Rehabilitation of Elbow Injuries

Sakiko Oyama, PhD, ATC
William E. Prentice, PhD, PT, ATC, FNATA

It is important to mention that the elbow is an integral part of the upper quarter (cervical spine to the hand). In open chain movements, position and orientation of the hand is determined by the orientation of the upper body, shoulder girdle, and elbow. Weakness, pain, or restricted range of motion (ROM) in any part of this upper quarter chain can lead to compensatory changes in the other areas. The proprioceptors that are abundant in the joint capsule that is continuous between the 3 articulations at the elbow24,26 and multi-articular muscles that cross the elbow complex (eg, wrist flexors, wrist extensors, biceps brachii, and triceps brachii) allow the elbow to function as an integral part of the upper quarter. Therefore, the appropriate strength and function of the entire upper quarter needs to be addressed when evaluating the elbow.

In sports skills such as pitching and hitting, where transfer of momentum from the lower body to the upper body is important, it is also important to evaluate and address function of the musculature in the lumbo-pelvic-hip region. Inability to control hip, pelvis, and trunk movement can hinder the transfer of momentum from the legs to the upper extremity. This may compromise performance, or lead to compensation within the upper quarter, which may increase the loading on the elbow joint. Therefore, strength and control of the lumbo-pelvic-hip muscles need to be addressed when rehabilitating athletes from elbow injuries.

Humeroulnar Joint

The humeroulnar joint is the articulation between the distal medial humerus and the proximal ulna. The distal articulating surface of the humerus has distinct features. An hourglass-shaped trochlea¹⁶ is located anteromedially on the distal humerus, and articulates with the trochlear notch of the proximal ulna. Because the trochlea extends more distally than the lateral aspect of the humerus, the elbow complex demonstrates a carrying angle that is an abducted (valgus) position of the elbow in the anatomical position. The normal carrying angle (Figure 18-1) in women is 10 to 15 degrees and in men, 5 degrees.³ When the elbow moves into flexion, the ulna slides forward until the coronoid process of the ulna stops in the floor of the coronoid fossa of the humerus. In extension, the ulna will slide backward until the olecranon process of the ulna makes contact with the olecranon fossa of the humerus.

The stability of the elbow first starts with the joint capsule that is continuous between all 3 articulations. The capsule is loose anteriorly and posteriorly to allow for movement in flexion and extension.1 It is taut medially and laterally due to the added support of the collateral ligaments. The capsule is highly innervated for proprioception.

The ulnar (medial) collateral ligament is fan shaped and has 3 aspects. The anterior aspect of the ulnar collateral ligament is the primary stabilizer in the ulnar collateral ligament from about 20 to 120 degrees of motion.⁴⁰ The posterior and the oblique aspects of the ulnar collateral ligament add support and assist in stability to the ulnar collateral ligament. The lateral elbow complex consists of 4 structures. The lateral ulnar collateral ligament, which is the primary lateral stabilizer, originates from the lateral epicondyle and inserts into the distal end of the annular ligament. The ligament reinforces the elbow laterally and reinforces the humeroulnar joint.^29,40 The radial collateral ligament also provides stability to the lateral elbow, and runs from the lateral epicondyle to the proximal end of the annular ligament. The accessory lateral collateral ligament passes from the tubercle of the supinator into the annular ligament, and functions to stabilize the annular ligament. The annular ligament, as previously stated, is the main support of the radial head in the radial notch of the ulna. The interosseous membrane is a syndesmotic condition that connects the ulna and the radius in the forearm. This structure prevents the proximal displacement of the radius on the ulna.

The Dynamic Stabilizers of the Elbow Complex

Elbow flexors, elbow extensors, and the flexor-pronator muscle group provide dynamic stability to the elbow joint. The elbow flexors include biceps brachii, brachialis, and brachioradialis muscles. The biceps brachii originate via 2 heads proximally at the shoulder: the long head from the supraglenoid tuberosity of the scapula and the short head from the coracoid process of the scapula. The insertion is from a common tendon at the radial tuberosity and lacertus fibrosis to origins of the forearm flexors. The biceps brachii function to flex the elbow and supinate the forearm.⁴⁶ The brachialis originates from the lower two-thirds of the anterior humerus to the coronoid process and tuberosity of the ulna. It functions to flex the elbow. The brachioradialis, which originates from the lower two-thirds of the lateral humerus and attaches to the lateral styloid process of the distal radius, functions as an elbow flexor, semipronator, and semisupinator.

