Elbow Interventions

Ed Mulligan, PT, DPT, OCS, SCS, ATCClinical Orthopedic Rehabilitation Education

Age Incidence of Elbow Injuries

Pediatric Adult

overuse injuries of the elbow

Lateral Epicondylitis/osis

tendinosis (collagen degeneration) at common extensor origin (ECRB)

Lateral Tendinopathy

Medial Tendinopathy

Recognition of Pathology PatternLateral Elbow Pain

LESIONORIGIN

LOCAL REMOTEElbow • Cervical Spine Segmental Facilitation or Hypersensitivity

• Adverse Neural Tension• Wrist Dysfunction

TISSUEINVOLVEMENT

CONTRACTILE NON‐CONTRACTILEECRB Tendinopathy

• RHJ/SRUJ Dysfunction• Radial Tunnel SyndromeSynovial PlicaeCapitellar OCDPLRI

ContributingFactors

OveruseErgonomic ViolationsPositional FaultsBiomechanics/Technique Errors5x more common than medial elbow pain

Lateral Epicondylosis

Subjective History FindingsOnset/MOI insidious onset from biomechanical overload or overuse

Associated Symptoms neck stiffness; rotator cuff/axioscapular weakness

Aggravating Factors • pain with gripping activities or with resisted wrist extension if elbow is in an extended position

• pain with passive overpressure in elbow extension, pronation, wrist flexion, and ulnar deviation

Symptom Location Lateral epicondyle/supracondylar ridge

Alternative Hypothesis Facilitated segments; Joint restriction; Radial Tunnel Syndrome

Lateral Epicondylosis

Objective Examination Findings

A/PROM‐End Feel Humeroradial joint restrictions; flexion contracture

Contractile Status Decreased grip strength (particularly in passively insufficient positions)

Palpation Tenderness at insertion of ECRB on supracondylar ridge; radial head (medial displacement) positional fault

Special Tests Cozen and Mills Test

Differential Diagnosis C6 radiculopathy; Radial Tunnel Syndrome (lateral); Pronator Syndrome (medial)

Outcome Tool DASH; Patient‐Rated Forearm Evaluation Questionnaire

Intervention Emphasis

Pain Based– Modalities – Physical Agents  ‐Manual Therapy

Impairment Based Local Contractile – ECRB Tendinopathy

– Therapeutic Exercise  Local Joint Dysfunction – SRUJ/RHJ

– Manual Therapy  (HVLA Thrust, MWM) Local Neural Dysfunction – PIN

– Splinting – Activity Limitations – Neural Flossing Remote Contributions

– Cervicothoracic and Wrist Manual Therapy– Axioscapular Strengthening– Neurodynamic Restoration

Addressing Primary Pain Complaint

Modalities/Physical Agents– Ultrasound or Phonophoreis (B)

When combined with physical interventions

– Iontophoresis (diclofenac) (B)– Acupuncture – (B)

– Cyrotherapy/Ice Massage – (C)– High Volt Galvanic Stimulation (C/D)– Graded mobilization – Education and rest from offending activities

based on systematic reviews by:Trudel D, et al, J Hand Ther, 2004; Biset L, et al,                                           Br J Sports Med, 2005; and Johnson GW, et al, Am Fam Physician, 2007

Low Level (cold) Laser

Level 1 meta‐analysis for effectiveness in short term relief for pain/disability when administered with optimal doses; probably not a good stand alone treatment 

Bjordal JM, BMC Musculoskeletal Disorders, 2008

Systematic review suggesting moderate                                                    to large effect size for reducing point                                                         tenderness and increasing grip force

Chang WD, et al, PhotoMed Laser Surg, 2010

Local Treatment:

ECRB Tendinopathy

Therapeutic Exercise – Value of eccentric emphasis– Prospective, RCT (LOE I) showed 

significantly greater function (DASH score), point tenderness, and strength (wrist and middle finger extension) for the eccentric training intervention group as compared to a traditional exercise program

Tyler TF, et al, J Shoulder Elbow Surg, 2010

Local Treatment:

ECRB Tendinopathy

Counterforce Bracing– Non‐elastic circumferential orthoses– No definitive conclusions can be made based 

on conflicting  or equivocal evidence– Wrist splint provided more pain relief than 

forearm strap in a prospective, RCT

Soft Tissue Mobilization  – Deep friction or deep tissue massage– no conclusive evidence regarding efficacy

Augmented Soft Tissue Mobilization

Prospective RCT comparing ASTM to medical advice, ergo-nomic counseling, and stretching

While both groups improved in pain, grip strength, and function there was not a significant difference between groups

Authors argue for a larger power sample to detect differences

Blanchette MA, J Manipulative Physiol Ther,  2012 

Local Treatment:

