ELBOW
Carson Finney
| Golfer's Elbow | Little Leaguer's Elbow | Tennis Elbow | Ulnar (medial) Collateral Ligament Tear |
| Radial Tunnel Syndrome | Cubital Tunnel Syndrome | Dislocations | Radial Head Fractures |
Golfer’s Elbow
Description: (A.K.A. Medial Epicondylitis) is caused by repeated medial tension or lateral compression (valgus) forces leading to microtearing of the wrist flexors at the common tendinous attachment on the medial epicondyle (tendinosis).
In adolescents (9-14 y/o) this places stress on the growth plate of the distal humerus.
Repetitive, high stress loads can lead to partial or complete avulsion of the medial epicondyle.
Along with the medial tensile forces, the lateral joint line undergoes compressive forces as well as shearing in the posteriorly located olecranon fossa.
Tenderness and pain are at the medial epicondyle are the most common symptoms, with flexion of the wrist further exacerbating the discomfort (stretching the wrist flexors may elicit the pain as well).
Treatment: Most can be managed with ice, NSAIDs, and immobilization in some cases for 2-3 weeks. Ultrasound can be used to decrease inflammation as well. Early pain-free range of motion exercises and gentle resisted isometric exercises should progress to isotonic strengthening and use of surgical tubing. Avoiding overhead throwing (as well as golfing) is recommended for 2-12 weeks depending on severity.
Prevention is normally gauged towards technique and decreasing overuse. Stretching and strengthening the forearm flexors will help as well, granted technique and frequency are not compromised.
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Little Leaguer’s Elbow
Description: Described as an avulsion of the common wrist flexor tendon from the medial epicondyle secondary to activities involving swift, powerful snapping of the wrist and forearm pronation.
In young baseball pitchers, these motions are repetitive and place great stress on the epicondyle.
Symptoms may be exactly the same as medial epicondylitis, with pain upon palpation of the entire length of the pronator teres muscle.
The detachment needs to be internally fixated; however, many go undiagnosed and heal somewhat weaker than those treated.
Treatment: This condition is usually diagnosed by a physician after X-ray, therefore is properly managed under direct supervision. Immobilization, restricted movement out of bracing, and functional strengthening should be the course of progression as the defect is allowed to heal. Ice and NSAIDs remain as staple treatment as well.
Prevention is the same as medial epicondyltis.
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Tennis Elbow
(A.K.A. - Lateral Epicondylitis) is cause by extensor tendon overload, most notably the extensor carpi radialis brevis (ECRB).
It can be attributed to several repetitive stresses; however, eccentric or negative loading of the extensor muscles is the most common culprit.
This is evident in the follow-thru deceleration sequence (forearm pronation and wrist flexion) during a tennis forehand swing.
Pain will be located over or slightly distal to the lateral epicondyle and is most evident during resisted eccentric muscle testing of the forearm extensors.
Treatment
Initially ice, compression, NSAIDs. A counterforce strap can also
be placed two to three inches distal to the
elbow, which can limit excessive tension placed on the epicondyle.
Ultrasound, friction massage (manual or ice cup) and electrical stimulation by trained
individuals can be used as helpful adjuncts. Restoring full strength, flexibility, and
endurance can be attained by proper stretching and high repetition-low resistance
exercises.
Prevention is with proper technique and muscle strengthening, stretching, and regular warm-up before activity.
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Ulnar (Medial) Collateral Ligament tear
Normally caused by repeated valgus stress applied to the elbow can cause the medial collateral ligament to become more lax or even tear.
Sudden, forceful throwing without proper warm-up can also lead to the same injury.
The MCL is comprised mainly of the anterior oblique, posterior oblique, and small transverse ligaments.
The primary stabilizer during elbow extension is the anterior oblique, while flexion stresses the posterior oblique.
At about thirty degrees of flexion the MCL is most vulnerable, thus throwing is one of the more prominent methods of ligament compromise.
A discernable "pop" has been described as a common symptom followed by varied amounts of pain, function, and swelling
Surgical correction (Tommy John surgery) is performed by harvesting a replacement, usually the palmaris longus tendon from the superficial forearm flexors, and then using it as a graft.
Typical recovery time from surgery to throwing full speed is anywhere from 12-18 months; however isolated cases have been below this estimation.
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Radial Tunnel Syndrome
The entrapment of the radial nerve in a tunnel created by surrounding muscles and bone as it passes on the lateral elbow (commonly under the supinator muscle).
