MSK2_ELBOW FOR DUMMIES

SHAKABOOM

Functional Range of elbow?

30° - 130° flex & extend, 100° of forearm rotation,

• equally divided between pronation and supination.

Type of Joint → Humeroulnar

• FLEX & EXT

modified hinge

• Convex : trochlea

• Concave: ulna

Type of Joint → Humeroradial?

• flex,ext, pronate & supinate

Modified hinge pivot

• Convex : capitulum

• Concave: radial head

Provides medial support to the elbow against valgus stresses and limiting end- range elbow extension.

Medial Collateral Ligament

Provides stability to the lateral aspect of the elbow against varus and supination forces

Lateral Collateral Ligament

• prevents posterior translation of radial head

Type of Joint → Proximal RadioUlnar Jt?

• pronate & supinate

Uniaxial Pivot

• Convex : radial notch

• Concave: radial head

This generates the greatest force of all the muscles that cross the elbow and its sole function is flexion of the elbow.

Brachialis

Brachialis MOINA

Origin	Distal half of anterior surface of humerus
Insertion	Coronoid process of the ulna; Tuberosity of ulna
Innervation	Musculocutaneous nerve (C5,C6); Radial nerve (C7)

Acts as supinator of forearm & most effective flexor of elbow at 80°-100° of flex

Biceps Brachii

Primary elbow flexor especially during rapid movements against high resistance and acts as a pronator when the forearm

Brachioradialis

3 Muscle Supinators

• Supinator

• Biceps Brachii ( at 90°)

• Brachioradialis

3 Muscle Pronators

• Pronator Teres

• Pronator Quadratus ( most active)

Most common sites for compression of the ulnar nerve in the elbow

Cubital tunnel & 2 heads of FCU

Most common sites for compression of the radial nerve in the elbow

under ECRB , Arcade of Froshe & distal edge of the supinator muscle

Most common sites for compression of the medial nerve in the elbow

• between heads of pronator teres

• under ligament of Struthers

• Bicipital aponeurosis/deep to FDS

Joint Hypomobility: Nonoperative Management →

• RA

• JRA

• Degenerative Jt Disease

• acute joint reactions after trauma,

• Dislocations

• Fractures

Joint Hypomobility: Nonoperative Management

• Acute Stage

  • (+) joint effusion

  • muscle spasm

  • Pain restrict elbow & Shoulder motion

  • No pain at rest.

Identify which is wrong

• +) joint effusion

• muscle guarding

• pain restrict elbow motion

• pain at rest.

Joint Hypomobility: Nonoperative Management

• Subacute & Chronic

  • (+) capsular pattern

  • Elbow extension > flexion

  • Bony end feel & INC joint play

  • pronation and supination restricted in OA

  • Pain on overpressure at the PRU jt (Arthritis)

Identify which is wrong

• (+) capsular pattern

• Elbow flexion > extension

• firm end feel & DEC joint play

• pronation and supination restricted in Arthritis

• Pain on overpressure at the DRU jt (Arthritis)

Common Activity Limitations & Participation Restrictions

• Difficulty turning a doorknob or key in the ignition

• Difficulty or pain with pushing and pulling activities, such as opening and closing doors

• Restricted hand-to-mouth activities for eating and drink-ing and hand-to-head activities for personal grooming and using a telephone

• Difficulty or pain when pushing up from a chair s Inability to carry objects with a straight arm

• Limited reach

Joint Hypomobility: Protection Phase ( READ)

• Educate pt

  • inform length of signs & symptoms

  • teach methods of jt protection & modify ADLs

  • avoid excessive fatigue

• Reduce effect of immobilization

  • Frequent periods of controlled movement within pain free range should be performed

    • complete immob can lead to joint hypomobility, contractures, and limited motion.