The elbow plays an important part in the upper quarter during functional activities. Anatomical position places the elbow in full extension and full supination. The elbow functions in flexion, extension, supination, and pronation movement patterns. The elbow allows for about 145 degrees of flexion and 90 degrees of both supination and pronation, although the normal ROM may vary for the involved and for the noninvolved joint.21 The capsule, as previously stated contains proprioceptors that allow coordination among the joints in the upper quarter. The multijoint muscles that cross the elbow joint support the capsule in providing joint stability and to coordinate movements with proximal and distal joints.

Functionally, the relationship between the hand and the shoulder needs the elbow for normal movement to occur. Function of the cervical spine and shoulder can also affect the elbow. Limitations in motion in either area can cause accommodations in the elbow complex. For example, for a patient who has a decrease in supination due to injury, an accommodation of the injury is an increase in adduction and external rotation at the shoulder to allow function to continue, which can increase the valgus loading to the elbow. This is why proper knowledge of biomechanics in the elbow complex and associated joints is essential for proper assessment of injury and rehabilitation.

In addition to being a part of the upper quarter, the elbow is a part of the whole-body kinetic chain in activities like pitching and hitting. In pitching and hitting, the momentum generated by the large muscle groups in the lower body and trunk is transferred to the arm. The coordination between the lower body, pelvis, trunk, and arm motion not only affects pitching/hitting performance, but also affect the amount of stress that will be placed on the shoulder and elbow joints.⁴ In pitching, opening up the shoulders (eg, rotating the trunk to face the hitter) too early in the pitching motion causes the arm to lag behind the torso, and causes increased stress on the shoulder and elbow joints. For this reason, is it crucial that the element of core stability and strengthening of the lumbo-pelvis-hip musculature is included in the rehabilitation of elbow injuries in overhead athletes. The rehabilitation progressions for the specific injuries described next are focused on the rehabilitation of the upper body. However, progressive core stability and strengthening of the lumbo-pelvis-hip musculature must be performed in parallel to the upper body rehabilitation program.

The elbow fractures can involve humeral shaft, distal humerus, the radial head, and the proximal ulna. These fractures will affect individual bones themselves, as well as the function of the entire elbow complex.41 The most common type of elbow fracture in adults is the radial head fracture. Radial head fractures make up one-third of all elbow fractures and one-fourth of all elbow trauma in adults.⁴¹ They are more common in women than in men by a 2 to 1 ratio.³⁹ In the pediatric population, supracondylar humeral fracture is the most common type of elbow fracture.

Dislocations might accompany an elbow fracture, depending on the specific mechanism of injury. For example, a forearm fracture will often occur in the shafts of both the radius and ulna. A fracture of one of the forearm bones can result in a dislocation of the other bone.^9,39 With elbow fractures, properly evaluating the neurovascular system is critical. The ulnar, radial, median, and musculocutaneous nerves pass the elbow in various positions anatomically. The brachial artery has various branches that provide the blood supply from the proximal elbow to the digits. The radial, ulnar, and common interosseous arteries (and the collateral and recurrent arteries), specifically, provide the circulation off the brachial artery to the structures at and distal to the elbow

The fracture of an elbow can occur from direct or indirect forces. A direct blow to the elbow via a fall on a hard surface or hit by an object (eg, stick, helmet, or bat) can fracture the bones of the elbow.35 For example, olecranon process fractures can occur with a fall directly on the tip of the elbow (eg, when a volleyball player falls on an elbow). Falling on an outstretched hand (eg, catching oneself during skating falls and biking accidents) or pushing off on a fixed hand (eg, a gymnast on a vault)¹⁰ results in transmission of forces along the forearm, which causes indirect compression, bending, and rotational or twisting loads at the elbow. Falling on an outstretched hand is the most common mechanisms for the radial head fracture in adults and supracondylar humeral fracture in children. In radial head fracture, the axial load on the pronated forearm forces the radial head to collide into the capitellum, causing the radial head to fracture. Most supracondylar humeral fractures in children occur as the elbow hyperextends during the fall on an outstretched hand. The fracture results as the olecranon process is compressed against the roof of the olecranon fossa and the supracondylar region on the humerus. Falling on an outstretched hand can also result in avulsion fracture and injury to the epiphyseal plate of an adolescent patient. This is because the axial loading on the forearm, combined with the carrying angle at the elbow, creates valgus load at the elbow, which results in tension within the ulnar collateral ligament and excessive tension on the open growth plate.

