretch the wrist extensor muscles◦To stretch the wrist flexor muscles
Exercises to Develop & Improve Muscle Performance & Functional Control
Isometric exercises◦Elbow flexion, elbow extension, and forearm
pronation/supination◦Rhythmic stabilization
Dynamic strengthening and endurance exercises◦Elbow flexion, elbow extension, pronation, and
supination◦Wrist flexion and extension
Functional exercises◦PNF patterns◦Pulling, lifting, and carrying activities◦Simulated tasks and activities
Strengthening Exercises
Progression◦Isometrics◦Isotonic
Straight plane Multi-plane
◦Plyometrics◦Functional exercises◦Activity specific exercises
Functional and Sport Specific Activities
Warm up and cool downBegin with low level and progress to
overhead exercises ◦Use easy activities at diminished distances,
forces, and speeds◦Gradually increase one component at a time
If pain occurs, return to previous level of exercises
Ligamentous Test
Varus and Valgus Stress Testing◦Note any laxity, decreased mobility or altered
pain with testing
Tests for Epicondylitis
Lateral Epicondylitis – Cozen’s Test◦A positive test is indicated by sudden severe
pain in the area of the lateral epicondyle of the humerus
Tests for Epicondylitis
Lateral Epicondylitis – Mill’s Test◦A positive test is indicated by sudden severe
pain in the area of the lateral epicondyle of the humerus
Tests for Epicondylitis
Medial Epicondylitis◦A positive sign is indicated by pain over the
medial epicondyle of the humerus.