Monograph 17
Arm and Elbow Trauma
By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997
Copied with permission from
ACAPress
Background
Screening Tests for the Arm and Elbow
Lower Arm and Elbow Pain
Dynamic Palpation of the Elbow
Upper Extremity Entrapment Syndromes
Determining Elbow Dislocations and Fractures
Physical Assessment
Roentgenography
Arthrokinematics
Basic Functional Anatomy
Elbow Motion
Biomechanics
Screening Kinetics
Elbow Kinesiology
Clinical Management Electives of Elbow Strain/Sprain
Common Arm Trauma
Rotator Cuff Injuries
Deltoid Contusion and Strain
The Bicipital Syndrome
Bicipital Tendon Dislocation
Rupture of the Transverse Humeral Ligament
Brachialis Contusion and Strain
Bicipital Tendinitis
Supraspinatus Tendinitis
General Rotator Cuff Tendinitis
Pitching and Related Injuries
Triceps Brachii Calcification
Roentgenography
|
Articular Therapy
Techniques to Release Humeroulnar Hypomobility
• Techniques to Release Proximal Radioulnar Hypomobility
• Posterior-Medial Radial Head Subluxation-Fixation Release
• Anterior Olecranon Subluxation-Fixation Release
• Posterior Olecranon Subluxation-Fixation Release
• Superior Olecranon Subluxation-Fixation Release
• Lateral Olecranon Subluxation-Fixation Release
• Medial Olecranon Subluxation-Fixation Release
Reducing and Managing Simple Dislocations
Elbow Trauma
Common Elbow Contusions and Strains
Distal Bicipital Strain
Olecranon Bursitis
Traumatic Arthritis
Common Elbow Sprains
Ligament Stability Tests
Tennis Elbow (Lateral Epicondylitis)
Golfer's Elbow (Medial Epicondylitis)
Exercises for Elbow Epicondylitis
Pitcher's Elbow
Little League Elbow
Javelin Elbow
Direct Peripheral Nerve Trauma
• Musculospiral Contusion
• Radial Nerve Compression at the Elbow
• Ulnar Nerve Compression at the Elbow
• Palsy of the Arm
References and Bibliography |
The shoulder girdle is a multiaxial intricately synchronized joint
complex that has considerable power and an extreme range of motion. The
anterior, superior, and posterior shoulder muscles provide the great power, and the
collateral ligaments do not appreciably limit motion in any plane. Thus,
stability must be provided by muscles: essentially the rotator cuff and
subscapularis muscles of the arm, which are aided slightly by the glenohumeral
ligaments.
BACKGROUND
The proximal ulna forms the most important articulation in the elbow area,
while the distal radius forms the most important articulation in the
wrist.
Elbow area injuries are commonly the result of direct blows or falls.
Avulsion-type injuries of the elbow are often seen as a result of acute or
chronic strain at a site of tendon or ligament attachment. As in all traumatic
injuries, the sooner the patient is examined after injury, the
more accurate
the diagnosis. Swelling, spasm, tenderness, and motion
limitations rapidly
cloud the picture. A list of common elbow injury syndromes is
shown in Table 1.
