Rehabilitation of Elbow Injuries

Elbow Anatomy

• 3 Joints w/Single Capsule

– Radioulnar

– Humeroulnar

– Humeral Radial

• Stable Joint

– Bony arrangement

– Ligamentous Stability

• Transmits and withstands high forces

– Jt b/t two long lever arms

• # of vessels/nerves

– Concern in traumatic injury

General Rehab Considerations

• Joint Stresses

• High velocities/forces

• Overhead motions place varus/valgus stresses on elbow jt.

– Deceleration

– Acceleration

• Proper Mechanics & Timing are critical

• Unique Structure

• Very congruent

• Muscle not tendon crosses the jt

Which one?

• Adhesions occur easily

• Thin anterior capsule

• Joint Mobility

• 3 Joints

– Different close packed and loose packed positions

• Force Applications

• Stresses differ depending on arm & wt. Position

– Elbow Ext-ant stress

– Elbow Flex-post stress

– Long lever arm > force

– Move wt up elbow

Epicondylitis

• Lateral: Tennis Elbow

– Extensor Carpi Radialis Brevis

– Overhead

– Poor Backhand Techn.

– Hitting ball too late

– Flipping wrist into ext.

• Medial: Golfer’s Elbow

– Common Flex origin

– Throw club down w/back hand

– Tennis: forehand w/ elbow ahead of racket

– Gymnasts: wt. Bear on hyperextended elbows

S/Sxs of Epicondylitis

• Gradual Onset

– Begins w/pain post activity

– Pain @ start; resolves & after

– Pain w/ ADLs & rest

– Grasping objects & shaking hands painful

• Lat: pain w/wrist ext

• Med: pain w/wrist flex

• Pro/Sup may be painful

• ROM may be restricted

Rehabilitation of Epicondylitis

• Determine cause of injury

• Modify Activities

• Address Inflammation

– Modalities

– Which ones?

– Injections

– Medications

Early Phase

• Pain/Inflammation Control

• Flexibility Exs:

– (Elbow, Wrist, Finger flex/ext & pro/sup)

• Joint Mobilizations (if moblity restricted)

Care should be taken to avoid aggressive stretchig exercises

Middle Phase

• ROM decreased: mobilizations if capsular

• Strengthening Progression

– Isometrics

– PRE: Emphasize Eccentrics

– Light Plyometrics

– Diagonals, Increased resistance & speed

Late Phase

• Plyometrics

• Functional Exs (increases no more than every 3^rd day)

• Consider Bracing

• Equipment & Tech.

Assessment

Assessment of Equipment

Racquet Sports

• Size: too heavy, large?

• Stiffness: too tight?

• Grip Size: proper size measured from tip of ring finger to palmar crease

• Utilize assistance of coach or professional

Surgical Treatment of Epicondylitis

• Release tendon

• Debride area

• Roughen bone to improve reattachment

• Suture back together

Post-Operative Rehabilitation

• Immobilizer x 1 wk

• 2^nd Day: AROM wrist/fingers

• 5^th Day: A & AAROM elbow

• 3 wks: ROM WNL

• 2wks: Exs against gravity; ball squeezes, pro/sup

• 3wks: Isometrics & straight plane exs

• Progress repetitions before weight

• 4-8 wks: diagonals; plyometrics (when good strength & control displayed)

• 3-4 mths: begin functional activities

• Return to activity:

– Lateral: 4-5 mths

– Medial: 5-6 mths

Little League Elbow

• Elbow inflammation occurring only in children

• Medial Elbow inflammation/avulsion of epiphyseal plate

• Signs/Symptoms

• Causes

Treatment of Little League Elbow

• RICE, ? Immobilization

• Stop pitching???

• AROM to tolerance

• Avoid Passive stretches

• Standard Exercise Progression (non-aggressive/non-intensive)

• Valgus stress avoided until pain-free

• Gradual throwing progression when full ROM and pain-free; normal strength and endurance

Elbow Sprains

• Which sprains are the most common?

• What are the MOI for each?

Treatment-Early Phase

• Pain & Inflammation Control

• Support Brace PRN comfort

• A & AAROM

• Straight Plane Strengthening Exs

• Strengthening:

– Biceps, Triceps, Wrist & Finger Flex/Ext, Pro/Sup

– Hyperextension: Biceps, Brachialis, Brachioradialis & supinators and triceps

– MCL: supinators/ Avoid: FCU

Middle Phase

• ROM: WNL

• Strengthening: progress reps/wt

– May add FCU

– May progress to diagonals

• PNF

• CKC

• Isokinetics

Late Phase

• Begin plyometrics

• Functional exs

Surgical Treatment for Elbow Instability

• MCL injury

• “Tommy John Surgery”

• Completely torn: graft using palmaris longus or plantaris

• Partially torn: repair

Rehab following UCL Recon

• Elbow Splint: locked at 90 deg flexion

• AROM: wrist/finger

• Ball squeezes

• Submax Biceps isometris

• Avoid ER

• End 2^nd Wk: Brace –30 ext and 100 flex

• Submax wrist & elbow isometrics

• ROM within brace limitations

• Each wk brace adjusted to allow more flex/ext until full motion at 6^th wk

• 4^th Wk: strength ex progression (wrist & elbow flex/ext, pro/sup against resistance)

• Proprioception:avoiding valgus stress

• Shoulder exs: except ER

• 6^th wk: Begin shoulder ER

– CKC exs

– Diagonals

– PNF patterns

– Tubing exs

– Stabilization

– Isokinetics

• 9^th Wk: begin plyometrics

– Push-up progressions

– Functional isokinetics

• 10-14 Wks: Begin functional progression

• 22-26 Wks: Return to activity

Ulnar Nerve Injury

• Most common in throwers

• MOI: improper mechanics

• Stretched, mechanically irritated or subluxed

• S/Sxs: 4^th/5^th digit numbness, tingling & posteromedial elbow pain

• Conservative and Surgical Txs

Conservative Tx of Ulnar Nerve Injury

• Pain and inflammation control

• ROM

• Strengthening Exs (low wt/ high reps in straight plane motions)

• Mobilizations: prn

• Address mechanics (shoulder strength)

• Avoid valgus stress initially

• Progress to diagonal and functional activities

Surgical Tx of Ulnar Nerve Injury

• Anterior transposition of nerve w/fascial sling

Post-Operative Tx

• Hinge brace locked at 90 flex for 2 wks

• -30 to –15 ext to 100-120 flex for 1 wks

• Discontinue brace at 3^rd wk

• 6 wks: full ROM

• Wk 1: ball squeezes, shoulder isometrics & AROM: pro/sup; wrist/finger flex/ext

• Wk 2: Elbow/wrist isometrics & ROM out of splint

– Proprioception

– Wrist exs w/resistance

• Wk 3: PRE for wrist, forearm & elbow

– Progress to diagonal planes as strength improves

• 8 Wks: plyometrics

• 10-12 Wks: functional progression

• 12-16 Wks: Return to activity

Elbow Dislocation

• Primarily posterior

• MOI: sudden hyperextension and abduction

Treatment

• Posterior immobilizing splint at 90 for 1 wk

• AROM of shoulder & wrist in splint

• Elbow isometrics/Wrist PREs

• 5 days: splint can be removed for ROM exs

Treatment of Elbow Dislocation

• Wk 2: splint prn

• Wk 3: discard splint, continue AROM exs

– Mild elbow resistive exs

• Wk 6: full ROM in all planes (??)

– Jt Mobs can begin 4-6 wks prn

• Strengthening emphasized elbow flexors

• 8-10 Wks: diagonals, plyos, functionals

• 16-26 Wks: Return to participation