General Principles
History and Physical Examination
History
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Hand dominance
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Location
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Medial, lateral, anterior, and posterior
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Type of pain
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Radiating symptoms
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Numbness/tingling
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Stiffness
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Mechanical symptoms (locking and catching)
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Duration of symptoms
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Mechanism of injury
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Pain modifiers
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History of previous injuries
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Treatments rendered and results of treatments
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Recent changes in technique or training regimen
Physical Examination
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Inspection:
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Compare to uninjured arm
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Skin changes
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Swelling
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Ecchymosis
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Muscle atrophy/hypertrophy
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Carrying angle (cubitus valgus and cubitus varus)
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Neurovascular examination
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Median, ulnar, radial, medial, and lateral antebrachial cutaneous sensation
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Two-point discrimination at the fingertips (≤5 mm is normal)
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Median, ulnar, and radial motor
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Range of motion (ROM) ( Fig. 50.1 )
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Flexion and extension
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Forearm pronation and supination
Figure 50.1
Measurement of pronation/supination.
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Strength testing with isometric resistance
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Stability
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Valgus–varus laxity
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Posterolateral rotary laxity
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Ulnar collateral ligament laxity
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Palpation: Identify areas of tenderness as anterior, posterior, medial, or lateral, and focus on key anatomic structures.
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Provocative maneuvers
Ancillary Tests
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Radiographs: Anteroposterior (AP) and lateral
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Special views:
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45-degree flexion view (capitellum)
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Oblique (radial head view)
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Axial projections (olecranon fossa or gun-sight view)
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Gravity/manual stress view
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Computed tomography (CT) or magnetic resonance arthrogram: Articular incongruity, loose bodies, and ligament injuries
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CT scan: Fracture-dislocation, osteophytes/exostosis, and tendon calcification
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Magnetic resonance imaging (MRI): Soft tissue mass, ligament attenuation/rupture, chondral defects, and loose bodies
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Arthroscopy (intra-articular inspection): Loose bodies, chondral lesions, and synovitis
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Electromyogram–nerve conduction study (EMG–NCS): Nerve compression
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Ultrasound: Dynamic evaluation for ligament laxity or ulnar nerve instability
Anterior Elbow Injuries
Distal Biceps Rupture
Description: Traumatic avulsion of the distal biceps tendon from the bicipital tuberosity of the proximal radius
Mechanism of injury: Eccentric muscle contraction against an extension load on a flexed elbow
Presentation: Atypical injury: 97% of biceps ruptures are proximal, only 3% of biceps ruptures occur at elbow; most often occur in males in the 4th–5th decades of life in the dominant extremity; often associated with a pop or tearing sensation in the proximal forearm or antecubital fossa
Physical examination: Tenderness to palpation in the antecubital fossa, acute swelling and ecchymosis are common, palpable tendon defect in complete tears (partial tears less common), tendon retraction if lacertus fibrosus torn (“Popeye sign”), and weakness with supination/elbow flexion
Differential diagnosis: Biceps tendonitis, bicipitoradial bursitis, and lateral antebrachial cutaneous nerve entrapment
Diagnosis: Primarily a clinical diagnosis
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Hook test: Flex the elbow to 90 degrees in full supination, and insert a finger from the lateral side into antecubital fossa to cord-like structure.
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Biceps squeeze test: Rest the elbow on a patient’s lap in slight pronation and midflexion, firmly squeeze the belly of the biceps muscle with both hands, and observe for supination.
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Pain and/or weakness with resisted forearm supination
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Imaging: Radiographs to rule out associated elbow injuries and evaluate irregularities around the radial tuberosity; ultrasound is cost effective but user dependent. MRI should be performed with the patient prone, shoulder abducted overhead, elbow flexed to 90 degrees, and forearm fully supinated.
Treatment: Acute anatomic repair superior to nonsurgical treatment. Allograft/autograft may be required in chronic cases if the tendon length cannot be restored. One- and two-incision repair techniques described; concern for heterotopic bone formation/radioulnar synostosis with the two-incision technique. Most common complication with either approach is LABC palsy (15%–40%), which is higher with the one-incision technique.
