Anatomy of the elbow joint
Type and variety: it is synovial hinge (uniaxial joint).
Articular surfaces:
The trochlea and capitulum of the lower end of the humerus
articulates with trochlear notch of ulna and the head of radius.
Fibrous capsule:
Characters: it is thin infront and behind (to allow flexion and
extension) but thick at the sides (to prevent abduction and
adduction).
Attachments:
Above:
o Anteriorly: it is attached to the front of the humerus just
above the coronoid and radial fossa and to the roots of the
medial and lateral epicondyles of the humerus.
o Posteriorly: it is attached to the back of humerus just above
the olecranon fossa.
Below:
It is attached to the margins of the trochlear notch of ulna and
to the annular ligament.
Ligaments support:
1- Ulnar collateral Ligament medial Epicondyle to the olecranon,
protects against valgus injuries
2- Radial Collateral Ligament protects against varus injuries, from the
lateral Epicondyle to annular ligament
3- Annular Ligament: from ulna to radius
4- Interosseous Membrane:
Run obliquely from the radius to the ulna between the
proximal and distal Radioulnar joints
Stabilizer against axial forces applied to the wrist
Origin for many muscles
Lateral and medial epicondylitis
Medial epicondylitis (golfers elbow):
Golfers elbow, or swimmers elbow in adults generally occurs as
result of repetitive microtrauma to the pronator teres and the flexor
carpiradialis muscles during pronation and flexion of the wrist.
These is tenderness at the medial epicondyle and pain is
exacerbated by:
o Resisted pronation.
o Resisted volar flexion of the wrist.
o Passive extension of the wrist with the elbow extened (flexor
ms stretched).
Associated ulnar neuropathy at the elbow has been reported in 25
to 60% of patients with medial epicondylitis.
Medial epicondylitis
Signs & Symptoms
o Tender medial epicondyle.
o Weakness secondary to pain.
o Pain increased with wrist flexion and forearm pronation.
o Limitation wrist flexion and pronation.
Lateral epicondylitis (tennis elbow):
Tennis elbow occure with repetitive microtrauma that results in
either concentric or eccentric overload of the wrist extensor and
supinators, most commonly the extensor carpiradialis brevis.
There is pain along the lateral aspect of the elbow increases:
o Passive flexion of the wrist with extended elbow.
o Resisted wrist dorsiflexion.
Usually result from repeated forceful wrist hyperextension in
hitting a backhand stroke in tennis.
Lateral epicondyle
Signs and Symptoms
o Pain on lateral epicondyle with A/R wrist extension
o Limitation ROM of wrist.
o Loss of function.
o Tenderness.
o Loss of grip strength.
Rehabilitation concerns:
Minimize the repetitive stress created by these activities by altering
the frequency, intensity, or duration of play.
Two rehabilitation approaches may be taken in treating medial and
lateral epicondylitis.
The first approach involves:
Reduce inflammation and pain. Rest for several weeks or at least
restricted activities.
Passive therapeutic modalities such as:
o Cryotherapy.
o Electrical stimulation.
o Ultrasound.
NSAID. If pain persists, some physicians may recommend a
steroid injection.
The second approach involves:
Would be to realize that the patient has a chronic inflammation.
The goal in this approach is to jump-start the inflammatory process
to increase the inflammatory response that allow healing to
progress as normal to the fibroblastic and remodeling phases.
Transverse friction massage over the point of maximum tenderness
(common extensor origin and common flexor origin) at the
epicondyle may be used to increase the inflammatory response.
Transverse friction massage should be done for 5 to 7 minutes
every other day, using a maximum of 5 sessions.
If pain does not resolve after 1 year of conservative treatment,
surgery should be considered.
Rehabilitation progression:
Regardless of which of the two techniques is used, some
submaximal pain free exercise can begin.
If test and anti-inflammatory measure are used, a 2 to 3 week
period of restricted activity with very limited or no submaximal
exercise may be necessary to control pain and inflammation.
If more aggressive approach, which uses a transverse friction
massage is chosen, sub maximal pain free exercises can be begin
immediately.
Exercise intensity should be based on patient tolerance and
exercise progression.
Throughout the rehabilitation process, pain should always be used
as a guide for progression.
Each of the following exercises should continue in a progressive
manner throughout the rehabilitive period:
o Gentle active and passive ROM exercises for both the elbow
and wrist.
o Gentle isometric elbow flexion and extension exercises.
o Progressive isotonic elbow flexion exercises.
o Elbow extension exercises.
o Pronation and supination exercises beginning with light
weight.
Lateral counterforce bracing should be used to decrease tension of
the extensor muscles at the elbow.
Eccentric elbow flexion and extension exercises, and functional
training.
Gradually increasing the frequency, intensity, and duration of
exercise.
Rubber bar exercise:
Theraband exercise:
