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:
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).
Tests
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).
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
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)
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.
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°
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
5) Acceleration: maximal external rotation to ball release
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)
6) Deceleration: initiated at ball release and terminates at full internal rotation at the shoulder and follow through with the body
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
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.
http://www.jaaos.org/content/9/2/99/F4.expansion
.
Valgus Extension Overload Test
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
Treatment Strategy
Non-Surgical
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
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.
References
1) American Academy of Orthopaedic Surgeons. (2011, April). Throwing injuries in the elbow in children. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00328
2) Benjamin, MD, FACSM, FAAP, H. J. (2011, April 19). Little league elbow syndrome. Retrieved from http://emedicine.medscape.com/article/97101-overview
3) Hang, D. W. (2004). A Clinical and Roentgenographic Study of Little League Elbow. American Journal of Sports Medicine, 32(1), 79-84. doi:10.1177/0095399703258674 4) Kaar MD, S. (2011, April 04). Little leaguer's elbow. Retrieved from http://www.sportsmd.com/SportsMD_Articles/id/293.aspx 5) Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics.
6) Wilk, K. E., Sattenvhite, Y. E., & Tedder, I. (1993). Physical Examination of the Thrower’s Elbow, 17(6).
7) youth pitching.pdf (application/pdf Object). (n.d.). Retrieved March 26, 2012, from http://www.orthonurse.org/portals/0/youth pitching.pdf
Panner's Disease (Osteochondrosis of capitulum)
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.
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.
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.
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 http://www.ncbi.nlm.nih.gov/pubmed/12457420
3. Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics.
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.
Possible Causes (1):
Microscopic Tearing Theory: Microscopic tearing that occurs when the tissue is attempting to repair itself. Microscopic tearing can progress 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.
Mechanism of injury
Repetitive gripping activities (Chronic)
Often Work related; also house work, hobbies
Movements involving wrist extension, pronation or supination
Trauma from direct blow (Acute)
Risk factors: using tools >1kg, holding weight >20 kg at least 10x/day, repetitive movement >2 hours/day (1)
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)
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)
Home Exercise Program
Initially, advise patient to passively stretch wrist and elbow in pain-free range.
20-30 seconds, 3 sets
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.
Modalities/ Pain Control
Cryotherapy (ice massage, ice/cold pack) for pain/inflammation.
Electrotherapy and thermotherapy have not been proven effective (3).
Weak evidence for effectiveness of US (3,4)
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)
Definition Radial head fractures are traumatic injuries that account for 20% of acute elbow injuries1. They are typically more common in men than women2.
Mechanism of Injury 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.
Modalities/Pain Control NSAIDs, cryotherapy, E-stim, Non-thermal US
Manual Therapy Joint mobilizations are not indicated for fractures.
Adaptive Device Consider the use of a functional brace3 or an extension splint4.
Education 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.
Therapeutic Exercises 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.
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.
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.
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.
*Remember to maintain shoulder, wrist and hand strength and ROM.
Home Exercise Program 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.
Phase 1: AROM flex and extension, putty squeezes, isometric elbow exercise at 90 degrees flexion
Phase 2: AROM supination/pronation, bicep curls/forearm extension with TB or can/weight
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):
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
Etiology of cubital tunnel syndrome(11):
Constricting fascial bands
Subluxation of the ulnar nerve over the medial epicondyle
Cubitus valgus
Bony spurs, Tumors, Ganglia
Hypertrophied synovium
Direct compression
Risk factors for developing cubital tunnel syndrome(1):
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).
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)
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)
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):
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).
Works Cited
1) American Academy of Orthopaedic Surgeons. (2011). OrthoInfo. Retrieved March 25, 2012, from Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome): http://orthoinfo.aaos.org/topic.cfm?topic=A00069
2) American Society for Surgery of the Hand. (n.d.). Hand and Arm Conditions. Retrieved March 25, 2012, from Cubital Tunnel Syndrome: http://www.assh.org/Public/HandConditions/Pages/CubitalTunnelSyndrome.aspx
3) Arlington Orthopedic Associates. (n.d.). Ulnar Nerve Transposition at the Elbow. Retrieved March 25, 2012, from Conditions and Procedures: http://www.arlingtonortho.com/ulnar-nerve-transposition-at-the-elbow.html
4) Coppieters, M. W., Bartholomeeusen, K. E., & Stappaerts, K. H. (2004). Incorporating Nerve-Gliding Techniques in the Conservative Treatment of Cubital Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics , 560-568.
5) Dutton, M. (2004). Orthopaedic Examination, Evaluation, and Intervention. Pittsburgh: McGraw-Hill.
6) Loudon, J. K., Swift, M., & Bell, S. (2008). The Clinical Orthopedic Assessment Guide. Champaign: Human Kinetics .
