Intro to the Elbow
• Elbow Joint = Hinge Joint
• Non-weight bearing bone, but still sustains significant loads
• Three Joints:
• Humeroulnar Joint (Flex/Ext)
• Humeroradial Joint (Flex/Ext)
• Radioulnar Joint (Pronation/Supination)
• ROM: Flexion, Extension, Pronation, Supination
• Acute Injuries: Fractures, Dislocations, Sprains, Strains,
Acute Bursitis.
• Chronic Injuries: Bursitis, Impingement, Epicondylitis
joints
• Reminder: A joint is where two
bones meet!
• Humeroulnar Joint = Trochlea
of the Humerus & the Proximal
Ulna.
• Humeroradial Joint = Capitulum
of the Humerus & the Proximal
Radius.
• Radioulnar Joint = Head of the
Radius & Radial notch of the
Ulna. *Held together by the
annular ligament*
Bony anatomy
• Radius
• Humerus
• Ulna
• Capitulum
• Radial Head
• Trochlea
• Radial Notch of the
Ulna
• Olecranon Process
• Olecranon Fossa
• Medial Epicondyle
• Lateral Epicondyle
Bony anatomy
Soft tissue anatomy:
Ligaments/Tendons/Bursa
• Radial Collateral Ligament
• Ulnar Collateral Ligament
• Annular Ligament
• Biceps Tendon
• Triceps Tendon
• Olecranon Bursa
Elbow musculature
• Biceps Brachii
• Long Head
• Short Head
• Triceps Brachii
• Long Head
• Lateral Head
• Medial Head
• Brachialis
• Brachioradialis
• Pronator Teres
• Supinator
• Anconeus
• Pronator Quadratus
Nerves
• Ulnar Nerve
• Median Nerve
• Radial Nerve
WARM UP
• What type of joint is the elbow?
• What movements occurs at the elbow joint?
• What are the three joints of the elbow?
• What structures form each joint?
• What are the primary nerves of the elbow
region?
Helpful vocabulary
• Valgus Stress: A force that is applied laterally causing
the distal portion of the extremity to go away from the
midline.
Helpful vocabulary
• Varus Stress: A force that is applied medially causing
the distal portion of the extremity to go toward the
midline.
Varus/valgus
• Known as “Carrying Angle”
Helpful vocabulary
• Cubital Recurvatum: Hyperextension of the elbow
Fractures of the
elbow/forearm
• Fractures can to occur to the:
• Area of the condyles
• Olecranon
• Head of the radius
• Radius
• Ulna (AKA – “Nightstick FX”)
• MOI: Fall on outstretched hand, direct blow, valgus/varus stresses.
• S&S: Pain, deformity, swelling.
• Special Tests: Percussion, Compression, Bowing
• Treatment: *Perform circulatory assessment!* Immobilize, ice, refer.
Fractures of the
elbow/forearm
Fractures of the
elbow/forearm
Fractures of the
elbow/forearm
Fractures of the
elbow/forearm
Fractures of the
elbow/forearm
Fractures of the
elbow/forearm
Elbow dislocation
• Usually involves a posterior displacement of the radius and ulna on the humerus.
• MOI: Hyperextension, fall on outstretched arm, sudden forceful valgus or varus
blow.
• S&S:
• Snapping or cracking sensation upon impact
• Immediate severe pain, swelling, and loss of function
• Profuse swelling
• Obvious deformity
• Elbow appears fixed in flexion with a prominent olecranon; forearm appears
shortened
• Numbness
Elbow dislocation
• Associated Conditions:
• Ruptured ulnar collateral ligament
• Fracture of radial head or olecranon process
• Neurovascular compromise
• Treatment:
• Carefully stabilize joint so as not to disrupt the ulnar nerve or
brachial artery
• Assess distal sensation, radial pulse, and capillary refill before/after
splinting
• Immediate physician referral
Elbow dislocation
Elbow dislocation
Elbow dislocation
Elbow dislocation
https://www.youtube.com/watch?v=jWe5lcXdN2I
Elbow contusion
• Common to the olecranon due to
general vulnerability.
• Common in contact sports.
• MOI: Direct contact
• S&S: Pain, swelling, ecchymosis,
minor loss of function, point
tenderness.