  • Gentle Gr 1-2 joint oscillation/ distraction to inhibit pain & move synovial fluid for nutrition

• Maintain Soft Tissue & Joint Mobility

  • PROM/AAROM within limits of pain including flex/ext & pro/sup

  • Multiple angle Isoms for all elbow muscles motion in pain free position

• Maintain Integrity & Function of related areas

  • Shoulder,wrist, & hand ROM should be done with tolerance

  • if edema develops, elevate arm above heart level

    • Consider retrograde massage

Joint Hypomobility: Protection Phase

6 Things You should do in this phase:

1. Educate

2. Gentle Gr 1-2 joint oscillation/ distraction

3. PROM/AAROM within limits of pain (all motions)

4. Multiple angle Isoms within limits of pain (all motions)

5. Shoulder,wrist, & hand ROM

6. Elevate arm if (+) edema

   1. retrograde massage

Precautions following Traumatic Injury to Elbow

• Heterotopic ossification

  • (+) inflammation

• Malunion can happen , preventing full ROM

• A bony block end feel → refer to doc

  • X ray a must

  • No Stretching or Joint Mob

Alam mo na yan

Joint Hypomobility: Controlled Motion Phase

How to Reduce a pushed elbow?

Apply a distal traction to the radius to reposition the radial head.

• If chronic, repetitive stretching with sustained grade III distal traction to the radius is necessary

Pushed Elbow

• MOI:

• radial head is pushed proximally in the annular ligament and impinges against the capitulum

• Accompanied by: ____ fx or _____ fx

• Limited elbow _______(3) & wrist ___

• MOI: FOOSH

• radial head is pushed proximally in the annular ligament and impinges against the capitulum

• Colles’ fracture or scaphoid fx

• Limited elbow ext/flex/pronation & wrist flex

Pulled Elbow

• ______ subluxation of the radius

• forceful ___ on the hand

• Head of the radius is unable to glide proximally in the annular ligament when supination is attempted = restricted _____

• (+) patient guarding

• Distal subluxation of the radius

• forceful pull on the hand

• restricted pronation

• (+) patient guarding

Joint Hypomobility: Controlled Motion Phase

How to Reduce a pulled elbow?

High-velocity thrust of the radial head with supination

Joint Hypomobility: Controlled Motion Phase

• Increase Soft Tissue and Joint Mobility

  • Passive joint mobilization techniques

  • Manipulate Pushed Elbow

  • Manipulate Pulled Elbow

  • Manual & Self Stretching

    • Light cuff weight placed on distal forearm with a low-intensity, long-duration stretch (alternative)

• Improve Joint Tracking of the Elbow

  • radial glide in pain free elbow flex/ext or grip

• Improve Muscle Performance and Functional Abilities

  • Initiate active and low-load resistance exercises in open- and closed-chain

    • Improves muscle endurance,strength

    • progress toward functional activities

Joint Hypomobility: Controlled Motion Phase

5 Things You should do in this phase:

1. Passive joint mobilization techniques.

2. Manipulation reducing pushed/pulled elbow (optional)

3. Manual stretching and self-stretching

4. MWM

5. Initiate active and low-load resistance exercises in open → closed-chain

Joint Hypomobility: Return to Function Phase

• Improve Muscle Performance

  • Progress strengthening exercises

• Restore Functional Mobility of Joints and Soft Tissues

  • Use manual or mechanical stretching and joint mobilization techniques.

• Promote Joint Protection

  • Modify high-load activities to minimize deforming stresses on the involved joints.

:))))))

Joint Hypomobility: Return to Function Phase

4 Things to do

1. Resistance Exercises Progression

2. Manual or Mechanical stretching

3. Vigorous Joint mobilization techniques.

4. Modify High-load activities/ Teach proper body mechanics

Progression of Resistance Exercises

Setting → Isometrics → Isotonics → Eccentrics

Joint Surgery and Postoperative Management

Most common fracture in the elbow region is

fracture of the head and neck of the radius.

• FOOSH c forearm pronated

Joint Surgery and Postoperative Management

basahin mo na lang gg talaga

Radial Head Excision or Arthroplasty

Indications:

• Severely comminuted fracture or fracture-dislocations of the head or neck of the radius that cannot be reconstructed

• Chronic synovitis and mild deterioration of the articular surfaces associated with arthritis of the HR and proximal RU joints

Radial Head Excision or Arthroplasty

This approach divides the radial collateral and annular ligaments while preserving the radial ulnar collateral ligament.

