Elbow

Medial Epicondylitis (Golfer’s Elbow)
__**Definition**__: The medial epicondyle is a common origin of the flexors of the wrist musculature. Medial epicondylitis is an injury classified as a tendinopathy involving the flexor carpi radialis and the humeral head of the pronator teres. The palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis also attach to the medial epicondyle, and thus potentially can be involved in this syndrome (4). The injury will usually start as a microtear of the interface between the pronator teres and flexor carpi radialis attachments. This leads to an inflammatory response.

__**Signs and Symptoms:**__ __**Tests**__
 * Pain over flexor carpi radialis/pronator origin,
 * Just distal and anterior to medial epicondyle (4)
 * Insidious onset
 * Tender palpations
 * Patient will report increased pain with the following movements: resisted wrist flexion or pronation, passive wrist extension or supination (4).
 * Local swelling and warmth in acute stage
 * ROM may be full initially, but may develop flexion contracture (2,3)
 * Symptoms of ulnar neuropathy can also be present
 * Some patients may reports numbness/tingling radiating to 4th and 5th digits indicating involvement of the ulnar nerve
 * Palpate ulnar nerve in ulnar groove during flexion—subluxation is possible in some patients (4).
 * Neurological exam (motor, sensory, reflex testing) to rule out cervical radiculopathy and ulnar neuropathy
 * Tinel’s sign between olecranon and medial epicondyle for ulnar neuropathy
 * ACTIVE Wrist flexion and pronation or PASSIVE wrist extension and supination – pain over medial epicondyle
 * []
 * []
 * Varus and valgus stress tests to evaluate ulnar and radial collateral instability (1).
 * MRI: sensitive and specific for medial epicondylitis (tendons, nerves, medial collateral ligament)
 * Ultrasound: to visualize degeneration of tendons (1)

__**Mechanism of Injury**__:
 * Overuse/Repetitive stress – This is the most likely cause, usually starting as a microtear. Degenerative changes in the pronator teres and flexor carpi radialis longus are most common.
 * Trauma—from direct blow or extreme eccentric contraction (2,3)
 * Sports related causes may include:
 * Excessive topspin or grip in tennis
 * Poor pitching mechanics
 * Improper golf swing (5)

__**Treatment**__**:**

__Therapeutic Exercise__: Progressive Exercises for Medial Epicondylitis:
 * Full, painless ROM of wrist and elbow
 * Stretching
 * Progressive Isometrics—Begin at 90 degrees of elbow flexion and progress to more extension as patient tolerates
 * Concentric and eccentric resistive exercises
 * Sprint repetitions to fatigue
 * Sport or occupation simulation (2,3)

__Education__: The patient should be educated on what activities contributed to their condition. Faulty mechanics may lead to this syndrome. In golfers, poor swing mechanics should be addressed to prevent reinjury. The motion should be initiated by the shoulder, not the wrist (1). A larger grip size can reduce the torque to the forearm and elbow (6). Baseball pitchers with this injury should be evaluated for proper form. If ulnar neuropathy is suspected, instruct patient to avoid elbow flexion and leaning on the elbow.

The patient also needs to understand the importance of exercises and how to safely progress them. For pain management, the patient should be instructed to ice the affected area 10-15 minutes several times a day in the acute stage of injury to help facilitate healing and reduce pain. Unless contraindicated, NSAIDs should be used to reduce inflammation and pain. If a night splint or brace is prescribed, the patient will need to be instructed on how properly fit the device and when they should remove it such as if there is increased pain or numbness or tingling. Note: Corticosteriod injections should be considered if symptoms persist after 2 weeks of conservative management. If conservation treatment fails after 6-12 months surgical treatment can be considered (1).

__Assistive Equipment__: Night splinting is recommended if patient does not respond to conservative measures of cryotherapy and NSAIDs.

Counterforce Bracing—The brace acts to decrease the intrinsic muscle forces which may be prescribed to athletes to return to sport. Bracing may also help to disperse the force over a great area (6).

__Manual Therapy__: Cross friction massage (1)

__Home Exercise Program__: Picture here: Dosage should be 15-30 seconds for the stretches and 15-20 repetitions for the strengthening exercises. Three sets of each exercise would be ideal. (7)
 * Wrist Flexion/Extension Stretch – Hold 15-30 seconds
 * Forearm pronation/supination—With elbow bent to 90 degrees have patient turn their palm into supination and hold for 5 seconds, then turn the palm into pronation and hold 5 seconds
 * Wrist flexion/extension strengthening—wrist curls and extensions with dumbbell, can of soup, water bottle
 * Grip strength—squeeze rubber ball and hold 5-8 seconds
 * Pronation/Supination strengthening—Pronate and supinate the forearm holding dumbbell, can of soup, water bottle
 * Elbow flexion/extension strengthening exercises—arm curls, triceps kickbacks