Joint Dysfunction

Manual Therapy– Cyriax extension and/or varus 

mobilization/manipulations– Short term benefit in regards to 

pain to palpation and pain‐free grip

Paungamali, et al, Phys Ther, 2003Vicenzino, et al, Man Ther, 2001

Stretching/Flexibility– studies tend to lump flexibility 

training in with other interventions

Joint Mobilization Mobilization with Movement

HVLA Thrust

Remote Interventions

Wrist Manual Therapy– Wrist manipulation more 

effective than traditional local treatment

Struijs, et al, Phys Ther, 2003

Neurodynamic Restoration– Neural Glides to address adverse 

neural tension and/or peripheral nerve hypersensitivity

Beneciuk JM, J Ortho Sports Phys Ther, 2009Ekstrom RA, et al, Phys Ther, 2002

Cervical Manual Therapy

Global Interventions

Axioscapular and RC training IADL and equipment modifications Job/Sport Specific technique analysis Postural and Ergonomic counseling

Medical Management to enhance physical therapy interventions

Oral NSAIDs Injections

– Corticosteroids vs. PRP Short vs. long term value

– Prolotherapy Topical Nitric Oxide Patches Extracorporeal Shockwave Therapy Surgical Intervention

Latest High Quality Trials Offer Conflicting Conclusions

Supervised Stretching/Eccentric Strengthening (12 visits over 4 wks) superior to friction massage/manipulation in regard to pain and self‐report outcomes

Viswas R, et al, Sci World J, 2012

Friction Massage/manipulation (12 visits over 4 wks) superior to stretch‐ing/eccentric training and phono‐phoresis (diclofenac) in regard to pain and self‐report outcomes

Nagrale AV, et al, J Man Manipul Ther, 2012

• Both groups in both studies improved in a relatively short follow‐up• Both groups had sound methodological design (PEDro) = 6/10)

My interpretation – manual interventions can be utilized in clinic and therapeutic interventions can be emphasized in the HEP

entrapment (compression between the radial head andsupinator muscle) of the posterior interosseous branchof the radial nerve in the radial tunnel

radial tunnel syndrome

Radial Tunnel Syndrome

Subjective History FindingsAggravating Factors Prolonged or repetitive gripping activities; 

Sustained positioning in extension‐pronation

Symptom Location Pain at radial head

Symptom Quality Deep burning pain may radiate down the dorsal forearm; possible paresthesias in  radial distribution

Alternative Hypothesis C6 radiculopathy; Lateral Epicondylitis

Radial Tunnel Syndrome

Objective Examination FindingsInspection/Observation Atrophy of any muscle                                                         

innervated by radial nerve

A/PROM‐End Feel Usually no joint restrictions

Contractile Status Pain with resisted supination or extension of index finger

Palpation Reproduction of symptoms with palpation over radial head (not supracondylar ridge)

Special Tests ULTT 2  (radial bias)

Neuro Screen Radial nerve tension test

InterventionModalities • Low‐intensity Ultrasound (1 MgHz pulsed at 1.0 wtts/cm2) 

for pain reduction• Iontophoresis (based on evidence supporting the treatment of CTS)

Manual Therapy Radial nerve glides - no strain or reproduction of symptoms allowed

Therapeutic Exercise Axioscapular and postural exercise

Posture/Ergonomics • Avoidance of elbow extension and pronation positions• Tilted angle and negatively sloped keyboards• Appropriate mouse use (no forearm posting)• Ergonomic evaluation of workstation

Radial Tunnel Syndrome

Intervention

Activity Limitations Prolonged static pinching or squeezing of objects or tools  is avoided

Bracing Nocturnal wrist extension splint and during activities of risk as needed to relax extensors and supinators

Regional Concerns Cervical dysfunction

Prognostic FactorsPoor prognosis for non‐operative treatment if notable atrophy of radially innervated muscles and severe pain (>8/10)

Radial Tunnel Syndrome

Cubital Tunnel Syndrome

Ulnar neuropathy secondary topressure, traction, or ischemiain the tunnel between the medial epicondyle and olecranon

Cubital Tunnel Syndrome

Subjective History FindingsOccupational Predisposition Repetitive wrist motions with elbow in flexion –

(baseball/tennis or carpenters/painters/musicians)

Associated Symptoms • Elbow Osteoarthritis• Excessive Cubital Valgus• Subluxing Ulnar Nerve• Elbow instability

Aggravating Factors • Prolonged elbow flexion ‐ increased tunnel pressure and excursion requirement as elbow moves out of extension and into flexion

• Elbow positioned on arm rests or on window when driving

‐ continued on next page

Cubital Tunnel Syndrome

Subjective History FindingsSymptom Location • Pain/paraesthias along medial forearm