Extensor digitorum splitting approach

Radial Head Excision or Arthroplasty

Approach that expose the joint between the ECU and anconeus muscles

Kocher aproach/ posterolateral

Radial Head Excision or Arthroplasty

Approach where there is incision between the extensor digitorum and the extensor carpi radialis bravis

Kaplan

Radial Head Excision or Arthroplasty

Muscle Graft used?

Palmaris Longus

Radial Head Excision or Arthroplasty Complications

• Damage to what nerve?

• Post Op complications?

• posterior interosseous nerve

• Delayed wound closure, infection, limited ROM of the elbow and/or forearm, radial tunnel syndrome, cubital laxity, persistent pain, and a sense of instability.

Radial Head Excision or Arthroplasty: Immobilization

• Arm is immobilized in a long arm orthosis or a hinged protective orthosis with an extension block for _____ wks

• Arm positioned at _____ ° with forearm in _____ and the wrist in _____

• Non hinged orthosis may be removed during ROM exercises but ibabalik sa gabi

• Immobilized in an orthosis with an extension block for up to 3 weeks

• positioned at 45° to 90° with the forearm in mid pronation and the wrist in neutral

• Non hinged orthosis may be removed during ROM exercises but ibabalik sa gabi

Radial Head Excision or Arthroplasty: Max Protect Phase

• Focus on pt education

• Manage Edema

  • elevate arm above heart & wear compression sleeve

  • wrist above the elbow; elbow above the shoulder

• Mobility of Uninvolved Jts

  • AROM of the shoulder, wrist, and hand immediately after surgery.

• Mobility of Elbow & Forearm

  • Initiate gentle protected ROM within 2 to 3 days postoperatively.

  • Self ROM within pain free limits

  • Active ROM is generally allowed within 1 week postoperatively and begins no longer than 3 weeks

• Minimize Atrophy

  • Submaximal, pain-free, multiple- angle isometric exercises of elbow and forearm musculature.

Radial Head Excision or Arthroplasty: Max Protect Phase

Inflammatory Phase extends for first ______

2-3 wks after surgery

Radial Head Excision or Arthroplasty: Max Protect Phase

5 Things to do?

• PT educ (wound care)

• Manage Edema

  • wrist above elbow; elbow above shoulder

• AROM of the shoulder, wrist, and hand immediately after surgery.

• Gentle protected ROM within 2 to 3 days postoperatively within pain free limits

  • AROM after 1-3 wks

• Submaximal, pain-free, multiple- angle isometric exercises of elbow & Forearm

Radial Head Excision or Arthroplasty: Mod & Min Protect Phase

• Wound healing should be satisfactory & Elbow AROM is pain free ~ ________

• restore functional ROM or nearly full ROM

2-3 wks until 8 wks

Radial Head Excision or Arthroplasty: Mod & Min Protect Phase

• INC ROM

  • Gentle (low-intensity, prolonged stretch) manual stretch-

    ing, hold-relax techniques, or self-stretching

  • Grade II joint mobilization techniques → grade III mobilizations once healing has occured

• Improve functional strength and muscular endurance.

  • Low-load (pain-free) resistance exercises (maximum

    1 to 2 lb), emphasizing high repetitions

  • Initiate grip and pinch resistance exercises

  • Use of the postsurgical upper extremity for light activi-

    ties of daily living (ADLs)

Radial Head Excision or Arthroplasty: Mod & Min Protect Phase

Things to do?

• Gentle (low-intensity, prolonged stretch) manual stretching, hold-relax techniques, or self-stretching

• Grade II joint mobilization techniques → grade III mobilizations

• Low-load (pain-free) 1-2lb resistance exercises only

• Initiate grip and pinch resistance exercises

• Use of the postsurgical upper extremity for light ADLs

Radial Head Excision or Arthroplasty: Min - No Protect Phase

• Ranges from how many months

2-6 months

Radial Head Excision or Arthroplasty: Min - No Protect Phase

5 Things to do

• Grade 3 → 4 joint mob c manual stretching and hold-relax

  techniques at end ROM.