• Treatment: PRICE method
• Prevention: Elbow pads, teach athletes
how to fall properly to avoid injury.
Olecranon bursitis
• Bursa lies between the olecranon process and the skin.
• Vulnerable to injury due to its superficial location.
• MOI: Direct contact (acute) or repeated stressful
motions (chronic).
• S&S: Pain, instantaneous swelling, point tenderness.
• Treatment: PRICE method.
• Prevention: Protective equipment such as elbow pads.
Olecranon bursitis
Olecranon bursitis
Olecranon bursitis
Ulnar nerve impingement
(Cubital tunnel syndrome)
• Impingement = Pinching of soft tissue,
such as a bursa, tendon, or a nerve,
between the ends of two or more bones.
• The Ulnar Nerve becomes impinged or
compressed.
• The Ulnar Nerve runs through the
“Cubital Tunnel.” AKA Cubital Tunnel
Syndrome
• MOI: Repeated stress or a direct blow.
• S&S: Point tenderness, pain with and
without motion, numbness, tingling
sensation, possible loss of strength.
• Special Tests: Tinel’s Sign
Ulnar nerve
impingement
Biceps brachii rupture
• Muscle Rupture = a complete tear of a muscle.
• The biceps brachii can be ruptured by pulling motions.
• Most commonly occurs to gymnasts, rowers, and weight
lifters.
• Rupture will commonly occur at the point of origin,
however a bulging deformity will appear in the muscle
belly. AKA – “Popeye Muscle”
• S&S: Pain, deformity, bulging biceps, ecchymosis, loss
or decrease of mobility. Sometimes the athlete will hear
a “pop” when the muscles tears.
Biceps brachii rupture
• Treatment: Place the athlete in the most
comfortable position possible. Immobilize the
upper arm using a splint and/or sling. Refer
the athlete to a physician for further
evaluation.
• Prevention: Athletes should stay within their
tolerance limits when training and competing.
Therefore, they should not push themselves
beyond their muscle tolerance or endurance.
Biceps brachii
rupture
Biceps brachii
rupture
Biceps brachii
rupture
Biceps brachii
rupture
Biceps brachii
rupture
Biceps brachii
rupture
Sprains
• Can occur to Radial Collateral Ligament (RCL) or
Ulnar Collateral Ligament (UCL).
• MOI: Fall on an outstretching arm resulting in
hyperextension, valgus force (UCL injury), or varus
force (RCL injury).
• S&S: Localized pain, point tenderness, swelling,
instability.
• Special Tests: Valgus Stress Test, Varus Stress Test.
https://www.youtube.com/watch?v=1h7HD5B3PWU
sprains
https://www.youtube.com/watch?v=1h7HD5B3PWU
sprains
sprains
• What type of
MOI is this?
• What
ligament
would be
injured?
epicondylitis
• Epicondylitis = inflammation of the medial or lateral
epicondyle of the humerus and its surrounding tissues.
Medial epicondylitis
• Inflammation of the medial
epicondyle of the humerus and its
surrounding tissues.
• Also known as “ little league
elbow” or “golfer’s elbow”
• Affects the flexor muscles.
• MOI: Chronic overuse of flexor
muscles.
• S&S: Pain and point tenderness that
is localized to the medial
epicondyle. In some cases swelling
may be present.
• Special Test: Medial Epicondyle
Test
Lateral epicondylitis
• Inflammation of the lateral
epicondyle of the humerus and
its surrounding tissues.
• Also known as “tennis elbow”
• Affects the extensors muscles.
• MOI: Chronic overuse of
extensor muscles.
• S&S: Pain and point tenderness
that is localized to the lateral
epicondyle. In some cases
swelling may be present.
• Special Test: Lateral Epicondyle
Test
Epicondylitis Treatment
• Treatment: PRICE. Evaluate and
correct the athlete’s mechanics to
decrease stress on the elbow joint.
If symptoms do not improve the
athlete should see a physician. In
some cases a counterforce strap
can help relieve the pain of
epicondylitis.
• Prevention: Proper body
mechanics should be emphasized
to player of sports involving
repeated motions at the elbow
joint such as javelin, tennis,
racquetball, baseball, etc.
