W11.3 Common Conditions of the Elbow Chart

What practice patterns are commonly associated with elbow and forearm conditions?

• 4c muscle performance

• 4d connective tissue dysfunction

• 4e local inflammation

• 4g fracture

• 4h joint arthroplasty

• 4i bony or soft tissue surgery

• 5f peripheral nerve injury

What is epicondylalgia and why is that term preferred over epicondylitis?

Epicondylalgia refers to pain at an epicondyle and is preferred because the condition is not always a true inflammatory process

What types of activities commonly contribute to epicondylalgia?

Overuse of the arm, especially repetitive rotation with flexion and extension

Which is more common: lateral or medial epicondylalgia?

Lateral epicondylalgia is 4-7x more common than medial epicondylalgia

What muscle-tendon structures are commonly involved in lateral epicondylalgia?

• ECRB most commonly

• Possible involvement of ECRL, ECU, and EDC

What are common aggravating activities in lateral epicondylalgia?

• Gripping (with wrist extension)

• Such as in tennis, racquet sports, golf, swimming, and weightlifting

What are the typical symptoms of lateral epicondylalgia?

• Lateral elbow or forearm pain with extensor contraction

• Diffuse achiness

• Morning stiffness

• Pain with grasping or wrist-extended activity

• Dropping objects

What are common palpation findings in lateral epicondylalgia?

Tenderness at the ECRB and ECRL

• Especially anterior to the lateral epicondyle and around the radial head

What resisted motion often reproduces symptoms in lateral epicondylalgia?

Resisted wrist extension with radial deviation and the elbow extended

What special tests are commonly positive in lateral epicondylalgia?

• Cozen’s test

• Mill’s test

• Extensor digitorum test

What proximal regions should be assessed in patients with lateral epicondylalgia?

• Shoulder

• Scapulothoracic region

• Cervical spine

• Thoracic spine

What is the general prognosis for lateral epicondylalgia with conservative treatment?

• Often self-limiting over 8 to 12 months

• About 95% recover with conservative management

What are the main exercise priorities for lateral epicondylalgia rehab?

• Wrist extensor eccentrics

• Elbow isometrics progressing through angles

• Isotonic and plyometric loading

• Shoulder and scapular stabilization

• Cervicothoracic stabilization

• Sport-specific technique training

What manual therapy options may be used for lateral epicondylalgia?

• Scaphoid manip

• Radial head mobs or manip

• Mill’s manip

• Neurodynamic techniques

• Cervical and thoracic mobs or manip

• MWM

• Cross friction massage

How do corticosteroid and PRP injections differ in lateral epicondylalgia management?

• Corticosteroids may help in the acute phase but can be detrimental in chronic cases

• PRP is mainly used to stimulate regeneration in chronic cases

What structures are most commonly involved in medial epicondylalgia?

Common flexor origin

• Especially flexor carpi radialis and pronator teres

What is the typical mechanism of medial epicondylalgia?

Overuse injury to the flexor tendons at the elbow with valgus stress

What are the main clinical findings in medial epicondylalgia?

• Pain and tenderness over the flexor-pronator origin

• Sx with resisted wrist flex or pronation

• Sx with passive wrist ext and supination

What special test is used for medial epicondylalgia?

Golfer’s elbow test

• Palpate med epicondyle

• Elbow flexed to 90

• Elbow ext. supinate, wrist ext. → elbow ext

• (+) pain at med epicondyle

What important differential diagnoses should be considered with medial epicondylalgia?

• MCL insufficiency

• Pronator teres syndrome

• Ulnar nerve entrapment

• Medial intra-articular pathology

What are the main rehab principles for medial epicondylalgia?

• Initial rest and activity modification

• THEN ROM, strength, and flexibility work

• Progressing from multi-angle isometrics → concentric → eccentric exercise

• Scapular and shoulder stabilization has to be done

What is the usual mechanism of a distal biceps tendon rupture?

Forceful resistance to elbow extension, usually traumatic

What population is classically associated with distal biceps tendon rupture?

Males

What are the hallmark findings of distal biceps tendon rupture?

• Burning sharp pain in the antecubital fossa

• Marked elbow flexion and supination weakness

• Ecchymosis (bruise) after 48 to 72 hours

• A Popeye sign (high peak in bicep) from tendon retraction

How is distal biceps tendon rupture commonly managed?

Surgical tendon repair in young or active patients

What are key post-op rehab considerations after distal biceps tendon repair?

• Protocol-driven rehab with bracing and limited ROM for 6-8 weeks

• Maintenance of shoulder and hand or wrist function

• Control of pain and swelling

• THEN progression to stretching, strength, and endurance

• Return to unrestricted activity after >6 months

Which nerve around the elbow is most commonly injured?

Radial nerve

What nerve entrapment is most common overall?

Carpal tunnel syndrome

What is the mechanism of humeral supracondylar process syndrome?

Compression of the median nerve under the Struthers’ Ligament

What are typical findings in humeral supracondylar process syndrome?

• Pain in the wrist or medial forearm

• Worse with full extension or pronation

• Paresthesias in the index and middle fingers

What are the functional deficits seen in a high median nerve injury?