7) Lund, A. T. (2006). Treatment of Cubital Tunnel Syndrome: Perspectives for the Therapist. Journal of Hand Therapy , 170-179.
8) Medical Multimedia Group. (2001). A Patient's Guide to Cubital Tunnel Syndrome. Retrieved March 25, 2012, from Orthopod: http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=84961a8273dfbf6d2c274cc747b59014
9) Oskay, D. (2010). Neurodynamic Mobilization in the Conservative Treatment of Cubital Tunnel Syndrome: Long-Term Follow-Up of 7 Cases. Journal of Manipulative and Physiological Therapeutics , 156-163.
10) Pho, C., & Godges, J. (n.d.). Ulnar Nerve Transposition. Retrieved March 25, 2012, from Loma Linda U DPT Program: http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/22Elbow-UlnarNerveTransposition.pdf
11) Verheyden, J. R., & Palmer, A. K. (2011, June 3). Medscape Reference. Retrieved March 25, 2012, from Cubital Tunnel Syndrome: http://emedicine.medscape.com/article/1231663-overview#showall
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:
- 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).
TestsMechanism of Injury:
Treatment:Therapeutic Exercise:
Progressive Exercises for Medial Epicondylitis:
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:
- 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
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)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 http://www.summitmedicalgroup.com/library/sports_health/medial_epicondylitis_exercises/.
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
http://www.youtube.com/watch?v=5OWd8VHIVKQ
13 y/o Pitcher (Normal & Slow Motion)
http://www.youtube.com/watch?v=yfpN8uLdUQk
9 y/o Pitcher (Normal Motion)
http://www.youtube.com/watch?v=RGnp4K4sXqo&feature=related
Sport-Specific Biomechanics (pertaining to the elbow)2
1) Wind-up: Elbow flexed2) 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°
- 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
5) Acceleration: maximal external rotation to ball release- 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)
6) Deceleration: initiated at ball release and terminates at full internal rotation at the shoulder and follow through with the bodyOpposed 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
Differential Diagnosis
Rule out the following:Treatment Strategy
Non-Surgical
Surgical
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.References
1) American Academy of Orthopaedic Surgeons. (2011, April). Throwing injuries in the elbow in children. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a003282) Benjamin, MD, FACSM, FAAP, H. J. (2011, April 19). Little league elbow syndrome. Retrieved from http://emedicine.medscape.com/article/97101-overview
3) Hang, D. W. (2004). A Clinical and Roentgenographic Study of Little League Elbow. American Journal of Sports Medicine, 32(1), 79-84. doi:10.1177/0095399703258674
4) Kaar MD, S. (2011, April 04). Little leaguer's elbow. Retrieved from http://www.sportsmd.com/SportsMD_Articles/id/293.aspx
5) Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics.
6) Wilk, K. E., Sattenvhite, Y. E., & Tedder, I. (1993). Physical Examination of the Thrower’s Elbow, 17(6).
7) youth pitching.pdf (application/pdf Object). (n.d.). Retrieved March 26, 2012, from http://www.orthonurse.org/portals/0/youth pitching.pdf
Panner's Disease (Osteochondrosis of capitulum)
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.http://www.orthogate.org/patient-education/child-orthopedics/panners-disease-of-the-elbow.html
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.http://www.youtube.com/watch?v=WR3Dc0bXUdI&feature=related (1:35-1:40)
http://www.youtube.com/watch?v=5OWd8VHIVKQ&feature=related (43s)
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:
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 http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/21302869
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 http://www.ncbi.nlm.nih.gov/pubmed/12457420
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 http://www.orthogate.org/patient-education/child-orthopedics/panners-disease-of-the-elbow.html
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
- 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
- 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.
- Possible Causes (1):
- Microscopic Tearing Theory: Microscopic tearing that occurs when the tissue is attempting to repair itself. Microscopic tearing can progress 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.
Mechanism of injury- Repetitive gripping activities (Chronic)
- Often Work related; also house work, hobbies
- Movements involving wrist extension, pronation or supination
- Trauma from direct blow (Acute)
- Risk factors: using tools >1kg, holding weight >20 kg at least 10x/day, repetitive movement >2 hours/day (1)
- Athletes: tennis, racquetball, squash, baseball, golf, javelin, swimming, weightlifting (3)
Signs/symptomsTreatment strategy **
Therapeutic Exercise (3)
Education
Adaptive Equipment
http://www.indiamart.com/vahe-akem-pvtltd/products.html
Manual Therapy
- Mobilizations to radial head (2)
- Friction massage (2)
- 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)
- 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)
Home Exercise Program- Initially, advise patient to passively stretch wrist and elbow in pain-free range.
- 20-30 seconds, 3 sets
- 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.