Table 1. Common Elbow Injuries
Syndrome |
Typical Clinical Picture |
MUSCULOTENDINOUS INJURIES |
Lateral Aspect
Extensor carpi radialis brevis strain, tendinitis
Lateral epicondylitis
Lateral epicondyle spur or adjacent calcium deposition
Posteromedial radial head subluxation
Lateral olecranon subluxation |
Pain on gripping, point tenderness at the attachment of the common extensor tendon. Pain is aggravated by
resisted hyperextension of the wrist or passive wrist flexion with the elbow extended
Some swelling is usually present |
Anterior Aspect
Biceps-brachialis strain, tendinitis, rupture
Anterior olecranon subluxation
Anterior olecranon subluxation
Superior ulna subluxation
Superior ulna subluxation
Avulsion at radial tuberosity |
Anterior elbow pain aggravated by use, tenderness over the insertion of the biceps tendon. Pain is
increased by resisted elbow flexion, forearm supination, and passive elbow extension. Antecubital swelling is usually present |
Medial Aspect
Strain, tendinitis, or rupture of wrist flexors and forearm pronators
Medial epicondylitis, with or without avulsion
Medial olecranon subluxation |
Pain on throwing, forearm tennis shot, or gripping. Point tenderness at attachment of common tendon to
medial epicondyle. Pain is aggravated by resisted flexion or passive wrist extension when the elbow is extended |
Posterior Aspect
Triceps strain, tendinitis
Olecranon avulsion (uncommon)
Bursitis
Posterior olecranon subluxation |
Pain on repetitive extension (eg, throwing, tennis, weight lifting, gymnastics). Point tenderness at or
just above the insertion of the triceps on the olecranon process. Pain is aggravated by resisted extension or passive flexion of the elbow |
ARTICULAR INJURIES |
Lateral Compartment
Traumatic damage to radial head, capitellum, or both
Osteochondral fractures
Compression osteochondritis of capitellum (youth)
Osteochondritis of radial head
Superior ulnar subluxation
Loose body formation |
Lateral elbow pain on throwing, gymnastics, racquet sports, sometimes associated with joint clicking,
catching, grinding. Tenderness and swelling over radiocapitellar joint. Grating on forced forearm
supination and pronation (often), and reduced ranges of elbow extension |
Medial Compartment
Capsular tear
Calcium deposition
Coronoid process spur
Ulnar nerve entrapment |
Medial elbow pain and swelling aggravated by valgus stress (eg, throwing, weight lifting), point tenderness
below medial epicondyle near humeroulnar joint, and possible sensitive ulnar nerve. Pain aggravated by passive wrist extension or active flexion |
Posterior Compartment
Olecranon tip spur
Olecranon hypertrophy
Loose body formation
Olecranon fatigue fracture
Posterior olecranon subluxation |
Posterior pain on elbow extension, often with a catching or locking sensation; point tenderness in the
olecranon fossa, reduced range of extension |
NEUROVASCULAR INJURIES |
Ulnar nerve entrapment Cubital tunnel syndrome |
Paresthesias and weakened motor power in the 4th and 5th fingers, point tenderness in cubital tunnel |
Median nerve entrapment
Pronator teres syndrome |
Anterior elbow pain, usually radiating into thumb, index finger, and middle finger. Forearm cramps
(sometimes), and tenderness over pronator teres. Pain is aggravated by resisted forearm pronation and passive supination. Possible thumb abduction weakness and sensory loss in the 1st, 2nd, and 3rd digits |
Musculocutaneous nerve entrapment |
Weak elbow flexion, absent biceps reflex, biceps and brachialis atrophy, and numbness/tingling along the
radial-volar aspect of the forearm |
Radial nerve entrapment (uncommon) |
Elbow pain along the lateral extensor muscle group. Tender-ness along the radial nerve anteriorly about the
radial head, but not over the lateral epicondyle as in tennis elbow. Pain is aggravated by passive forum supination and pronation and forced extension of the wrist and 3rd finger. Weakness and stiffness of the extensor-supinator
muscles are usually exhibited |
Brachial Artery Obstruction
Supracondylar fracture
Posterior or posterolateral dislocation |
Signs of vascular insufficiency; eg, progressively increasing pain, pain on passive extension of the
fingers, median nerve paresthesia |
Screening Tests for the Arm and Elbow
The pain from arm strain implies
(1) abnormal strain on a normal joint,
(2) normal strain on an unprepared joint, or
(3) normal strain on an abnormal joint.
Because all tendons are relatively avascular, they are primary targets of
chronic trauma resulting in microtears, slow repair, and aging
degeneration in
the shoulder. Overuse is the common cause. Various forms of
shoulder tendinitis can often be differentiated solely by range of
motion tests. For example:
(1) infraspinatus tendinitis features pain on resisted
external rotation;
(2) subscapular tendinitis features pain on resisted
internal rotation; and
(3) intracapsular bicipital tendinitis expresses
pain on resisted supination and flexion of the elbow.
Lower Arm and Elbow Pain
Branch lists the most common causes of extrinsic elbow pain
as medial or lateral epicondylitis and olecranon bursitis and of intrinsic
elbow pain as synovitis, loose bodies, elbow subluxations, dislocations, and
fractures. A
large number of functional and pathologic disorders (local or
remote) may also
manifest within the elbow area. Symptoms of upper extremity
causalgia are shown in Table 2.