• Employ radial (lateral) and ulnar (medial) gapping

  techniques

• Orthotic intervention by 8 wks

• Progress to Mechanical Resistance Exercise for the whole UE

• Patient educ on return to functional activities

Contraindications to Total Elbow Arthroplasty

LEL

Total Elbow Arthroplasty

• linked (articulated)

  • Linked designs derive inherent stability from one or two pins, which couple the humeral and ulnar components

• Unlinked (nonarticulated)

  • artificial humeral and ulnar components of the joint are not mechanically connected to each other

• Triceps Reflecting approach

  • distal attachment of the triceps is detached and reflected laterally

• Triceps Sparing approach

  • preserves the attachment of the triceps tendon on the olecranon but makes insertion of the implants more technically challenging

Postoperative Management: TEA

• Immobilization

  • triceps-reflecting approach: full or almost full elbow extension

  • extended position is also indicated if symptoms of ulnar neuropathy are present

• Duration

  • 1-2 days only unless several weeks if may RA

  • If delayed wound healing → maintain in extension for 10 to 14 days postoperatively

• Exercise Progression

  • rehabilitation is RAPID when triceps-sparing approach is used to insert a linked replacement

Specific Precautions After Total Elbow Arthroplasty

Analysis of Three Potential Complications After Total Elbow Arthroplasty

POST OP TEA: Maximum Protection Phase

• Extends approx __weeks

• AAROM tolerated intiated within ____ days after linked TEA

• If significant pre-op instability, ROM is delayed for ____ days

• Extends approx 4 weeks

• AAROM tolerated intiated within 2-3 days after linked TEA

• If significant pre-op instability, ROM is delayed for 7-10days

POST OP TEA: Maximum Protection Phase

5 Things to do:

• AROM of shoulder, wrist & hand (Essential for RA/JRA patients)

• Gentle self-assisted elbow all motions with the elbow comfortably flexed and the forearm in mid-position → AROM

• Gentle, pain-free muscle-setting exercises of elbow

• Low-intensity, isometric resistance exercises of the shoulder, wrist, and hand.

• Use of the hand for light functional activities as early as 1 to 2 weeks if linked replacement but several weeks if Unlked

POST OP TEA: Maximum Protection Phase

If the triceps mechanism was reflected and repaired, limit assisted flexion to _____ for ___ wks

• If the triceps mechanism was reflected and repaired, limit assisted flexion to 90° to 100° for the first 3 to 4 weeks

POST OP TEA: Maximum Protection Phase

Perform active elbow flexion/extension in ________

seated or standing

T/F:

If a linked replacement was implanted using a triceps- sparing approach, AROM in all planes of motion is permissible immediately.

True

POST OP TEA: Maximum Protection Phase

• Use of the hand for light functional activities as early as ____ weeks postoperatively if a linked replacement was inserted but _____ weeks later after an unlinked TEA.

• 1-2 wks if linked

• several weeks if unlinked

POST OP TEA: Moderate and Minimum Protection Phases

• Starts at ____ weeks postoperatively (sot tissues are healed to withstand increasing stresses)

• By ____ weeks, barring complications, only minimum protection is necessary

• Full level of activity with ongoing lifting restrictions varies from _ weeks → _to _ months

• Starts at 4 to 6 weeks postoperatively (sot tissues are healed to withstand increasing stresses)

• By 12 weeks, barring complications, only minimum protection is necessary

• Full level of activity with ongoing lifting restrictions varies from 6 weeks to 3 to 4 months

POST OP TEA: Moderate and Minimum Protection Phases

• Permanent lifting restriction of _ pounds.

• Strength and muscular endurance usually continue to improve up to ____ months

• Emphasize end-range _____ before end- range ____ to protect the posterior capsule and the triceps mechanism.

• 5lb restriction

• 6-12months

• End range extension → end range flexion

POST OP TEA: Moderate and Minimum Protection Phases

5 Things to do:

• Low-intensity, manual self-stretching / Low load Long duration orthotic intervention

• Resisted, multiple-angle isometric exercises at 5 weeks

• Light ADLs (initially <1 lb of weight) performed with the arm positioned along the side of the trunk and the elbow flexed

• Lifting excercises & functional activities limited to 1lb → + 1 lb 3mos → single lift <10-15lb

• Low-load, closed-chain activities, such as wall push-ups, after 6 weeks or later

POST OP TEA: Moderate and Minimum Protection Phases

• Start Resisted, multiple-angle isometric exercises at __ weeks

• If a triceps-reflecting approach was used, include elbow ____ activities → elbow _____ → _____ chain motions

• 5 wks

• elbow flexion activities → elbow extension → close chain motions

Myositiis Ossificans is most commonly located at the _______ aspect of the elbow

posteromedial aspect of the elbow

• distal brachialis muscle is tender

Lateral Elbow Tendinopathy (Tennis Elbow)

• Pain over the lateral epicondyle of the humerus, primarily with gripping activities.