Rehabilitation Concerns

Generally, undisplaced or minimally displaced fractures in adults and children are treated conservatively and require little or no immobilization. Cases managed using open reduction and internal fixation (ORIF) surgical procedures require only slightly longer periods of immobilization. The joint may be aspirated if the swelling is extremely painful. With the elbow flexed 90 degrees, a posterior plaster splint and sling are applied. Early motion is encouraged, and the splint is removed in 1 to 2 weeks, while a sling is continued for another 1 to 2 weeks as tolerated.

Displaced or comminuted radial head fractures in adults are usually treated by early surgery (within 24 to 48 hours) to minimize the likelihood of permanent restriction of joint motion, traumatic arthritis, soft tissue calcification in the anterior elbow region, and myositis ossificans. Undisplaced supracondylar humeral fractures in children are treated conservatively with a cast at 90 degrees of elbow flexion for 3 to 4 weeks. Displaced supracondylar humeral fractures in children are treated surgically using closed reduction and pinning.

Fractures of the olecranon can be either displaced or undisplaced. The extensor mechanism is intact in undisplaced fractures, and further displacement is unlikely. The undisplaced fracture is treated with a posterior plaster splint for 2 weeks, followed by a sling and progressive ROM exercises. Displaced fractures usually require ORIF to restore the bony alignment and repair the triceps insertion.

Regardless of the method of treatment, some loss of extension at the elbow is very likely; however, little functional impairment usually results.

Rehabilitation Progression

Immediately following the injury or with ORIF surgical procedures, the goal is to minimize pain and swelling by using cold, compression, and electrical stimulation. Active and passive ROM exercises (Figures 18-17 through 18-22) should begin immediately after injury. The goal should be to achieve 15 to 105 degrees of motion by the end of week 2. Within the first week, isometric elbow flexion and extension exercises (Figure 18-3A) and gentle isometric pronation/supination exercises (Figure 18-3B) should begin. Isotonic shoulder and wrist exercises should also be used and should continue to progress throughout the rehabilitation program. Joint mobilizations should begin during the second week in an attempt to minimize loss of extension (see Figures 13-21 through 13-25).

Progressive lightweight (1 to 2 lbs) isotonic elbow flexion exercises (Figure 18-4) and elbow extension exercises (Figure 18-5) can be incorporated during the third week and should continue for as long as 12 weeks. Active assisted passive pronation/supination exercises (Figure 18-6) should begin at week 6, progressing as tolerated.

Beginning at week 7, eccentric elbow flexion and extension exercises (Figures 18-7 and 18-8) along with plyometric exercises can be used. Exercises designed to establish neuromuscular control, including closed kinetic chain activities, should also be used to help regain dynamic stability about the elbow joint (Figures 18-9 through 18-11 and 18-23 through 18-25). Functional training activities will also begin about this time and should progressively incorporate the stresses, strains, and forces that occur during normal activities. Isokinetic training for elbow flexion and extension can also begin at this time (Figures 18-13 through 18-16). Each of these exercises should continue in a progressive manner throughout the rehabilitative period.

Criteria for Return

Full return to activity is expected at about 12 weeks. The patient may return to full activity when specific criteria have been successfully completed. There should be clinical healing of the fracture site. ROM in flexion, extension, supination, and pronation should be within normal limits. Strength should be at least equal to the uninvolved elbow, and the patient should have no complaint of pain in the elbow while performing a progression of activities in normal conditions. The return to sport is progressed with the use of restrictions (eg, pitch counts in baseball), which can be helpful in objectively measuring activity and progression. The throwing progression for the elbow shows a gradual increase in activity in terms of time, repetitions, duration, and intensity (Table 18-1).

Osteochondritis Dissecans/Panner’s Disease

Pathomechanics

Osteochondritis dissecans and Panner’s disease are injuries that affect the lateral aspect of the elbow. Osteochondritis dissecans at the elbow is a condition that affects the central and/or lateral aspect of the capitellum or radial head in adolescents. The flattening of the underlying osteochondral bone can progress to detachment of bone fragment from the articular surface and formation of a loose body in the joint. While the exact cause of the osteochondritis dissecans remains unclear, ischemia, microtrauma, and genetic factors are considered to play a critical role.

Osteochondrosis is a general term use to describe any conditions affecting the immature skeleton. Panner’s disease is an osteochondrosis of the humeral capitellum, generally found in patents aged 10 years and younger. Softening and fissuring of articular surfaces of the radiocapitellar joint is caused by a localized avascular necrosis that leads to loss of the subchondral bone of the capitellum.¹⁸ Some suggest that Panner’s disease and osteochondritis dissecans of the capitellum might be a continuum of the same condition with varying patient age and severity of the lesion.

