Ligaments Prone to Elbow Sprain

ULNAR COLLATERAL LIGAMENT SPRAIN

• Stressed due to a valgus loading
• Increased likelihood during pitching or overhand movments

SIGNS and SYMPTOMS

• Pain on the medial aspect that increases with motion
• Pain towards the fingers and hand
• Anterior swelling
• Tenderness from the medial epicondyle to the coronoid process

DIAGNOSIS

• ROM testing
• Valgus stress testing
• Flexion
• Neurologic assesment

SPECIAL TESTS

• Posterolateral Rotary Instability Test: extension with axial load, valgus stress and forearm supination.  A positive test yields elbow subluxation during extension and relocation during flexion. 

TREATMENT

• Muscle strengthening
• Rest
• RICE
• Surgery in extreme cases

Courtesy of Southern California Orthopedic Institute:

Ulnar Collateral Ligament

RADIAL COLLATERAL LIGAMENT SPRAIN

• Rare elbow injury
• Caused by varus forces

SIGNS and SYMPTOMS

• Varus laxity
• Pain
• Weakness during pronation and supination
• Swelling in the anterior, medial, and posterior joint compartments
• Tenderness along the joint line

TREATMENT

• Rest
• RICE
• Muscle strengthening of the wrist extensors, supinators, and brachioradialis.

EPICONDYLITIS

• Inflammation of flexors and/or extensors of the forearm
• See lateral epicondylitis or medial epicondylitis

Lateral Epicondylitis (above)

 
Medial Epicondylitis (below)

Pictures Courtesy of Healthgate.partners.org

LATERAL EPICONDYLITIS

• “Tennis Elbow”
• Inflmmation of the lateral epicondyle
• More prominent among individuals with repeated forearm muscle use
• Causes secondary irritation of the wrist extensors, most commonly the extensor carpi radialis brevis
• Repeated eccentric contractions enhance degenerative forces

   

SIGNS AND SYMPTOMS

• Severe, burning pain on the outside part of the elbow
• Possible Swelling
• Pain gradually worsens over weeks or months
• Increased pain by pressing on the outside part of the elbow or by gripping or lifting objects.
• In more severe cases, pain can occur with simple motion of the elbow joint
• Pain can radiate to the forearm.

DIAGNOSIS

• Press directly on the bony prominence on the outside part of the elbow to see if it causes pain
• Lift the wrist or fingers against pressure to see if that causes pain
• Xrays, and MRI’s (rarely) to determine ligamentous injury

SPECIAL TESTS

• Range of Motion testing
• Tennis Elbow Test: 90 degree flexion, with forearm pronation, followed by resisted wrist extension. Positive test includes pain in the lateral epicondyle.

TREATMENT

• Stop activities that may aggravate symptoms
• Orthotics
• Braces
• Anti-inflammatory drugs
• Chronic pain may provide need for corticosteroids, physical therapy, or surgery
• Physical therapy

 Lateral Epicondylitis

MEDIAL EPICONDYLITIS

• “Little League Elbow”
• “Golfer’s Elbow”
• Provoked by snapping of the wrist and forearm pronation

SIGNS AND SYMPTOMS

• Severe, burning pain on the outside part of the elbow
• Possible Swelling
• Point tenderness along the origin of the pronators teres, FCR, Palmaris longus, and FCU.
• Pain can radiate to the forearm.
• Possible pain radiation to medial forearm and fingers caused by ulnar nerve compression

SPECIAL TESTS

• ROM
• Point tenderness
• Sensory and Motor tests to observe for nerve injury

   

TREATMENT

• Stop activities that may aggravate symptoms
• Orthotics
• Braces
• Anti-inflammatory drugs
• Chronic pain may provide need for corticosteroids, physical therapy, or surgery

 Medial Epicondylitis

DISTAL BICEPS TENDON RUPTURE

• Caused by eccentric loading of the biceps brachii during extension
• Avulsion of radial tuberosity may occur with DBTR

SIGNS and SYMPTOMS

• “popping” sound
• Immediate pain
• Loss of arm strength during flexion and supination
• Cubital fossa swelling and ecchymosis

SPECIAL TESTS

• Active ROM: normal limits
• Passive ROM: normal limits
• Resisted ROM: decreased strength during elbow flexion and supination
  
  

TREATMENT

• Surgical repair is desired method for rehabilitation
• Immobilization
• Physical therapy

 Distal Biceps Tendon Rupture

HYPEREXTENSION

• Elbow is stabilized by the locking of the olecranon process  in its fossa
• Olecranon process must be evaluated in addition to ligaments when valgus or varus stresses have been placed on extended elbow
• HYPEREXTENSION: stresses the elbow's anterior capsule and compresses the posterior structures
• Clinically hyperextenion is when the elbow extends an additional 10 degrees past normal extension