Modalities/ Pain Control1. Norton H, Vanderlinden N. Lateral Epicondylitis. Retrieved from http://www.physio-pedia.com/Lateral_Epicondylitis
2. Loudon, J. (2008). The clinical orthopedic assessment guide. Champaign, IL: Human Kinetics. Pg 203.
3. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.Pg 683-705
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: http://informahealthcare.com/doi/abs/10.1080/07853890310004138
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.
(http://www.sciencedirect.com/science/article/pii/S0363502311012834)
Radial Head Fracture
Definition
Radial head fractures are traumatic injuries that account for 20% of acute elbow injuries1. They are typically more common in men than women2.
Mechanism of Injury
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.
Picture: http://www.wikiradiography.com/page/Imaging+Radial+Head+Fractures
Signs/Symptoms2
Diagnostic
X-ray
Rule Out:
- Vascular or nerve injury – presence of numbness, tingling, loss of sensation
- Compartment syndrome – presence of severe pain
- Elbow instability – valgus/varus tests (Elbow MCL/LCL)
If FOOSH, also need to evaluate the wristTREATMENT STRATEGY
*Typical union time is between 6-8 weeks3
Conservative:
Surgical
Picture:http://emedicine.medscape.com/article/1240337-overview
Modalities/Pain Control
NSAIDs, cryotherapy, E-stim, Non-thermal US
Manual Therapy
Joint mobilizations are not indicated for fractures.
Adaptive Device
Consider the use of a functional brace3 or an extension splint4.
Education
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.
Therapeutic Exercises
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.
*Remember to maintain shoulder, wrist and hand strength and ROM.
Home Exercise Program
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.
References:
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):- 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
Etiology of cubital tunnel syndrome(11):- Constricting fascial bands
- Subluxation of the ulnar nerve over the medial epicondyle
- Cubitus valgus
- Bony spurs, Tumors, Ganglia
- Hypertrophied synovium
- Direct compression
Risk factors for developing cubital tunnel syndrome(1):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).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).Treatment Strategy
Cubital Tunnel Syndrome can often be treated without surgery. However, surgery may be indicated under the following conditions (10):- No improvement in presenting symptoms after 6-12 weeks of conservative treatment
- Progressive palsy or paralysis
- Clinical evidence of a long-standing lesion (muscle wasting, clawing of the 4th and 5th digits)
Surgical Options Include (1):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
Manual Therapy
Neurodynamic mobilizations can be performed for the following reasons (4):http://www.sciencedirect.com.proxy.kumc.edu:2048/science/article/pii/S0161475404002386
Passive manual joint mobilizations and manipulation to treat articular dysfunctions of the elbow and thorax, specific examples include (4):
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
Exercise
Progressive Exercises: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).Works Cited
1) American Academy of Orthopaedic Surgeons. (2011). OrthoInfo. Retrieved March 25, 2012, from Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome): http://orthoinfo.aaos.org/topic.cfm?topic=A000692) American Society for Surgery of the Hand. (n.d.). Hand and Arm Conditions. Retrieved March 25, 2012, from Cubital Tunnel Syndrome: http://www.assh.org/Public/HandConditions/Pages/CubitalTunnelSyndrome.aspx
3) Arlington Orthopedic Associates. (n.d.). Ulnar Nerve Transposition at the Elbow. Retrieved March 25, 2012, from Conditions and Procedures: http://www.arlingtonortho.com/ulnar-nerve-transposition-at-the-elbow.html
4) Coppieters, M. W., Bartholomeeusen, K. E., & Stappaerts, K. H. (2004). Incorporating Nerve-Gliding Techniques in the Conservative Treatment of Cubital Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics , 560-568.
5) Dutton, M. (2004). Orthopaedic Examination, Evaluation, and Intervention. Pittsburgh: McGraw-Hill.
6) Loudon, J. K., Swift, M., & Bell, S. (2008). The Clinical Orthopedic Assessment Guide. Champaign: Human Kinetics .
7) Lund, A. T. (2006). Treatment of Cubital Tunnel Syndrome: Perspectives for the Therapist. Journal of Hand Therapy , 170-179.
8) Medical Multimedia Group. (2001). A Patient's Guide to Cubital Tunnel Syndrome. Retrieved March 25, 2012, from Orthopod: http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=84961a8273dfbf6d2c274cc747b59014
9) Oskay, D. (2010). Neurodynamic Mobilization in the Conservative Treatment of Cubital Tunnel Syndrome: Long-Term Follow-Up of 7 Cases. Journal of Manipulative and Physiological Therapeutics , 156-163.
10) Pho, C., & Godges, J. (n.d.). Ulnar Nerve Transposition. Retrieved March 25, 2012, from Loma Linda U DPT Program: http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/22Elbow-UlnarNerveTransposition.pdf
11) Verheyden, J. R., & Palmer, A. K. (2011, June 3). Medscape Reference. Retrieved March 25, 2012, from Cubital Tunnel Syndrome: http://emedicine.medscape.com/article/1231663-overview#showall