__Modalities and Pain Control__:

__Acute Stage__ Cryotherapy, compression, electrical stimulation, ultrasound (nonthermal), LASER, phonophoresis, iontophoresis

NSAIDs preferred, but if patient does not respond corticosteroid injection may be indicated (2,3)

__Subacute__ Thermotherapy, electrical stimulation, compression, ultrasound

__Chronic__ Ultrasound, low level laser therapy, shockwave therapy (more research needed) (1).

__**References**__ 1. Alfonso, L. (2010). Surgery for medial epicondylitis. Retrieved from http://emedicine.medscape.com/article/1231997-overview. 2. Ciccotti MG, Ramani MN. Medial epicondylitis. Techniques in hand & upper extremity surgery. 2003;7(4):190-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16518220. Accessed March 23, 2012. 3. Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clinics in sports medicine. 2004;23(4):693-705, xi. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15474230. Accessed March 23, 2012. 4. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. 5. Gibbs, S.J. (2012). Physical medicine and rehabilitation for epicondylitis treatment and management. Retrieved from http://emedicine.medscape.com/article/327860-treatment. 6. McCarroll JR. Overuse injuries of the upper extremity in golf. Clinics in sports medicine. 2001;20(3):469-79. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11494835. Accessed February 10, 2012. 7. White, T. & Clapis, P. (2009). Medial epicondylitis (golfer’s elbow) rehabilitation exercises. Retreived from [].

=Little Leaguer’s Elbow (Medial Apophysitis)=

Definition
Little Leaguer’s Elbow (LLE) is a condition in young (age 12-18) athletes in which the medial aspect of the elbow, particularly the growth plate, becomes inflamed and painful due to repetitive throwing motions.

MOI
Little Leaguer’s Elbow is commonly associated with the repetitive throwing nature of year-round youth pitchers. Studies have shown that catchers and fielders yield similar results when they participate in year-round sport resulting in an overuse injury. Although not as common, LLE can also be seen in other young athletes such as tennis players and quarterbacks. A similar condition arises in adult pitchers called “Valgus Medial Overload Syndrome” often resulting in Tommy John surgery (UCL reconstruction) to repair the ulnar collateral ligament.

Slow Motion Adult Biomechanics
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13 y/o Pitcher (Normal & Slow Motion)
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9 y/o Pitcher (Normal Motion)
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Sport-Specific Biomechanics (pertaining to the elbow) 2
1) Wind-up: Elbow flexed 2) Stride begins and the 2 arms separate into extension 3) Throwing elbow moves from extension to 80-100° of flexion 4) Cocking: humerus is in extreme abduction/external rotation with the elbow flexed 80-100° 5) Acceleration: maximal external rotation to ball release 6) Deceleration: initiated at ball release and terminates at full internal rotation at the shoulder and follow through with the body
 * Here the lead foot contacts the ground with pelvic/trunk rotation
 * Extreme torque is applied through the elbow resulting in medial tension and lateral compression
 * As trunk rotation occurs the elbow slightly extends
 * Maximal angular velocity is achieved at the elbow
 * Varus torque acts to resist valgus extension (the overload phenomenon)
 * The elbow becomes relaxed in a flexed position crossing the anterior portion of the body

Opposed to adults, adolescents are susceptible at the growth plate rather than the ligamentous tissue. The growth plates are especially vulnerable during the later stages of the cocking phase and the earlier point of the acceleration phase.

Symptoms
As with most overuse injuries pain is often associated with Little Leaguer’s Elbow; specifically on the medial aspect. Along with pain, locking of the elbow and/or a restriction in the range of motion are associated with LLE.

Diagnosis
Inspection of the joint in question is key to diagnosis. Looking for flexion contractures or an odd carrying angle my reveal potential LLE. During the initial examination, muscle hypertrophy or atrophy, bone deformities, and/or the presence of swelling or bruising should be noted. Palpation of bony landmarks such as the olecranon process, medial and lateral epicondyles, capitellum, and radial head will also aide in a positive diagnosis.

Tests
Milking Maneuver . Valgus Extension Overload Test
 * Grasp the thrower's thumb with the arm in the cocked position of 90° of shoulder abduction, 90° of elbow flexion and forearm in neutral (thumb pointing posteriorly). Then apply a valgus stress by pulling the thumb inferior and posterior simulating a resisted throwing motion.
 * Stabilize the humerus from the lateral side, force the elbow to end range extension and apply a valgus force to stress the medial aspect of the joint. Pain is more likely associated with posterior impingement if this test result is positive.