It may be secondary to the tunnel being too small, repetitive forceful pushing and pulling, flexion and extension of the wrist, and gripping or pinching.
Symptoms are very similar to that of tennis elbow, however the pain and discomfort will more commonly be about two inches distal to the attachment of the wrist extensors.
Treatment: depends on severity, intensity, duration, magnitude, and cause of the problem. If initiated early, total rest with NSAIDs can help acute conditions. Padding to protect areas in cases where direct contact and trauma are the etiology. Infrequently, chronic nerve damage may require surgery to release pressure or nerve entrapment. In cases of muscle hypertrophy, the person may need to lower the resistance of his/her exercises.
Proper technique and avoiding traumatic compression of the area help greatly, with technique adjustment being the easier of the two. Correcting the direct cause however (i.e., hypertrophy, excessive flexion/extension) is the best way to prevent these types of conditions.
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Cubital Tunnel Syndrome
Can be caused by frequent bending of the elbow such as pulling levers, reaching, or lifting.
Given that the ulnar nerve passes through the cubital tunnel (formed by bone, muscles, and ligaments), it is held somewhat in place by the surrounding structures and is caused to stretch several millimeters when the elbow bends.
The nerve can also snap over the medial epicondyle, thereby producing discomfort.
Symptoms include numbness in the fifth digit and the ulnar half of the ring finger; this may lead to further hand pain and muscle weakening.
The sensation may resemble being hit on the "funny bone", which is actually a misnomer being that the ulnar nerve is what is being referred to as it passes between the medial epicondyle of the humerus and the olecranon (cubital tunnel).
The discomfort or pain has been compared to that of medial epicondylitis.
Tapping on the nerve over the cubital tunnel reproduces the discomfort and sensation (Tinel’s sign).
Treatment: depends on severity, intensity, duration, magnitude, and cause of the problem. If initiated early, total rest with NSAIDs can help acute conditions. Padding to protect areas in cases where direct contact and trauma are the etiology. Infrequently, chronic nerve damage may require surgery to release pressure or nerve entrapment. In cases of muscle hypertrophy, the person may need to lower the resistance of his/her exercises.
Proper technique and avoiding traumatic compression of the area help greatly, with technique adjustment being the easier of the two. Correcting the direct cause however (i.e., hypertrophy, excessive flexion/extension) is the best way to prevent these types of conditions.
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Dislocations
The second most common major joint dislocation.
The direction is usually posterior
Simple dislocations are termed if they are not accompanied by a fracture
Dislocations usually occur after falling on an extended elbow
The medial collateral ligament is the major stabilizer of the elbow joint, therefore spraining or tearing the MCL will reduce the amount of effective protection versus dislocation
The radial head is the most important secondary stabilizer against dislocation.
Treatment: Immediate support, if possible by the uninjured arm, with ice application to reduce swelling and inflammation is necessary. It is very important to assess radial pulse, skin color, and capillary refill due to the nature of the injury. Immobilization with a vacuum splint (if you have one near) or other appropriate splinting is needed because fractures can easily occur with dislocations. Vitals, recheck pulse and sensory, and treat for possible shock. Transport to the nearest medical facility should be considered emergent.
Prevention is the same as for fractures.....get out of the way and protect yourself!!!!
Radial Head Fracture
This is the most common adult elbow fracture (radial neck fractures more prevalent in PEDS
Usually a result from a fall onto an outstretched hand, which causes the radial head to be driven proximally into its articulation with the humerus (capitulum)
Pain, swelling in and around the joint, tenderness over site are common symptoms; ROM difficulties are likely as well.
Treatment: Anytime a fracture is suspected, a neurological and vascular assessment is warranted. Pulses can be taken at the ulnar or radial arteries, while noting capillary refill will also be of aid. Sensory to the hand should be assessed over all fingers, front and back, to rule out nerve damage. Referral to an ER or healthcare clinic must be initiated in a timely fashion as well. In the meantime, splinting of the area to reduce the chance of neurovascular compromise is highly recommended. If there is more than 30 degrees of angulation, more than 30 percent of the articular surface involved, or greater than 3 mm of fracture gap shown on X-ray, open reduction surgery (screws, pins, plates...all the toys!!) is normally performed.
Prevention: Avoiding the fall or direct blow has been shown to greatly reduce fractures. Padding and proper technique, depending on the activity or sport, also are advised.
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