Table 2. Symptoms of Upper Extremity Causalgia According to Stage
First Stage (1-6 Months)
Burning pain; hot dry tender skin; dusky red edema of hand and fingers, stiff fingers and shoulder, early finger motion restriction |
Intermediate Stage
Decreased pain and edema; atrophic skin, subcutaneous tissues, and
muscles in hand; palmar fascial and joint contractures; moderate osteoporosis.
|
Chronic Stage
Skin becomes cool, cyanotic, and atrophied; brittle nail edges; hand
flexion contractures, frozen shoulder; advanced osteoporosis |
Dynamic Palpation of the Elbow
The elbow is generally thought of as a simple hinge joint. Soderberg,
however, points out that biomechanical and kinesiologic studies
show that this is an oversimplification of the actual conditions required for
normal elbow mobility.
The relatively strong elbow complex consists of three joints:
(1) the
radiohumeral joint,
(2) the ulnohumeral joint, and
(3) the superior radioulnar
joint. Because the elbow has such wide ranges of motion in flexion, extension,
supination, and pronation, freedom of joint play must be checked to determine
the point of possible fixation. These are:
Glide of the
olecranon process of the ulna into the olecranon fossa of the
humerus during
elbow extension.
Glide of the
coronoid process of the ulna into the coronoid fossa of the
humerus during elbow flexion.
Downward glide of the head of the radius on the head of the ulna.
Upward glide
of the head of the radius on the head of the ulna.
Lateral
glide of the olecranon on the distal humerus when the elbow is
flexed.
Medial glide
of the olecranon on the distal humerus when the elbow is
flexed.
Upper Extremity Entrapment Syndromes
Entrapment syndromes in the upper extremity may manifest in the axilla,
elbow area, forearm, or wrist. See Table 3.
Table 3. Common Upper Extremity Nerve Entrapment Syndromes
Syndrome |
Site |
Nerve |
Major Findings* |
Anterior interosseous |
Proximal forearm |
Anterior interosseous
(median) |
Abnormal pinch sign; normal sensations,
weakness of flexor pollicis longus, pronator quadratus, and
flexor digitorum profundi of index and middle fingers; poorly defined ache in
forearm. Pain intensifies during the night. |
Carpal tunnel |
Wrist |
Median |
Pain, paresthesias, numbness, and poor two-
point discrimination in thumb and radial 2-1/2 fingers;
hypesthesia especially on palmar aspect of 2nd digit; thenar weakness and
wasting; positive Tinel's and Phalen's signs; positive EMG signs.
|
Cubital tunnel |
Elbow |
Ulnar |
Sensory loss in ulnar 1-1/2 fingers and ulnar
aspect of the hand; weakness and wasting of ulnar intrinsics
and flexor digitorum profundus; ache in medial elbow and forearm; little
finger numbness; positive Tinel's sign. |
Guyon's canal |
Wrist |
Ulnar |
Sensory loss in ulnar 1-1/2 fingers; weakness and wasting of ulnar intrinsic muscles. |
Postcondylar groove |
Elbow |
Ulnar |
Sensory loss in ulnar 1-1/2 fingers and ulnar aspect of the hand; weakness and wasting of ulnar intrinsics and flexor carpi ulnaris muscles; elbow joint deformity. |
Posterior interosseous |
Proximal forearm |
Posterior interosseous
(radial) |
Normal sensation; wrist drop; dull ache in dorsal forearm; difficult finger extension. |
Pronator |
Proximal forearm |
Median |
Proximal forearm pain and tenderness; flexor pollicis longus and abductor pollicis brevis weakness; paresthesias in thumb and radial 3-1/2 fingers; forearm and hand pain; positive
Tinel's sign.
|
Radial |
Midarm, spiral groove |
Radial |
Sensory loss in radial side of dorsal hand; wrist drop; weak wrist and finger extensors; possible sensory impairment in web of thumb |
Crutch or sleep palsy |
Axilla, humeral
groove |
Radial |
Sensory loss of radial forearm; loss of elbow extension; wrist drop. |
* Note that one or more of the major features presented in this table may be absent and that the symptoms and signs may vary in severity from one patient to another.
Determining Elbow Dislocations and Associated Fractures
Most injuries of the forearm are from falls or direct blows.
Forearm fractures frequently involve both bones. Sometimes, however,
these bones do not fracture at the same level. When a midarm blow fractures
the radius or ulna, both ends of each bone must be evaluated for possibly
associated subluxation, fracture, dislocation, and rotational
abnormality.