Differential Diagnosis
Rule out the following:
 * Elbow dislocation
 * Osteochondritis dissecans
 * Medial or Lateral epicondylitis
 * UCL injury

Non-Surgical
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 * Education
 * Rest (Acute to Sub Acute Phase)
 * No throwing for a period of 4-6 weeks4 following the injury
 * NSAIDs should be supplemented
 * Progressive Throwing Program (Recovery Phase)
 * Approximately weeks 4-8 of treatment
 * Must have full, non painful ROM
 * Late progression should include long-toss and noncompetitive pitches
 * Incorporate 6 biomechanical criteria at this point
 * Maintenance Phase
 * Patient should note any flare-up in pain, loss of ROM/strength, neuromuscular fatigue or loss of throwing endurance
 * Pitch count should be strictly monitored
 * Therapeutic Exercise
 * Limit ROM and progress to ROM exercises with joint mobilization
 * Weightless flexion-extension with pronation-supination
 * Hypermobile athletes should focus on joint stabilization exercise
 * Tricep/Bicep strengthening
 * Brachioradialis, Biceps Brachii
 * Limit wrist flexors to reduce pull on medial epicondyle until cleared
 * Core strengthening should be initiated prior to elbow strengthening exercise
 * Swiss ball jack knives, Supine lateral trunk rotations
 * Dumbbell/resistance band exercise may be initialized around the 6-8 week mark
 * Wrist curls, tricep extensions, elbow flexor (biceps brachii, brachioradials) strengthening
 * Pain Control/Modalities
 * Ice twice daily to reduce inflammation/pain
 * Superficial ultrasound to facilitate tissue remodeling near the medial epicondyle
 * Assistive Devices
 * Compressive brace to reduce tension on the medial apophysis (no evidence provided)
 * Manual Therapy
 * Humeroulnar Mobilization: Grades I & II for pain reduction
 * 1-2 bouts of 20-30 seconds
 * Medial & Lateral Glides of the Ulna
 * Home Exercise Plan
 * Should follow the phases associated with patient education
 * Example
 * Acute: ice, rest, NSAIDs
 * Recovery: light wrist curls with a can of soup 2 x daily; 3 sets x 12 reps
 * Late Recovery: non competitive throwing of a tennis ball against a wall 2 x daily; 50 tosses
 * Maintenance: return to sport monitoring symptoms and pitch count
 * <10: 75 pitches/day
 * 11-12: 85 pitches/day
 * 13-16: 95 pitches/day
 * 17-18: 105 pitches/day
 * Throwing Mechanics
 * A specialized physical therapist should evaluate the patients throwing mechanics prior to, during, and post treatment
 * http://www.orthonurse.org/portals/0/youth%20pitching.pdf
 * link to the official Little League Baseball guidelines on pitching

Surgical

 * Fractures of the medial epicondyle require closed reduction with casting
 * Type II osteochondrotic lesions are treated surgically if the loose body interferes with ROM by removal of the body, drilling to fascilitate healing and architectural support such as K-wires/bone grafts
 * Type III osteochondrotic lesions are simply removed surgically
 * It should be noted that any patient undergoing surgery requires progressive rehabilitation post-operative

Recovery
Typically it takes 12 weeks for the athlete to return to sport. Following treatment the athlete should pay special attention to the number pitches attempted. Higher stress pitches, such as the curveball, should be avoided temporarily. The athlete should also continue the exercise program to prevent further injury.

**Definition:**
Panner’s disease is an osteochondrosis condition of the growth plate of the capitulum, which means that the blood supply to the capitulum is disrupted, causing flattening, avascular necrosis, and possible fragmentation. This is the most common cause of chronic lateral elbow pain in athletes under 10 years old1. It is typically seen in young baseball pitchers or gymnasts, and 90% of the cases are males. This issue resembles Legg-Calve-Perthes of the hip, which is when the blood supply to an immature femoral head is disrupted. Panner’s is often confused with osteochondritis dissecans (OCD) of the capitulum, which does not affect the growth plate, but is the leading cause of long-term elbow dysfunction in the adolescent athlete. OCD is characterized by pieces of broken cartilage in the joint, but this is normally seen in kids aged 12-15. It can also be confused with little leaguer’s elbow, however that is a medial epicondyle issue.

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Mechanism of Injury:
The exact mechanism of injury of Panner’s disease is unknown. Researchers believe it is hereditary or an overuse injury, but it is not a traumatic injury. I would say there is a hereditary predisposition, but it is mainly an overuse issue. The article by Klingele and Kocher explains that the repetitive pitching motion puts a valgus compressive force on the elbow during the late cocking and acceleration phases of throwing. He also says that the deceleration results in a shearing force on the humeroradial joint. This repetitive compression disrupts the blood supply to the developing capitulum, causing the symptoms.