Volkmann’s
contracture
• Volkmann’s contracture = contracture and damage to the
muscles of the forearm because of injury to their blood supply.
• Injury that may occur when swelling, muscle spasm, bone
displacement, or a bone fracture near the elbow puts pressure
on the arteries in the arm.
• The pressure decreases the blood supply to the hand and
forearm resulting in muscle damage and possibly paralysis.
• There will be an absent or diminished brachial and radial pulse.
• This is a medical emergency, activate EMS!
Volkmann’s
contracture
Volkmann’s
contracture
scenario
• A football player is complaining of pain in his
right arm during blocking drills. Palpation
reveals a hardened mass of soft tissue over the
distal tricep that is very tender and sore. There
is good bilateral strength but the pain is
progressively getting worse. What potential
injury do you suspect?
scenario
• Myositis Ossificans in the Tricep
muscle.
scenario
• A wrestler falls directly on their flexed elbow
after being taken down. There is acute
swelling about an inch in diameter on the
proximal posterior ulna. What condition is
present?
scenario
• Olecranon Bursitis
scenario
• A little league baseball pitcher is
complaining of pain on the medial elbow
that is aggravated during the acceleration
phase of throwing. Palpation reveals
point tenderness on the medial
epicondyle of the humerus. What
condition do you suspect? What muscle
group is involved?
scenario
• Medial Epicondylitis; the flexor muscle
group.
Evaluation of
elbow/forearm
injuries
Review H.O.P.S
• H.O.P.S.
• History – How did it happen (MOI), location
of pain, previous hx.?
• Observation – What do you see/observe?
• Palpation – Palpate for crepitus, spasm, point
tenderness, warmth, etc.
• Special Tests – Assess ROM, Manual Muscle
Tests (MMT) and Special tests.
history
 Mechanism of Injury – Acute vs. Chronic?
Example: How did the injury occur?
 Pain – Location, Type, Severity
Example: Where is the location of your pain? What type of pain is it –
sharp, dull, aching, tingling, numbness, burning? On a scale of 1-10 how
bad is your pain?
 Did your hear a Snap, Crack, or Pop?
 What increases and decreases the pain?
 Do you have a previous history of an elbow/forearm injury?
 Do you have pain with certain motions?
 What sport do you participate in and what position?
observation
Observation =
What you see or
observe.
Remember to
compare
bilaterally!
(Compare the
uninjured side to
the injured side)
CHECKLIST:
Carrying Angle – Cubital
Valgus or Cubital Varum
Cubital Recurvatum
Deformity
Guarding
Apprehension
Swelling
Ecchymosis
Hematoma
Abrasions
Scars
Atrophy
palpation
• Palpate bilaterally
• Palpation Checklist:
• Palpate ALL:
Crepitus
①BONEY
Structures
Spasm
②SOFT Tissue
Structures
(Muscles,
Tendons,
Ligaments)
Tension
Point Tenderness
Warmth
Special tests
①Assess ROM in all directions
②MMT’s (Manual Muscle Tests)
③Shoulder Special Tests:
ROM
• Ask the athlete to perform the following motions:
• Check both arms simultaneously, noting any differences.
• The motion should be smooth and painless.
• Limited ROM on one side indicates potential injury or
deformity.
• Flexion
• Extension
• Supination
• Pronation
Manual muscle tests
MMT = manually testing an athlete’s
strength to note any abnormalities due to
injury.
Compare the strength between the
involved and uninvolved extremity to
note any differences.
Weakness on one side indications
potential injury or deformity.
Manual muscle tests
• Flexion: Ask the athlete to face you with the forearm
supinated and the elbow flexed to 90 degrees. Place
one hand on top of the athlete’s wrist and use your
other hand to stabilize the elbow. Instruct the athlete
to flex their arm against your resistance.
• Extension: With the athlete sitting, ask the athlete to
face you with the arm flexed at a 90 degree angle.
Place one hand on the back of the athlete’s wrist and
use your other hand to stabilize the elbow. Instruct the
athlete to extend the arm against your resistance.
Manual muscle tests
• Pronation: Ask the athlete to face you with the
forearms supinated and the elbow flexed to 90 degrees.
Place your hands on the bottoms of the athlete’s
hands, grasping the medial aspect of the hand.