• Hand of Benediction pattern

• Loss of extrinsic flexors on the median nerve side → inability to flex DIP and PIP joints and weakened MCP flexion

• Loss of APB function → thumb rests in adduction

• When making a fist, the 1st and 2nd digits cannot flex

What is the typical presentation of pronator teres syndrome?

• Insidious onset of anteromedial forearm pain or “heaviness”

• Pain/paresthesias or sensory impairment in the median nerve distribution

What strength test may reproduce symptoms in pronator teres syndrome?

Pronation strength testing at 90 degrees of elbow flexion

How can pronator teres syndrome be differentiated from carpal tunnel syndrome?

Pronator teres syndrome does NOT usually have:

• Tinel’s at the wrist

• Nocturnal symptoms

What are key management strategies for pronator teres syndrome?

• Activity modification

• Relative rest

• Ice or anti-inflammatory care

• Stretching

• Soft tissue mobilization

• Neural gliding

• Maintaining strength

• Scapular and shoulder stabilization

• Addressing cervical mobility and posture

What is the defining feature of anterior interosseous nerve syndrome?

Motor involvement only with no sensory loss

What are the key findings in anterior interosseous nerve syndrome?

• Weakness in the flexors of the index finger and thumb

• Positive pinch test, and no sensory deficits

Which muscles are innervated by the anterior interosseous nerve?

• Flexor pollicis longus

• Lateral half of flexor digitorum profundus

• Pronator quadratus

How is anterior interosseous nerve syndrome usually managed?

Resolves spontaneously

What boundaries form the cubital tunnel?

• Floor is the UCL

• Ceiling is the arcuate ligament from FCU

• Anterior border is the medial epicondyle

• Posterolateral border is the olecranon

• Ulnar nerve passes through it

What are common causes or contributors to cubital tunnel syndrome?

• Repetitive use

• Shortened FCU

• Ulnar nerve subluxation

• Elbow synovitis

• Cubitus valgus deformity

• Repetitive flexion traction forces

• Trauma

• Laceration

What are the sensory symptoms of cubital tunnel syndrome?

• Activity-related pain or paresthesias in the ulnar nerve distribution

• With medial elbow pain, often worse at night

What are the motor findings of cubital tunnel syndrome?

• Inability to abduct the digits

• Loss of grip power or dexterity

• Late atrophy or weakness of ulnar intrinsic muscles

What special tests may be positive in cubital tunnel syndrome?

• Elbow flexion test

• Tinel’s sign

• Wartenberg’s sign

• Froment’s sign

• ULTT 4

What hand deformity may appear later in cubital tunnel syndrome?

Ulnar claw hand

• Caused by paralysis of the ulnar lumbricals and interossei → loss of MCP flexion and intrinsic control of the extensor mechanism in digits 4–5

• Unopposed extensor digitorum hyperextends MCPs while FDP flexes PIP and DIP → claw posture

• Finger flexion remains intact via FDS and FDP, but full finger extension is impaired due to loss of intrinsic muscle function

What conservative treatment is used for cubital tunnel syndrome?

• Activity modification

• Elbow pad over the cubital tunnel

• Limiting extreme elbow flexion

• Night splinting at 40 to 60 degrees

• Possibly full-time splinting in more severe cases

• Exercises in a limited arc

• Stretching the FCU

When is surgery considered for cubital tunnel syndrome?

• When symptoms fail to improve after 3 to 4 months of conservative care

• OR when there is muscle atrophy, persistent sensory change, or persistent symptoms

What is the classic sign of high radial nerve palsy?

Wrist drop with extensor atrophy and the hand hanging in flexion

What is compressed in radial tunnel syndrome?

The deep branch of the radial nerve, often by ECRB and the supinator

How does radial tunnel syndrome commonly differ from lateral epicondylalgia?

Pain is usually more distal in the extensor mass and tenderness is about 5 cm distal to the lateral epicondyle

What tests commonly provoke pain in radial tunnel syndrome?

Resisted third digit extension, resisted supination with the elbow extended, and elbow extension plus pronation plus wrist flexion

How is radial tunnel syndrome managed?

Activity modification, splinting in about 45 degrees of wrist extension, extensor stretching, soft tissue mobilization, nerve glides, and surgery if conservative care fails

What is the key distinguishing feature of posterior interosseous nerve syndrome compared with radial tunnel syndrome?

Posterior interosseous nerve syndrome has motor loss without sensory deficits

What motor deficits are seen in posterior interosseous nerve syndrome?

Loss of extension at the MCPs of the fingers and thumb, loss of thumb IP extension, and loss of thumb abduction

What is a common mechanism for UCL or medial elbow instability?

Throwing-related valgus stress, FOOSH, or iatrogenic causes such as excessive medial epicondylectomy

What clinical tests are used for UCL or medial elbow instability?

Valgus stress test at 25 degrees of elbow flexion, moving valgus stress test, and milking maneuver

What findings distinguish complete versus incomplete UCL tears?

Complete tears may show palpable medial gapping, while incomplete tears cause pain without gapping

What are the phases of conservative rehab for UCL or medial elbow instability?