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Signs and Symptoms:
Diagnosing Panner’s disease is a difficult task. You will be looking for a child 10 years old or younger, most likely male, who is active and complaining of an insidious lateral elbow ache during activity. For an objective exam, you may be able to measure some swelling if it is in the acute stage, or after an activity. Also, the lateral elbow area will be tender to palpate. The therapist can also measure AROM of supination, pronation, and elbow extension. A decrease in these motions due to pain would be expected. Rest from all activity should decrease symptoms. An X-ray is the best way to confirm the diagnosis.

Treatment:
The recommended treatment for Panner’s disease is rest. Allowing time for the issue to calm down and new blood vessels to vascularize the capitulum is essential to allow regeneration and ossification of the epiphysis. In severe cases the arm may be immobilized for 3-4 weeks. If activity is modified, this condition should resolve itself and be good as new in 1-2 years. Other interventions include:
 * Gentle ROM activities to maintain or gain elbow extension, pronation, and supination.


 * Ice or heat may also help. Ice after activity or if swelling is present, but heat may be beneficial to draw blood to the avascular capitulum.


 * Ultrasound is NOT recommended because it would be done over an active epiphysis, which could lead to premature closure of the growth plate or other damaging effects.


 * Therapeutic exercises to maintain or improve proper elbow function are needed once pain and inflammation are under control. Also, rotator cuff strengthening can be implemented to help with biomechanics of the arm. Elbow extension, flexion, pronation, and supination with a light weight or theraband could be done at home. As well as external and internal rotation of the shoulder. All of these are done in a pain-free range to avoid irritating the capitulum.


 * Patient education on allowing proper rest time to decrease pain and inflammation. Attempting to explain to the child how the nutrient supply to their elbow is being blocked, so they need rest to allow it to heal. Also, if the patient is a pitcher, proper mechanics should be taught.


 * I would not recommend manual therapy because the bone is compromised.
 * There is no research on assistive devices.
 * Arthroscopic surgery is available, but not normally necessary.

With proper activity modification Panner’s disease should resolve on its own. The therapist should be involved with education, calming down symptoms, and maintaining or improving ROM. The prognosis is very good for kids that follow the instructions.

References:
1. Atanda A Jr, Shah SA, O’Brien K. (2011). Osteochondrosis: common causes of pain in growing bones. //American Family Physician//, 83(3), 285-91. Retrieved from []

2. Klingele, K. E., & Kocher, M. S. (2002). Little league elbow: valgus overload injury in the paediatric athlete. //Sports medicine (Auckland, N.Z.)//, //32//(15), 1005-15. Retrieved from []

3. Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics.

4. Orthogate. (2006, July). Panner’s disease of the elbow. Retrieved from []

5. Institute for Sport’s Medicine. (2009, June). Panner’s disease (osteochondritis of the capitellum). Retrieved from __[|http://www.childrensmemorial.org/depts/sportsmedicine/panner-disease.aspx] __

**Lateral Epicondylitis (Tennis Elbow, Writer’s Cramp)**

** Definition ** ** Mechanism of injury ** ** Signs/symptoms **
 * Most common overuse syndrome in elbow joint due to repetitive gripping/ wrist extension actions
 * Wrist extensors contract to stabilize wrist during gripping activities (3)
 * Tendinopathy of extensor tendon origin:
 * ECRB(most commonly) ECRL, Ext Digitorum, Ext Carpi Ulnaris
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Because this is normally due to overuse, acute inflammation is usually not present unless injury is associated with a recognizable mechanism although a low grade inflammation may be present due to repeated microtearing. This can develop into tendonosis if not taken care of.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Possible Causes (1):
 * <span style="font-family: Arial,Helvetica,sans-serif;">Microscopic Tearing Theory: Microscopic tearing that occurs when the tissue is attempting to repair itself. Microscopic tearing can progres s to macroscopic tearing.
 * Degenerative Condition Theory: Lateral Epicondylitis may be a tendinosis injury that results from degeneration caused by repetitive eccentric or concentric overloading of ECRB.
 * Hypovascularity: Because lateral epicondyle is not a comparatively vascular area, the tendon does not repaired sufficiently after an occurrence of trauma to the area.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Repetitive gripping activities (Chronic)
 * Often Work related; also house work, hobbies
 * Movements involving wrist extension, pronation or supination
 * <span style="background-color: white; font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Trauma from direct blow (Acute)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Risk factors: using tools >1kg, holding weight >20 kg at least 10x/day, repetitive movement >2 hours/day (1)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Athletes: tennis, racquetball, squash, baseball, golf, javelin, swimming, weightlifting (3)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Symptoms
 * Pain anterior & distal to lateral epicondyle
 * ** Tenderness to touch over anterior aspect of lateral epicondyle ** (most common), radial head, lateral aspect of common extensor tendon origin
 * Morning stiffness
 * Night pain
 * Dull achiness at rest
 * Sharp pain when lifting objects
 * Dropping objects (especially with palm facing down) (2)(3)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Age: 35-54 years
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Dominant arm usually affected
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Duration of symptoms: 6 months - 2 years with gradual onset
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">ROM
 * Passive stretching is painful
 * Active motion usually painless (may be pain with wrist flexion + elbow extension)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Tests
 * ** Resisted wrist extension **
 * ** Resisted 2nd or 3rd digit extension **
 * ** Cozen’s test (3) **
 * Pronation, extension and radial deviation of wrist (elbow in extended position) + manual resistance
 * []
 * ** Decreased grip strength **
 * Mill’s Test (3)
 * Pain with palpation of lateral epicondyle + passive stretch in pronation, wrist flexion, elbow extension
 * []
 * Coffee Cup Test (1)
 * Pain when picking up cup of coffee
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Differential Diagnosis: (1)
 * Radial Tunnel Syndrome
 * Elbow OA
 * Fracture of radial head, distal radius, olecranon
 * Cervical Radiculopathy
 * Pain following dermatomes, neck pain/headaches, numbness, muscle weakness following myotome, reflex deficiency or loss, scapular pain
 * Test isometric wrist extension with varying angles of position for cervical spine and shoulder to differentially diagnose
 * **Cervical radiculopathy can be a cause of lateral epicondylitis (hypertonicity, weakness in extensor muscles)**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">**Bold phrases indicates validation of diagnosis (1)**