Hyperextension of the elbow

NERVE TRAUMA at Elbow and Forearm

(Ulnar, Radial, and Median Nerves)

• Inhibition of these nerves at elbow radiates distally and results in wrist, hand, and finger dysfuntion (decreased strength, parasthesia, and loss of motor function)

• Ulnar Nerve
   
  • crosses superficially at medial aspect of elbow joint line ( HINT: FUNNY BONE ) leaving it vulnerable to impact forces
  • if supporting structures are unstable, nerve may subluxate ( move )during forearm flexion and cause PROGRESSIVE INFLAMMATION
  • increased size of inflamed structures decreases size of cuboital tunnel, leading to COMPRESSION of Ulnar Nerve

            SIGNS AND SYMPTOMS

• decreased sensory and motor functions in hands and fingers
• ACUTE TRAUMA = 1) burning sensation in medial forearm, little finger, and ring finger, 2) decreased strength of finger flexor muscles, lumbricals interossei, thumb abductors, and                                                            flexor carpi ulnaris
• CHRONIC DEFICIT = 1) hand deviates radially during flexion, 2) inhibits ability to make a fist due to lack of flexion in 4th & 5th distal interphalangeal (DIP) joints CLAWHAND POSITION

• typically injured or compressed on distal portion of the forearm
• less typical for cuboital fossa to compress nerve as it crosses joint line
• pronator teres can sometimes compress a branch of the median nerve (interossesus nerve)

FOREARM COMPARTMENT SYNDROME

• Compartment syndrome (CS) is a condition in which increased tissue pressure within a closed osteofascial compartment compromises blood flow to muscles and nerves within that compartment, which results in tissue and nerve damage. Possibly due to hypertrophic muscles, hemorrhage, or fratcures throughout forearm.
• Often problematic for climbing athletes, motorcyle racing enthusiasts, and weightlifters!

SIGNS AND SYMPTOMS

• Early Stages

• complaints of pressure within the forearm
• sensory disruption (tingling, numbness) in hands and fingers              
• decreased muscular strength
• PAIN! during passive elongation of involved muscles

• Increased severity (condition becomes more chronic)
  • decrease or even absence of radial or ulnar pulses
  • possible development of Volkman's ischemic contracture  
  • surgery (fasciotomy) often required to relieve intracompartmental pressure (SEE RIGHT...NOT FUN!)                                          

Fasciotomy to release compartment syndrome

3 Compartments of Forearm

1. Volar Wad 

• Boundary: The interosseous membrane, the radius, and the ulna, the intermuscular septum, and the antebrachial fascia 
  
  
• Muscles: flexor digitorum profundus (FDP) and superficialis, the flexor pollicus longus (FPL), the pronator teres, the palmaris, the flexor carpi radialis (FCR), and the flexor carpi ulnaris (FCU)
  
  
• Nerves that traverse the volar compartment: median nerve, ulnar nerve and anterior interosseous nerve
  
  
• The blood supply to these muscles is from the anterior interosseous artery, branches of the radial artery, branches of the ulnar artery, and the collateral arteries around the elbow (Doyle 1998).
  
  
• MOST COMMONLY AFFECTED DUE TO ITS DEEP LOCATION!

2. Dorsal Wad

• Boundary: The interosseous membrane, the ulna, the radius, the deep investing muscle fascia, an intermuscular septum separates it from the mobile wad radially and the dorsal antebrachial fascia is the superficial border.
  
  
• Muscles: extensor digitorum communis (EDC), the extensor digiti minimi, the extensor carpi ulnaris (ECU), the abductor pollicis longus, the extensor pollicis brevis, the extensor pollicis longus, the extensor indicis proprius, the supinator, and the anconeus.
  
  
• Some believe that the anconeus muscle may have its own fascial enclosure and be an independent compartment (Abrahamsson 1987).
  
  
• The blood supply to this compartment is from the radial artery, the posterior interosseous artery, the anterior interosseous artery, and the interosseous recurrent artery (Doyle 1998).

3. Mobile Wad (below middle)

• Boundary: Originates on the lateral humerus and extends down to the wrist. It is defined by the antebrachial fascia, an intermuscular septum dorsally, and the radius.
  
  
• Muscles: The brachioradialis (BR), extensor carpi radialis brevis (ECRB), and extensor carpi radialis longus (ECRL)
  
  
• Nerves: superficial radial nerve
  
  
• The blood supply is from the radial artery, the recurrent radial artery, the inferior ulnar recurrent artery, and the collaterals from the profundi brachii artery (Doyle 1998).

Compartments of the Forearm