Instruct the athlete to pronate their forearm against
your resistance.
• Supination: Ask the athlete to face you with the
forearms pronated and the elbow flexed to 90 degrees.
Place your hands on top of the athlete's hands,
grasping the medial aspect of the hand. Instruct the
athlete to supinate their forearm against your
resistance.
Special tests
• Varus Stress Test – RCL injury
• Valgus Stress Test – UCL injury
• Compression Test - FX
• Percussion Test (tap or bump) - FX
• Tinel’s Sign – Impingement
• Medial Epicondylitis Test - Epicondylitis
• Lateral Epicondylitis Test - Epicondylitis
Compression test
• Definition: Compressing above and below an injury site to
assess the possibility of a fx.
• Injury: Radius or Ulna Fracture
• Patient Position: Standing or sitting
• Examiner Position: Standing in front or side of the patient
with hands distal or proximal to the fx site
• Exam Procedure: Apply compression to the radius and ulna
distal or proximal to the possible fx site. Compress the area
between your hands. Do NOT place either hand directly over
the suspected fx site!!
• + Sign: Pain at the fx site
Percussion test (aka:
tap or bump)
• Definition: Tapping a bone to assess the possibility of a
fx.
• Injury: Radius or Ulna Fracture
• Patient Position: Seated or standing, elbow flexed and
making a fist
• Examiner Position: Standing in front of the patient and
stabilizing the elbow
• Exam Procedure: Apply a firm strike to the fist with an
open hand
• + Sign: Pain at the fx site
Varus stress test
• Injury: Radial Collateral Ligament injury
• Patient Position: Standing or sitting with 30 degrees
of elbow flexion
• Examiner Position: Standing medial to the patient’s
arm with one hand placed on the medial elbow with
fingers over the lateral joint line and the other hand
at the distal forearm
• Exam Procedure: Apply a varus stress to the elbow
• + Sign: Joint laxity and/or pain
Varus stress test
• https://www.youtube.com/watch?v=-4Sbis5qpJc
Valgus stress test
• Injury: Ulnar Collateral Ligament injury
• Patient Position: Standing or sitting with 30 degrees
of elbow flexion
• Examiner Position: Standing lateral to the patient’s
arm with one hand placed on the lateral elbow with
fingers over the medial joint line and the other hand
at the distal forearm
• Exam Procedure: Apply a valgus stress to the elbow
• + Sign: Joint laxity and/or pain
Valgus stress test
https://www.youtube.com/watch?v=KXQxH0UTn-8
Tinel’s sign
• Injury: Ulnar Nerve Pathology
• Patient Position: Sitting with elbow in slight flexion
• Examiner Position: Standing lateral to the patient
with one hand at the wrist and the other supporting
the elbow
• Exam Procedure: Tap the ulnar nerve in the cubital
tunnel with one finger
• + Sign: Tingling throughout the ulnar nerve
distribution (forearm, hand, and fingers)
Tinel’s sign
Tinel’s sign
• https://www.youtube.com/watch?v=LsnCxAFO8GE
Medial epicondylitis
Test
• Injury: Medial Epicondylitis (Golfer’s Elbow)
• Patient Position: Standing, 90 degrees of elbow
flexion, forearm pronation with fingers flexed
• Examiner Position: Standing in front of patient with
one hand stabilizing the elbow while palpating the
medial epicondyle and the other on the wrist
• Exam Procedure: Passively supinate the forearm and
extend the elbow and wrist while palpating the
medial epicondyle
• + Sign: Pain over the medial epicondyle
Medial epicondylitis
Test
• https://www.youtube.com/watch?v=92qXtO3DhEY
lateral epicondylitis
Test
• Injury: Lateral Epicondylitis (Tennis Elbow)
• Patient Position: Sitting, 90 degrees of elbow
flexion, forearm pronation with fingers flexed
• Examiner Position: Standing lateral to the patient
with one hand stabilizing the elbow while palpating
the lateral epicondyle and the other over the top of
the wrist and/or hand
• Exam Procedure: Resist wrist extension while
palpating the lateral epicondyle
• + Sign: Pain over the lateral epicondyle
lateral epicondylitis
Test
• https://www.youtube.com/watch?v=iDQUeF77DOA