Treatment strategy **
 * <span style="font-family: Arial,Helvetica,sans-serif;"> Treatment strategy is aimed at breaking the cycle of pain using rest or medication and then slowly resuming protected motion (5)

<span style="font-family: Arial,Helvetica,sans-serif;">__ Therapeutic Exercise __ (3) >>
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Avoid painful movements but progress towards establishing pain-free ROM
 * Wrist flex/extension, forearm pronation/supination passive ROM/stretching
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Sub-max isometrics at multiple angles for pronation, elbow extension, wrist extension & radial deviation
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Implement concentric/eccentric exercises of implicated muscle group to increase strength & endurance
 * Start with low resistance, 1-2 sets x 10 reps
 * Progress to 5 sets of 10 reps
 * Progress to adding resistance
 * Example exercises:
 * Pronators: hammer exercise
 * Wrist extensors: broom handle exercise
 * Grip strength: tennis ball squeezes, putty
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Address any muscular deficiencies at shoulder joint or trunk.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Return to sport/occupation related activities

<span style="font-family: Arial,Helvetica,sans-serif;">__ Education __
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Patient should be educated on cause of injury and how to modify activity
 * Use pain as limiting factor but do not immobilize completely
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Proper racket technique
 * Use entire trunk and shoulder instead of elbow and wrist only to disperse forces more evenly
 * Attempt to hit ball in “sweet spot” of strings for better shock absorption
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Stress importance of exercises
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Pain management
 * NSAIDS, ice

<span style="font-family: Arial,Helvetica,sans-serif;">__ Adaptive Equipment __
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Equipment modification: grip size, string tension, shock absorbers, size of racket head (3)
 * Larger head= decreased forces being transmitted through forearm muscles
 * Larger grip= used if weak wrist extensors
 * Lower string tension= allow slight increase in time to spread forces
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Protective 20̊ wrist extension splint at initiation of therapy(3)
 * To help offload ECRB
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Counterforce brace
 * In theory, brace will limit expansion which will decrease the force production of muscle fibers proximal to strap although this has not been proven(3)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;"> <span style="color: windowtext; font-family: Arial,Helvetica,sans-serif; font-size: 7pt; text-decoration: none;">[]