• Sensory changes in ulnar distribution

Symptom Quality Intermittent to constant paraesthias in ulnar pattern

Alternative Hypothesis • Thoracic Outlet Syndrome• Cervical Radiculopathy, • Apical Lung Tumor• Handlebar Palsy

Cubital Tunnel Syndrome

Objective Examination FindingsInspection/Observation • + Wartenberg’s sign (abducted 5th digit)

• Motor deficits evidenced by 4th‐5th digit clawing – Bishop’s Hand  ‐ usually indicating more advanced stage

Contractile Status Weakness of ulnar innervated muscles; hypothenar muscles

Palpation Tinel’s (careful of false +)

Special Tests • Flexed Posture• Digital Compression• combination of pressure/position most accurate• + Froment’s Sign (FPL substitutes for AP)

Neuro Screen Semmes Weinstein monofilament for sensory impairment or 2 point discrimination for more severe cases

Outcome Tool DASH or Mayo Elbow Function Score

InterventionModalities No proven value for any physical agent or 

electrotherapeutic modality

Manual Therapy Careful ulnar nerve glides; normalize joint restrictions

Therapeutic Exercise Restore identified impairments. Promotion of total arm strength and endurance

Posture/Ergonomics No elbow weight bearing or crossing arms when sitting; use of elbow pads

Cubital Tunnel Syndrome

Cubital Tunnel Syndrome

InterventionActivity Limitations REST; Activity modification, ergonomic 

recommendations, and rest from offending activities

Bracing Nocturnal splinting in mid range flexion (40‐70°); day time as well for severe cases; towel wrap at night

Regional Concerns Cervical Dysfunction

Prognostic Factors • 75‐90% of patients with mild to moderate cases benefit from conservative care

• Success of non‐op intervention directly related to severity of condition (more on next slide)

• Failed conservative interventions may require subsequent surgical decompression, epicondylectomy, and/or transpositions

Intervention Success

Highly dependent upon presenting severityGrade Motor Deficit Sensory Deficit

I Undetectable weakness Intermittent paresthesias

II Intrinsic weakness

Decreased sensory/vibratory detection

IIIVisible atrophy/Papal Sign

Constant paresthesia; abnormal   2‐point discrimination

Surgical Procedures

Decompression Medial Epicondylectomy Transposition

– Subcutaneous– Submuscular– Intramuscular

Overuse Throwing MOI

Medial traction– Apophysitis (younger; 9‐12)– Avulsions– UCL strain (older; 12‐16)

Medial tensile strain– Epicondylitis (older; 12‐16)

Lateral compression– AVN; OCD; synovial plicae

Extension overload– Posterior impingement

Throwing Faults

Violation of “Rule of 2s” Biomechanical faults

– Open up to soon (arm behind body)

– Excessive ER– Glove arm low and lateral

• Medial tension• Lateral compression

Spectrum of Injuries

Apophysitis Medial epicondyle avulsion Common flexor strain UCL sprain/tear

Examination

Position(s) played, number of throws/week, and pitch type Palpation for area of tenderness Special Tests

– Valgus Stress Test at 30°– Moving Valgus Test– Milking Sign– Valgus Extension Overload

Elbow Flexor/Pronator Strength Axioscapular/Scapulohumeral Strength

Clinical Presentation

Progressive elbow pain with diminished throwing effectiveness (decreased velocity and control)

Medial epicondylar tenderness

Contractile symptoms – pain with passive stretch or resisted contraction of common flexor insertion muscles

May have mild flexion                                                          contracture if  chronic

UCL Sprain/Tear

Non‐Op– Rest, NSAIDs, and 2‐3 months throwing avoidance 

– Address elbow impairments– Nocturnal valgus protection bracing 90° until symptom free– Throwing progression begins at 3 months with elbow 

hyperextension protection 

– 40‐50% should be able to return                                                           to previous function at about                                                                 6 months

UCL ReconstructionPost-Op Protocol

Initially splinted in 70‐90° of flexion with neutral forearm Splint removed at 10 days to initiate active wrist, elbow, and 

shoulder ROM exercises (elbow brace limits of 30‐100°) with full ROM expected at 5‐6 weeks

Begin PREs at 6‐8 wks with valgus stress                                               protection

Elbow brace discontinued at 8 wks Throwing progression at 4‐6 months with                                               

expected return to play at 12‐18 months BW reference provided in resource file

Local Exercise TherapyFlexor/Pronator Tendinitis-Strain

Ball flips Tubing pulls Flex bar bends

Elbow Fractures-Dislocations

Supracondylar Fractures Radial Head Fractures Humeroulnar Posterior Dislocations

supracondylar fracture

Mechanism:– Usually in children (under 12) from a fall– Boys > Girls; Left > Right