Injury Mechanism

Osteochondritis dissecans is most commonly seen in baseball pitchers and gymnasts aged 12 to 15 years.^23,42 In baseball pitchers, the primary cause of osteochondritis dissecans is thought to be a trauma due to repetitive compressive forces between the radial head and the capitellum at the radiocapitellar joint. The compressive force at the radiocapitellar joint develops with valgus loading on the elbow during the arm-cocking and acceleration phases of the pitching motion.^6,18 In gymnasts, the condition is caused by the compressive stress at the radiocapitellar joint that results from weightbearing on the extended/hyperextended elbow.

Panner’s disease is also considered to develop as a result of compressive stress at the radiocapitellar joint. The compressive stress at the joint can lead to disruption of the blood supply to the capitellum, causing local ischemia.

Rehabilitation Concerns

Impaired motion and pain to the lateral aspect of the elbow are among the most common complaints. Panner’s disease is treated conservatively by treating the symptoms and avoiding any throwing or impact-loading activities as seen in gymnastics. Stable osteochondritis dissecans with no displaced fragments is also treated conservatively, unless the symptoms do not improve within 3 months. Osteochondritis dissecans that is unstable or causes pain and locking sensation during activities of daily living is treated with surgery. Smaller lesions (< 12 mm) are commonly treated with arthroscopic debridement/free body removal, while the larger lesions may require articular reconstruction using osteochondral plug grafts.

The functional progression after the injury has been diagnosed should be first and foremost pain-free. The injury is articular in nature, and a cautious rehabilitation program should be followed. ROM exercises should be full and pain-free (Figures 18-17 through 18-22). Strengthening exercises (Figures 18-4 through 18-6) will progress at the pain-free level and with restriction from increased pressure between the radius and the capitellum. The patient might have to decrease or modify the activity level to avoid the compressive nature in the joint. A slow, progressive program that gradually increases the load on the injured structure is essential.

Following arthroscopic debridement and removal of loose bodies, the goal is to minimize pain and swelling by using cold, electrical stimulation, and compression using a bulky dressing initially, followed by an elastic wrap. Active and passive ROM exercises (Figures 18-17 through 18-22) should begin immediately after surgery, as tolerated. The goal should be to achieve full ROM within 7 to 14 days after surgery, although the patient must continue to work on ROM throughout the rehabilitation period. Within the first 2 days, isometric elbow flexion and extension exercises (Figure 18-3A), and isometric pronation/supination exercises (Figure 18-3B) should begin. Isometric shoulder and wrist exercises should also be used and should continue to progress throughout the rehabilitation program.

Progressive lightweight (1 to 2 lb) isotonic elbow flexion exercises (Figure 18-4), elbow extension exercises (Figure 18-5), and pronation/supination exercises can be incorporated between days 3 and 7. Isotonic shoulder and wrist exercises should begin during this period and continue to progress throughout the rehabilitation program.

At 3 weeks, eccentric elbow flexion and extension exercises (Figures 18-7 and 18-8) can be used. Joint mobilizations should begin in an attempt to normalize joint arthrokinematics (see Figures 13-18 through 13-22). Beginning at week 5, in addition to continuing strengthening and ROM exercises, activities that progressively incorporate the stresses, strains, and forces that prepare the patient for gradual return to functional activities should begin. For throwing athletes, the interval throwing program can be initiated. Exercises designed to establish neuromuscular control, including closed kinetic chain activities, should also be used to help regain dynamic stability about the elbow joint (Figures 18-9 through 18-11 and 18-23 through 18-25).

Criteria for Return

The patient may return to full competitive activity when (1) full ROM in flexion, extension, supination, and pronation has been regained; (2) strength is at least equal to that in the uninvolved elbow; (3) there is no complaint of pain in the elbow while performing throwing or loading activities; and (4) the interval throwing program has been completed.

Athletic trainers should be cautious in making prognoses for full return to throwing or to loading activities, as in gymnastics and wrestling, especially at a competitive level. The athletic trainer should educate parents, coaches, and children about this problem so that early recognition and subsequent intervention and referral to medical personnel can reduce the likelihood of need for surgical intervention. Following an arthroscopic procedure, proper rehabilitation protocol allows the patient to return to overhead throwing after 1 to 2 months, and full throwing after 2 to 3 months.

Related posts:

Maintaining Cardiorespiratory Fitness During Rehabilitation Restoring Range of Motion and Improving Flexibility Regaining Muscular Strength, Endurance, and Power Rehabilitation of Lower Leg Injuries Rehabilitation of Injuries to the Spine Rehabilitation of Ankle and Foot Injuries

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