Acute phase reduces inflammation and restores ROM, subacute phase gradually restores ROM and strengthens, and chronic phase builds strength, power, endurance, neuromuscular control, and throwing mechanics

Who is more likely to be a surgical candidate for UCL injury?

High-level athletes and heavy manual laborers

What graft is classically used in Tommy John reconstruction?

An ipsilateral palmaris longus tendon autograft

Why is little league elbow important to recognize early?

It involves a medial epicondylar physeal injury in a skeletally immature athlete and can affect growth if not managed properly

What age group is commonly affected by little league elbow?

Ages 9 to 14

What is the red flag palpation finding in little league elbow?

Tenderness at the medial epicondyle in an adolescent thrower

What imaging finding may be seen in little league elbow?

Widening of the apophyseal line, fragmentation, or enlargement, with oblique views helping visualization

What is the core management principle for little league elbow?

Rest from throwing, ice, gradual progression through ROM and strengthening, shoulder rehab, and correction of throwing mechanics before return

What ligament complex is insufficient in posterolateral rotary instability?

The lateral collateral ligament complex, especially the lateral UCL

What is the classic mechanism of posterolateral rotary instability?

Axial compression plus supination plus valgus force, often with a FOOSH

What symptoms suggest posterolateral rotary instability?

Buckling or clunking with the arm in extension and supination

What special test is used for posterolateral rotary instability?

The PLRI apprehension test, also called the pivot shift test

What is emphasized in rehab for posterolateral rotary instability?

Whole kinetic chain rehab, immobilization or bracing, AROM, swelling control, progressive strengthening, and avoiding valgus loading

Who is a typical candidate for total elbow arthroplasty?

A person with rheumatoid arthritis or an elderly patient with humeral fractures and low ADL demands

Why is total elbow arthroplasty considered a last resort?

It is performed rarely, mainly for pain relief in low-demand patients, and is not recommended for younger high-level patients

What is the typical mechanism of radial head fracture?

Traumatic FOOSH

What associated injuries should be considered with radial head fracture?

Osteochondral injury, wrist or shoulder injury, torn capsule, UCL tear, RCL tear, brachialis tear, distal radioulnar instability, medial elbow instability, and PLRI

What is the red flag symptom in radial head fracture suggesting forearm compartment syndrome?

Severe pain even after immobilization and reduction

What are the key rehab principles after radial head fracture?

Restore ROM, restore strength, maintain function during immobilization, and mobilize as soon as appropriate depending on fracture stability

What defines a Monteggia fracture?

Dislocation of the proximal radius with fracture of the ulna

What mechanism commonly causes a Monteggia fracture?

A direct forearm blow or FOOSH

What is a common mechanism of olecranon fracture?

Fall backward or FOOSH, sometimes with triceps avulsion from forced flexion during muscle contraction

What special test may be positive with olecranon fracture?

The elbow extension test

What is a coronoid fracture?

An injury where the anterior humerus shears off part of the coronoid process during posterior dislocation

What early management is used for a stable non-displaced elbow fracture?

Sling or splint for about 3 days with immediate active elbow flexion exercise

Why should early PROM often be avoided after elbow fracture or ORIF?

Because it may stimulate heterotopic ossification

What is a common ROM complication after elbow dislocation?

Loss of terminal extension, often around 10 to 15 degrees

What vascular complication can occur with humerus dislocation?

Brachial artery injury

What nerve is most commonly injured in elbow dislocation complications?

The ulnar nerve

What is nursemaid’s elbow?

A partial slippage of the annular ligament over the radial head into the radiocapitellar joint

What age group commonly gets nursemaid’s elbow?

Children around 2 to 3 years old

What mechanism causes nursemaid’s elbow?

Longitudinal traction on an extended and pronated elbow

How does a child with nursemaid’s elbow typically hold the arm?

At the side with the palm facing down

What is Panner’s disease?

Aseptic necrosis of the capitellar epiphysis in a growing child

What age group is commonly affected by Panner’s disease?

Ages 5 to 12, mostly males

How does Panner’s disease usually present?

Insidious lateral elbow pain in a self-limiting condition

How is Panner’s disease usually managed?

Short immobilization, avoiding repetitive stress, symptom management, and gradual return once symptoms resolve

What is osteochondritis dissecans of the capitellum?

Localized fragmentation of bone and cartilage of the capitellum with loss of subchondral bone and breakdown of articular cartilage

What age group commonly develops capitellar OCD?

Athletes ages 10 to 16, mainly in the dominant arm

What mechanism is associated with capitellar OCD?

Insidious onset from repetitive valgus loading and microtrauma, such as in baseball pitchers and gymnasts

What symptoms suggest capitellar OCD?

Lateral elbow pain, possible locking or catching in advanced stages, flexion contracture, pain with extension and pronation, and possible MCL laxity

How is capitellar OCD generally managed?

Stop aggravating activity, do ROM exercise, gradually strengthen once symptoms stop, and use surgery for unstable lesions or failure of conservative management

How can capitellar OCD be distinguished from Panner’s disease?

OCD occurs in older children or adolescents and is associated with repetitive sports trauma, while Panner’s disease occurs in younger children and is self-limiting