Signs/Symptoms– appears to be a dislocation with distal                    

humerus and olecranon displaced backwards and proximal humeral shaft displaced forward                                                    

Miscellaneous:  – Injury must be treated as an orthopedic                         

emergency ‐ complications include  Volkman's ischemic  contracture

radial head fractures

Mechanism of Injury: FOOSH

Type I undisplaced fx (< 2mm)

Type II > 2-3 mm displaced and involves more than 30% of radial head

Type III comminuted fx

Type IV elbow dislocation and radial head fx

I

IVIII

II

radial head fractures

Signs/Symptoms– pain and tenderness over radial head– swelling lateral to olecranon– primary limitation is pronation/supination

Prognosis– usually minimally displaced and rapid recovery– aggressive recovery after  a short period of                  sling immobilization

radial head fracture rehabgeneral guidelines

Pain‐free, AA/AROM in stable range after swelling/pain subside in first 10 days

Manual therapy and isometrics  at 3‐4 weeks

PREs and progression to functional  activities at 4‐6 weeks

Humeroulnar Dislocation

10‐25% of all adult elbow injuries Fall on outstretched hand with elbow extended and 

shoulder abducted usually the ulna and radius                                                                

dislocate in a posterolateral                                                      direction from  the ulna

obvious "short" forearm                                               deformity

intense pain and rapid swelling prominent olecranon

• perched vs. complete – perched, not as serious ligament damage– faster rehab and recovery 

• complete rupture of UCL – anterior band is essential lesion– probable rupture of RCL and anterior capsule− possible damage to brachialis muscle

• 25‐50% of dislocations have concurrent fractures of                                radial head

• possible vascular and neurological injury – monitor C6 distribution for median nerve                                                         

injury and radial pulse

Complete

pathoanatomy

Perched

perched– 2‐3 days in sling at 90°

complete– 7‐10 days in hinged splint at 90°

post-injury immobilization

general expectations

• 30° flexion contracture at 10 weeks– if less than 45° extension at 3‐4 weeks; employ dynasplint like device

• 10° flexion contracture at  average of two years post‐injury

• perched dislocation – normal ROM in 6‐8 wks

• complete dislocation – 80‐90% normal function at 3 months

• recurrent instability is rare

general rehab guidelines

AAROM in extension no PROM strength training begins at 3 weeks unrestricted strength training at 6‐8 wks

rehab with ACTIVE ROM to avoid heterotopic ossification of soft tissues

beware of ulnar nerve entrapment from scar tissue formation

MINIMIZE IMMOBILIZATION

rehabilitation points of emphasis

# of Subjects Immobilization Duration (days) Extension Loss () Time of Disability (wks)

27 < 5 3 613 10‐15 11 197 > 20 21 24

Protzman RR, J Bone J Surg, 1978

Elbow Dislocation importance of early motion

early mobilization is safe, effective, and advantageous after 48 hours 

Paschos NK, et al, J Orthop Trauma 2013

specific rehabilitation phases

Phase I ‐ protection phase– reduce swelling, pain, inflammation– ice, electrotherapy, massage– gripping exercises– shoulder ROM

Phase II ‐ motion phase– warm whirlpool– UBE– AAROM‐AROM– isometric strengthening– proprioceptive drills

specific rehabilitation phases

Phase III strengthening phase• isotonic‐isokinetic• PNF• MET• body blade• shadow boxing• bicep eccentrics

specific rehabilitation phases

Phase IV functional training‐ ball dribbling‐ sock toss‐ ball plyometrics‐ inertial ‐ total gym‐ protection from hyperextension with taping or brace

specific rehabilitation phases

Post-Traumatic Stiff Elbow

• Despite high level evidence for early motion following most fracture/ dislocations ‐ high level evidence is sparse in the literature to direct therapeutic care when motion complications develop

• Functional goal is to regain active control 30‐130° of sagittal plane motion and 50‐0‐50° of transverse plane motion

Therapeutic InterventionLoss of Motion Protocol and Treatment Sequencing

Thermal preparation of effected tissue• Passive intervention: heat, diathermy, ultrasound• Active intervention: arm bike or air‐dyne

Manual Therapy followed by facilitated stretching• Joint and soft tissue mobilization• PNF hold or contract relax

Antagonistic muscle training in newly acquired range

Stretching HEP review• Static/Dynamic stretching and/or flexibility training

Cold application concurrent with LLPD stretch 

Treatment Pearls

Early motion Heat‐Treat‐Cool Low load prolonged duration philosophy Treat the extra‐articular restriction

– Soft tissue/myofascial techniques– Joint mobilization

Post-Op Protocol References

Total Elbow Replacement Distal Tendon Repair UCL Reconstruction

Questions -Discussion