Prognosis and return to sport: A season-ending injury; patients surgically treated early can be expected to have near-full return of power and function with elbow flexion and supination.
Pronator Syndrome (Median Nerve Entrapment)
Description: Compression of the median nerve at the level of the elbow with resultant nerve irritation ( Fig. 50.2 )
Figure 50.2
Nerves of the upper extremity.
Mechanism of injury: No specific mechanism of injury has been associated with this disorder. Four possible sites of compression have been identified:
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Tendinous arch of the flexor digitorum superficialis (“sublimis bridge”)
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An accessory head of the FPL (Gantzer’s muscle)
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Beneath the ligament of Struthers in patients with a supracondylar process
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At the lacertus fibrosus at the level of the elbow joint
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Presentation: Presents similarly to carpal tunnel syndrome with numbness and paresthesias in the volar radial three and a half digits and volar forearm/wrist pain; distinguished from carpal tunnel syndrome by decreased sensation over the thenar eminence in the distribution of the palmar cutaneous branch of the median nerve. Symptom severity may increase with activity such as weightlifting, competitive driving, and underarm pitching. Nighttime symptoms are less common than those in carpal tunnel syndrome.
Physical examination:
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Pronator compression test: Apply pressure proximal/lateral to proximal edge of PT muscle belly, which reproduces pain/paresthesias within 30 seconds.
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Resisted pronation/supination can reproduce symptoms
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Resisted flexion of PIP of the middle finger can reproduce symptoms caused by compression of FDS heads.
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May have a positive Tinel sign over volar forearm
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Differential diagnosis: Carpal tunnel syndrome, cervical spine or brachial plexus nerve compression, flexor–pronator tendonitis, and biceps tendonitis
Diagnostics: Plain radiographs are often normal but can reveal a supracondylar process (present in 1% of people, 5 cm proximal to the medial epicondyle); electromyogram (EMG) and nerve conduction study (NCS) help to rule out other sites of compression; however, EMG may not reveal nerve compression despite symptoms.
Treatment: Initial nonsurgical management with activity modification, forearm flexor stretching, and anti-inflammatory medications administered from weeks to months; if not responsive to nonsurgical management, then complete decompression of median nerve throughout its course in the proximal forearm should be performed by targeting release of the ligament of Struthers, the lacertus fibrosus, deep head of the pronator teres, and the FDS arch.
Prognosis and return to sport: Early active ROM, full return to activity by 6–8 weeks, and return to sport dependent upon restoration of strength and ROM
Posterior Elbow Injuries
Triceps Rupture
Description: Traumatic avulsion of the triceps tendon from its insertion on the olecranon process of the ulna or avulsion of the olecranon process from the ulna with triceps tendon attached
Mechanism of injury: Most commonly occurs from forceful eccentric contraction of triceps such as fall onto outstretched hand or weightlifting
Presentation: Twice as common in males; associated with chronic anabolic steroids, systemic corticosteroids, and certain metabolic/systemic disorders. Patients report a recognizable event including a painful pop or a tearing sensation in the posterior elbow usually during an eccentric load with loss of elbow extension strength after the injury.
Physical examination: Tenderness to palpation along olecranon and distal triceps, acute ecchymosis, and edema; palpable defect of triceps tendon or step-off at olecranon; weak elbow extension/inability to hold elbow extended against gravity but not necessarily complete loss of extension strength; modified Thompson squeeze test: compressing the muscle bulk of the triceps fails to cause elbow extension
Differential diagnosis: Triceps tendonitis, partial triceps tear, olecranon bursitis, olecranon stress fracture, and posterior elbow impingement
Diagnostics: Largely a clinical diagnosis; “flake sign” (small bony avulsion fragment from olecranon process) observed in 80% of cases and pathognomonic for triceps rupture; MRI or ultrasound can help distinguish partial from complete tendon rupture and should be obtained to confirm severity of injury
Treatment: Nonsurgical treatment indicated only in elderly sedentary patients and is controversial in those with partial tears, comprises splint immobilization with the elbow in 30 degrees of flexion for approximately 3–4 weeks, followed by progressive flexion mobilization. Most complete ruptures or high-grade partial ruptures are managed with primary surgical repair within 2–3 weeks of injury.