<span style="font-family: Arial,Helvetica,sans-serif;">__ Manual Therapy __ <span style="font-family: Arial,Helvetica,sans-serif;">__ Home Exercise Program __ <span style="font-family: Arial,Helvetica,sans-serif;">__ Modalities/ Pain Control __
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Mobilizations to radial head (2)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Friction massage (2)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Joint mobilization in conjunction with exercise has demonstrated better results than corticosteroid injection and the “wait and see” method at 6 weeks but not at 52 weeks. (3)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Cervico-thoracic mobilizations in addition to treatment directly involving lateral epicondyle showed better results in strength pain, and activity tolerance versus local treatment alone. (3)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Initially, advise patient to passively stretch wrist and elbow in pain-free range.
 * 20-30 seconds, 3 sets
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">As progression occurs, patient can begin wrist/elbow strengthening exercises holding light weight (soup can, bottle of water, etc.) to perform exercises listed in Ther. Ex. Section. Patient could also use tubing or theraband in place of a weight. A tennis ball or putty can be used to increase grip strength.
 * 15-20 reps, 3 sets for strength/endurance.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Cryotherapy (ice massage, ice/cold pack) for pain/inflammation.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Electrotherapy and thermotherapy have not been proven effective (3).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Weak evidence for effectiveness of US (3,4)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">Corticosteriod injection is standard of care. However, current evidence suggests that iontophoresis (Dexamethasone) is “an effective, noninvasive means of decreasing acute pain in lateral Epicondylitis” and may have better function outcomes (grip strength and work return to work) versus CSI(5)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">1. Norton H, Vanderlinden N. Lateral Epicondylitis. Retrieved from [] <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">2. Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics. Pg 203. <span style="font-family: Arial,Helvetica,sans-serif;"> 3. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. Pg 683-705 <span style="font-family: Arial,Helvetica,sans-serif;"> 4. Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, van der Windt DA, Bouter LM. [|Effectiveness of physiotherapy for lateral epicondylitis: a systematic review]. (2003). Retrieved from: [] <span style="background-color: white; font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">5. Stefanou A, Marshall N, Holdan W, Siddiqui A. A Randomized Study Comparing Corticosteroid Injection to Corticosteroid Iontophoresis for Lateral Epicondylitis, The Journal of Hand Surgery, Volume 37, Issue 1, January 2012, Pages 104-109, ISSN 0363-5023, 10.1016/j.jhsa.2011.10.005. <span style="background-color: white; font-family: Arial,Helvetica,sans-serif; font-size: 10.5pt;">([])

__<span style="font-family: Arial,Helvetica,sans-serif; font-size: 130%;">**Radial Head Fracture** __

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Definition** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Radial head fractures are traumatic injuries that account for 20% of acute elbow injuries1. They are typically more common in men than women2.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Mechanism of Injury** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Radial head fractures commonly occur from falling on an outstretched hand ( FOOSH ) where the radius is forced into the capitulum3. Fracture can also occur after a dislocation : as the humerus and ulna move back into alignment, part of the radius can be broken off1. According to the AAOS, radial head fractures are classified according to the amount of dislocation present. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Picture: http://www.wikiradiography.com/page/Imaging+Radial+Head+Fractures
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Type 1: Minimal displacement, angulation and head involvement
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Type 2: Single piece is displaced
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Type 3: Comminuted and can’t be fit back together

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Signs/Symptoms2**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pain over radial head
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Stiff joint
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Localized swelling
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Decreased motion
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pain with pronation and supination
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Arm held in resting position (80 degrees of flex)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Diagnostic** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">X-ray <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Rule Out: <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">If FOOSH, also need to evaluate the wrist
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Vascular or nerve injury – presence of numbness, tingling, loss of sensation
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Compartment syndrome – presence of severe pain
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Elbow instability – valgus/varus tests (Elbow MCL/LCL)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**TREATMENT STRATEGY**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">*Typical union time is between 6-8 weeks3

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Conservative**:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Closed Reduction, Type 1 and Type 2 (if minimally displaced)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Early motion with a functional brace

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**S****urgical**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Required if involves __>__ 1/3 of articular surface, angulated 30 degrees, displaced 3mm
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Open Reduction Internal Fixation, Replacement or Resection/Removal
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Type 2 (if maximally displaced), Type 3
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">ROM exercises as soon as the wound is healed

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Picture:http://emedicine.medscape.com/article/1240337-overview

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Modalities/Pain Control** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">NSAIDs, cryotherapy, E-stim, Non-thermal US

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Manual Therapy** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Joint mobilizations are not indicated for fractures.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Adaptive Device** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Consider the use of a functional brace3 or an extension splint4.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Education** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Patient should be educated on what structures are involved and how the injury occurred. Patient should also be educated on the rehab protocol and the healing process for a fracture. Pain management at home should also be discussed. It would be important to include any physician precautions to prevent further injury.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Therapeutic Exercises** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Exercises will be similar for both conservative and surgical procedures with the major difference being initiation of exercise. For conservative treatments, exercises should be conducted immediately to prevent joint stiffness. For surgical treatments, wound should be healed before initiating exercise. Below is an example of a rehab protocol4.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 1__ (Days 0-14): Begin early AROM and AAROM exercises for elbow flexion and extension. Avoid flexion in pronation. Putty and grip exercises to help strengthen the muscles around the joint. Also initiate isometric strengthening for elbow flexion/extension.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 2__ (Day 15-6 Weeks): Continue A/AROM exercises. Begin A/AROM supination and pronation exercises. Initiate concentric and eccentric strengthening for elbow flexion and extension.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 3__ (Weeks 7-12): Continue A/AROM exercises for supination and pronation. Progress into concentric and eccentric strengthening for elbow flexion, extension, supination and pronation. Involve work/sport specific activities.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">*Remember to maintain shoulder, wrist and hand strength and ROM.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;"> **Home Exercise Program** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">HEP should include elbow stretches and A/AROM exercises that coincide with the above protocol and healing process. May include exercises for the hand, wrist and shoulder to maintain function.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 1__: AROM flex and extension, putty squeezes, isometric elbow exercise at 90 degrees flexion
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 2__: AROM supination/pronation, bicep curls/forearm extension with TB or can/weight
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__Phase 3__: hammer exercise for pronation/supination