Elbow fractures and dislocations should be reduced by an
orthopedist. Splint in "as is" position, sling, and refer. Delay in referral
can easily result in massive heterotopic bone formation. Poorly reduced
supracondylar fractures, resulting in cubitus valgus, readily lead to ulnar
neuritis. Myositis ossificans, nerve damage, brachial arterial
compression, contractures, abnormal carrying angle, and joint stiffness may
complicate recovery from any severe elbow injury.
Physical Assessment
If obvious deformity and crepitus are not present, slowly
and gently check range of motion, and determine the radial pulse. Assess
sensation by light touch and distal motion by having the patient appose thumb and
forefinger. Comminuted or marginal fracture fragments from the radial head
are frequently associated with elbow dislocations.
Roentgenography
Elbow dislocations usually result from excessive hyperextension where the olecranon and radial head are displaced posteriorly. Severe soft-tissue damage is associated, usually resulting in subperiosteal hematoma. In uncomplicated
cases, gentle forward traction on the forearm with the humerus stabilized can
be conducted to ease pain before orthopedic referral. Roentgenography is required to analyze possible complications before considering even simple dislocation reduction.
As a consequence of avulsion injury, bone fragments may be seen in the area of the epicondyles or olecranon process, and epicondyle spurs
may point to chronic stress. Standard projections are A-P, lateral, and
oblique views. An intra-articular bone fragment may sometimes be only elicited by
tomography, and comparative views of the sound limb are frequently
necessary.
The most common fracture is a line running from the anterior
to the posterior surface of the humeral shaft (supracondylar) with the
proximal
fragment shifted anteriorly. Fractures in the area of the elbow
usually
involve the joint. In the order of frequency, the most common
fractures are
supracondylar, fractures of the humerus, olecranon, head of the
radius, and
coronoid process. A fracture line between the condyles
(intercondylar) or
through one or both of the condyles (diacondylar) may be seen.
Fracture of the
ulnar shaft with dislocation of the radial head (Monteggia
injury) and fracture of the radial head may also be presented.
Soft-Tissue Evaluation. Displacement of fat pads is
often found at
the elbow after injury. This can occur in any injury that
distends the joint
capsule. A pad appears as a thin strip of radiolucent fat
density. The
anterior fat pad is normally seen on lateral views, but the
posterior humeral
pad is hidden by the epicondyles' posterior extensions.
However, the posterior
pad will become visible at the posterior edge of the humerus on
lateral views
if effusion causes displacement of the pad. The most important
complication is ischemia of the forearm, which may cause an irreversible
contracture deformity.
Growth-Center Evaluation. Especially within the
adolescent athlete,
trochlea, capitellum, and epicondyle growth centers may be
enlarged,
fragmented, displaced, or prematurely fused. Epiphyseal lines
cause the most errors in interpretation of this area. Epiphyseal cartilage may
be lacerated and the ossification centers displaced, sometimes into the
articular cavity.
Normal ossification of distal humeral epiphyses is not an
even process, especially during the periods of rapid growth and development;
thus knowledge of secondary ossification centers of the elbow is necessary in
dealing with children or teenagers. One or more bony centers may remain
uneven in density and irregular on the margins, especially the trochlea and
olecranon epiphyses. Because of this irregularity, careful differentiation must be
made from osteochondrosis and epiphysitis.
The trochlear center is irregularly mineralized and always
develops from several small foci. The lateral epicondyle does not fuse
directly with the humerus as the medial epicondyle does; rather, it fuses first
with the neighboring epiphyseal ossification center, the capitellum,
then the fused mass joins the end of the shaft of the humerus. After injury,
the position of various centers must be evaluated for possible displacement,
laceration, and incarceration into the joint.
ARTHROKINEMATICS
Basic Functional Anatomy
The semilunar notch of the ulna is hinged with the hyperboloid trochlea of the humerus. The proximal head of the radius pivots with the spherical capitulum of the humerus and glides against both the proximal and distal ends
of the ulna.
The distal end of the humerus consists of two columns: a larger one medially articulating with the semilunar notch of the ulna and a smaller one laterally articulating with the head of the radius. The
pulley-like trochlea
apparatus has
(1) a depression at the front that lodges the
coronoid process
of the ulna and
(2) a depression at the rear that holds the
olecranon process
of the ulna when the elbow is extended. The olecranon process
restricts
hyperextension of the elbow and protects the ulnohumeral
articulation
posteriorly.