Prognosis and return to sport: In general, a season-ending injury with at least 4–6 months of recovery/rehabilitation time expected; most athletes are able to return to sport at a level similar to that during the preinjury state with slight loss of extension strength and ROM, with a re-rupture rate of up to 20%.
Valgus Extension Overload
Description: Repetitive forceful shearing of olecranon within its fossa causing chondromalacia and olecranon osteophyte formation
Mechanism of injury: Overuse injury frequently seen in throwing athletes; bony constraints provide secondary stability to valgus stress to the elbow, which increases with extension; the olecranon traumatically abuts posteromedial olecranon fossa near full extension
Presentation: Pain localized to the medial aspect of olecranon in acceleration/deceleration throwing phases; limited extension because of impinging osteophytes; mechanical symptoms from loose bodies; exacerbated by medial ulnar collateral ligament (UCL) laxity; throwing athletes may complain of premature fatigue, loss of velocity, or loss of control
Physical examination: May demonstrate loss of terminal extension; posterior pain with pronation, valgus and extension; possible pain or laxity of the UCL with valgus stress; possible ulnar nerve irritation; can have palpable loose bodies/crepitus
Differential diagnosis: Olecranon bursitis, olecranon stress fracture, and triceps tendonitis
Diagnostics: Radiographs may posteromedial osteophytes, loose bodies, hypertrophic bone formation, calcification of the UCL, or medial epicondyle avulsion fractures. A 110-degree flexion oblique view can profile the posteromedial ulnar humeral joint. Radiographs may be normal; MRI can help to further assess the status of articular cartilage and better identify loose bodies
Treatment: Initial nonsurgical management of activity modification, NSAIDs, focused physical therapy with eccentric strengthening of wrist flexors, and when symptoms allow, a supervised throwing program with correction of flawed pitching mechanics. Patients failing nonsurgical treatment may be candidates for arthroscopic debridement to decompress the posterior compartment; avoid debriding >3 mm of bone because it increases the force in the medial UCL.
Prognosis and return to sport: A gentle throwing program should begin at approximately 6 weeks after surgery. Most throwing athletes return to previous level of competition within 3–4 months after surgery; patients with loose bodies or posterior impingement have better prognosis than those with degenerative changes within joint
Olecranon Stress Fracture
Description: Stress injury across the proximal portion of the ulna
Mechanism of injury: Similar to valgus extension overload; repetitive abutment of olecranon into the olecranon fossa with repetitive traction from triceps contraction during deceleration phase of throwing and impaction of medial olecranon onto the medial olecranon fossa.
Presentation: Less common in adult throwers than adolescents and children; patients usually report insidious onset of pain in the posterior or posteromedial elbow.
Physical examination: Tenderness to palpation over the posterior/posteromedial olecranon; pain with forced passive elbow extension and resisted extension; patients may demonstrate limited terminal extension
Differential diagnosis: Triceps tendonitis, olecranon bursitis, and valgus extension overload
Diagnostics: Plain radiograph: May show a transverse/oblique fracture line and/or sclerosis; MRI: May better delineate fracture patterns if not seen on radiographs; contralateral radiographs useful in skeletally immature patients because of variability in location of the olecranon physis
Treatment: Immediate cessation of throwing; may temporarily immobilize using a cast/splint; no return to sport until radiographic evidence of fracture healing and cessation of clinical symptoms (may take up to 6 months); patients failing to respond to conservative therapy may be considered for surgical treatment, consisting of compression screw fixation (oblique fractures) and tension band fixation (transverse fractures)
Prognosis and return to sport: Fractures typically heal with nonsurgical management or surgical fixation; athletes generally can return to sport within 3–6 months
Olecranon Bursitis
Description: Inflammation of the bursa overlying the triceps tendon and olecranon of the ulna; can be acute or chronic and septic or aseptic ( Fig. 50.3 ).