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**References**:
 * 1) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">"Radial Head Fractures." //American Academy of Orthopedic Surgeons//. Web. <http://orthoinfo.aaos.org/topic.cfm?topic=A00073>.
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Loudon, J., Swift, M., Bell, S. (2008). The Clinical Orthopedic Assessment Guide.
 * 3) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Rabin, MD, Steven. "Radial Head Fractures." //Medscape Reference//. Web. <http://emedicine.medscape.com/article/1240337-overview>.
 * 4) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">"Radial Head Fracture." //ORIF//. Web. <http://www.eorif.com/Elbowforearm/Radial%20Head%20fx.html>.

= = =** Ulnar Nerve Transposition (Cubital Tunnel Syndrome) **=

**Definition**
The ulnar nerve can become entrapped or compressed in a number of locations; however, one of the most common sites of entrapment is the cubital tunnel. The cubital tunnel is a fibro-osseous canal which the ulnar nerve passes through. Ulnar nerve entrapment in the cubital tunnel is commonly referred to as Cubital Tunnel Syndrome (5). Cubital Tunnel Syndrome is the second most common compressive neuropathy (after carpal tunnel syndrome), and it affects men 3-8 times as often as women (11). Numbness, tingling, and pain may be felt in the elbow, forearm, hand and/or fingers (2). http://images.kamalaoverhere.multiply.com/image/1/photos/upload/300x300/RrJK3woKCoIAAA8zaUo1/cubitalTunnel.jpg?et=OXzH1dTt3p6%2C812uXfyt1A

**Mechanism of Injury**
The ulnar nerve is vulnerable to compression at the elbow because it travels through a narrow space with very little soft tissue to protect it (1). Listed below are some of the common causes of cubital tunnel syndrome(8): Etiology of cubital tunnel syndrome(11): Risk factors for developing cubital tunnel syndrome(1):
 * Frequent bending of the elbow, such as pulling levers, reaching, or lifting
 * Constant direct pressure over the elbow
 * Leaning on the elbow or resting the elbow on a hard surface
 * Fluid buildup/swelling in the elbow
 * Direct blow to the cubital tunnel
 * Constricting fascial bands
 * Subluxation of the ulnar nerve over the medial epicondyle
 * Cubitus valgus
 * Bony spurs, Tumors, Ganglia
 * Hypertrophied synovium
 * Direct compression
 * Prior fracture or dislocations of the elbow
 * Bone spurs/arthritis of the elbow
 * Swelling of the elbow joint
 * Cysts near the elbow joint
 * Repetitive or prolonged activities that require the elbow to be flexed

**Signs and Symptoms**
The major sign and symptom is activity-related pain or paresthesias that involve the 4th and 5th digits. Pain may extend distally or proximally in the medial aspect of the elbow (1, 5). http://www.eorthopod.com/images/ContentImages/elbow/elbow_cubital_tunnel/elbow_cubtun_symptom01.jpg
 * Aching pain on the inside of the elbow
 * “Falling asleep” of the 4th and 5th digits, especially when the elbow is bent
 * Numbness and tingling of the 4th and 5thdigits, especially when the elbow is bent
 * High incidence occurs when driving, talking on the phone, or sleeping
 * Weakening of the grip and pinch strength, and difficulty with finger coordination
 * Decreased sensation in the ulnar distribution of the hand
 * Progressive inability to separate the fingers
 * Atrophy or weakness of the ulnar intrinsic muscles of the hand (late sign)
 * Clawing contracture of the 4th and 5th digits (late sign)

**Diagnosis/Test and Measures**
A physical examination should include checking elbow ROM, examining the carrying angle, palpating for areas of tenderness and examining ulnar nerve subluxation (11).
 * Positive Tinel’s sign at the elbow (tap along the ulnar nerve where it travels between the olecranon and medial epicondyle)
 * Positive response is tingling, reproduction of symptoms (6)
 * Positive Elbow Flexion Test (elbow is fully flexed, wrist is neutral, shoulder girdle abduction and depression, patient holds position for 3-5 minutes)
 * Positive response is tingling/paresthesia in ulnar nerve distribution (6)
 * Positive Froment’s Sign (assesses adductor pollicis weakness from ulnar nerve injury) (6)
 * Positive Wartenberg’s Sign (examine for clawing/abduction of the small finger with extension) (11)
 * Evaluate sensation, vibratory perception and light touch, and 2-point discrimination
 * Imaging: x-rays to look for bony abnormalities that may be compressing the nerve (1)
 * Electromyography tests and nerve conduction studies to confirm area of entrapment
 * Differential Diagnosis: C8 nerve impingement, thoracic outlet syndrome, entrapment of the nerve at the Guyon canal