• Aggravated by Activities requiring firm wrist stability

  • backhand stroke in tennis

  • repetitive work tasks that require repeated wrist extension

    • computer work or pulling weeds in a garden

• Primary Structure involved → ORIGIN OF ECRB AND ED

Do THIS para maalala:

• pain with resisted wrist extension performed with the elbow extended,

• pain with resisted middle finger extension

• pain with passive wrist flexion with the elbow extended and forearm pronated.

Medial Elbow Tendinopathy (Golfer’s Elbow)

• Repetitive movements into wrist flexion

  • swinging a golf club

  • pitching a ball

  • work-related grasping and lifting heavy objects.

• Concomitant ulnar neuropathy may be associated

DO THIS

• pain with resisted wrist flexion performed with the elbow extended

• pain with passive wrist extension performed with the elbow extended.

Common Impairments of Structure and Function

• Gradually increasing pain in the elbow region after excessive activity of the wrist and hand

• Pain when the involved muscle is stretched or when it con- tracts against resistance

• Decreased muscle strength and endurance for the demand

• Decreased grip strength, limited by pain

• Proximal weakness of shoulder and scapular musculature

• Decreased mobility of the lower cervical and upper thoracic spine

• Tenderness with palpation over the lateral or medial epi-

  condyle or tendon origin

Common Activity Limitations and Participation Restrictions

• Inability to participate in provoking activities, such as racket sports, throwing, or golf.

• Difficulty with repetitive forearm/wrist tasks, such as sort- ing or assembling small parts, typing on a keyboard or using a computer mouse, gripping activities, using a ham- mer, turning a screwdriver, shuffling papers, or playing a percussion instrument.

Nonoperative Management of Overuse Syndromes: Protection Phase

7 Things to do:

• Rest/ Immob in wrist extension/ Cryotherapy

• Cross Friction Massage/ Massage

• Neuromob

• Gentle hold-relax techniques to either the wrist extensor or flexor muscles

• Passive Stretching for 20-30 secs & few reps

• ROM to all joints

• Shoulder and scapular stabilization exercises with resistance applied proximal to the elbow.

Nonoperative Management of Overuse Syndromes: Protection Phase

• Begin with the muscles in the shortened position with the elbow flexed and wrist either in extension or flexion → lengthening the muscle across the elbow by increasing elbow extension

In short???

• Stretch to flexion → extension

Nonoperative Management of Overuse Syndromes: Protection Phase

• To stretch the wrist extensors,

  • extend the elbow

  • pronate the forearm

  • flex and ulnarly deviate the wrist

  • flex the fingers

  • gently press on the back of the hand until a pain-free stretch is felt in the forearm.

DO IT

• To stretch the wrist flexors

  • extend the elbow

  • supinate the forearm

  • extend and radially deviate the wrist

  • extend the fingers

  • gently press on the palm of the hand until a pain-free stretch is felt in the forearm.

DO IT

Overuse Syndromes : Controlled Motion and Return to Function Phases

7 Things to do?

• Manual stretching ( agonist contract & hold relax)

• Self stretch

• Massage

• MWM & Self MWM

• Dynamic Resistance

  • low intensity c multiple reps

  • progress to eccentric

    • Fasters speeds → Higher loads

• Pylometrics

• Activity Modifications

Overuse Syndromes : Controlled Motion and Return to Function Phases

• MWM parameters?

• 3 sets ; 10 reps (lateral glide always)

CUBITAL TUNNEL SYNDROME:PROTECT PHASE

CUBITAL TUNNEL SYNDROME: MOD & MIN PHASE

PNI: ACUTE PHASE

PNI: RECOVERY PHASE

PNI: CHRONIC PHASE

PERIPHERAL NERVE MOBILIZATION TECHNIQUES

WAZZUP MAH _________?

Sigma boi