**Treatment Strategy**
Cubital Tunnel Syndrome can often be treated without surgery. However, surgery may be indicated under the following conditions (10): Surgical Options Include (1):
 * 1) No improvement in presenting symptoms after 6-12 weeks of conservative treatment
 * 2) Progressive palsy or paralysis
 * 3) Clinical evidence of a long-standing lesion (muscle wasting, clawing of the 4th and 5th digits)
 * Cubital Tunnel Release
 * The ligament “roof” of the cubital tunnel is cut and divided to increase the size of the tunnel and decrease the pressure on the nerve
 * Works best on mild cases of ulnar nerve compression
 * Ulnar nerve anterior transposition
 * The ulnar nerve is moved from behind the medial epicondyle to in front of it
 * Can be subcutaneous, intermuscular, or submuscular transposition
 * Link to video: [] (Arlington Orthopedic Associates)
 * Medial epicondylectomy
 * Remove part of the medial epicondyle to prevent the ulnar nerve from getting caught on the bony ridge and stretching when the elbow is bent

For non-operative rehabilitation, the treatment plan would be to initially reduce overload, pain, and inflammation. After that, total arm strength and normal joint arthokinematics would want to be achieved with the goal of returning to full activity (9).

**Modalities and Pain Control**

 * NSAIDs (non-steroidal anti-inflammatory medicines) to help reduce swelling around the nerve
 * Steroid injections (like cortisone) are effective anti-inflammatory medicines
 * Injecting steroids around the ulnar nerve is typically not used because there is a risk of damaging the nerve (1)
 * Use of modalities for pain reduction: use specific parameters and closely monitor effectiveness
 * Ice: decrease swelling and pain over symptomatic areas, use in conjunction with gentle AROM
 * Ultrasound used in the rehabilitation of nerve compressions (7)
 * Intensity of 0.5 W/cm2, frequency of 1.0 MHz increased the recovery rate of the nerve
 * Intensity of 1.0 W/cm2, frequency of 1.0 MHz slowed the rate of nerve recovery

**Manual Therapy**
Neurodynamic mobilizations can be performed for the following reasons (4): []
 * Enhance ulnar nerve gliding
 * Reduce intraneural and extraneural edema
 * Increase blood circulation
 * Restore neural tissue mobility

Passive manual joint mobilizations and manipulation to treat articular dysfunctions of the elbow and thorax, specific examples include (4):
 * Elbow: passive extension mobilization, grade III
 * Elbow: passive pronation mobilization, grades II and III
 * Elbow: distraction, grade III, in -10° extension
 * Radial glide of ulna in ulnar nerve preloaded position, grades III-IV
 * T1-T2 and T2-T3: high-velocity distraction thrust

**Assistive Device**
Splinting the elbow can help decrease swelling and can allow the nerve and surrounding structures rest and relief from compression and traction. The long arm splint is typically positioned with the elbow in comfortable flexion (40-70°), and the forearm and wrist in neutral (7). http://ars.els-cdn.com/content/image/1-s2.0-S0894113006000433-gr6.jpg

**Education**

 * Patients need to be educated on how they developed their symptoms, and how they contribute to them by their daily actions
 * The physical therapist should explain the anatomy of the ulnar nerve and where it is being compressed in the cubital tunnel
 * Teach patients how to analyze their daily tasks and how they can minimize the impacts of behaviors that aggravate their symptoms (7)

**Exercise**
Progressive Exercises:
 * Nerve mobilization exercises
 * Active wrist flexion and extension
 * Submaximal isometrics for shoulder and wrist
 * Isotonic exercises with 1-2 lb. weight:
 * o Wrist flexion/extension
 * o Forearm pronation/supination
 * o Elbow flexion/extension
 * o Rotator cuff exercises
 * PNF patterns (D1, D2 flexion and extension)
 * Swiss ball closed chain exercises
 * Elbow in extended position over the ball
 * Extremity bears progressive amounts of weight into the ball (9)

**Home Exercise Program**
The patient should be instructed on how to perform nerve gliding exercises at home along with the other therapeutic exercises. The therapist should only choose a few exercises that they want the patient to complete at home to facilitate patient compliance. In addition, the patient should be educated on how to progress their exercises by increasing resistance (with a theraband or weight).