The concave head of the radius glides against the spherical capitulum of the humerus. The capitulum and trochlea are separated by a bony crest that fits into the opening between the proximal ulna and the radius and serves as a
fixed rudder to guide elbow motion. The elbow flexors originate from the medial epicondyle, and the extensors originate from the lateral epicondyle. This structural arrangement should be visualized during examination to discriminate normal from abnormal motion.
Elbow Motion
The basic range of elbow joint motion involves elbow flexion and extension, and forearm supination and pronation. The patient may be examined in either the standing or sitting position. If a blockage is obtained in active motion,
passive motion should be checked and the type of block and degree of restriction noted.
Biomechanics
The elbow functions as a first-class lever during extension. The mechanical advantage is poor because of the short lever arm between the insertion of the triceps and the center of the joint. During flexion, the elbow functions as a
third-class lever. Force from the biceps and brachialis act between the fulcrum and weight of the forearm.
Screening Kinetics
Flexion and Extension. The excursion of the head of the radius over the capitulum in full flexion is about 140°. Active flexion is judged by having the patient touch an ipsilateral shoulder with the supinated hand, and extension is checked by the patient straightening the elbow as far as possible. Many females normally reach 5° hyperextension. The easiest testing maneuver is to have the patient flex and extend both
elbows at the same time in one continuous movement. Flexion is limited normally by the biceps muscle mass, and extension is limited when the olecranon touches the olecranon fossa.
Pronation and Supination. During forearm pronation, the ulna remains fixed and the radius crosses over it. In supination, the bones merely uncross. Active pronation and supination are checked with the patient's
elbow 90° in flexion and firmed against the waist. The patient is then instructed to
turn the closed fist first downwards to that the palmar surface is parallel with the
floor (pronation) and then upward so that the dorsal surface is
parallel with the floor (supination). Restriction in pronation suggests
pathology at the elbow, radioulnar articulation at the wrist, or within the
forearm. Restriction in supination is associated with an elbow disorder
or with a blocked radioulnar articulation at the wrist.
Elbow Kinesiology
Flexion. Elbow flexion is controlled by the
brachialis (C5–C6) and
biceps brachii (C5–C6) with assistance by the brachioradialis
(C5–C6) and
supinator (C6). Strength is tested with the examiner in front
of the patient
placing his stabilizing hand cupped under the patient's
90 degree flexed elbow
and his active
hand gripping the patient's wrist. Increasing resistance is
added as the
patient attempts to flex the elbow. See Table 4.
Table 4. Elbow and Forearm Motion
Joint Motion |
Prime Movers |
Accessories |
ELBOW |
Flexion |
Biceps brachii
Brachialis
Brachioradialis |
Flexor carpi radialis
Flexor digitorum superficialis
Pronator teres
Extensor carpi radialis longus
Palmaris longus |
Extension |
Triceps |
Anconeus |
FOREARM |
Supination |
Supinator
Biceps brachii |
|
Pronation |
Pronator teres
Pronator quadratus |
|
Extension. Extension of the elbow is provided by the triceps (C7–C8) with
help from the anconeus (C7–C8). The examiner's stabilizing and active hands
are in the same position described above, and increasing
resistance is offered
as the patient attempts elbow extension.
Supination. Forearm supination is conducted by the
biceps (C5–C6)
and supinator (C6), aided by the brachioradialis (C5–C6). The
examiner's
stabilizing hand remains cupped under the elbow, and the active
hand grips the
patient's pronated wrist. Increasing resistance is applied as
the patient
attempts to turn the forearm from pronation to supination.
Pronation. Pronation of the forearm is provided by
the pronator
teres (C6–C7) and pronator quadratus (C8–T1), with assistance
from the
flexor carpi radialis (C7–C8). The examiner's stabilizing hand
remains in
place as described above, and the active hand grips the
patient's supinated
wrist. Increasing resistance is applied as the patient attempts
to turn the
forearm from supination to pronation.
CLINICAL MANAGEMENT ELECTIVES OF ELBOW STRAIN/SPRAIN
1. Stage of Acute Inflammation and Active Congestion
The major goals are to control pain and reduce swelling by
vasoconstriction, compression, and elevation; to prevent
further irritation,
inflammation, and secondary infection by disinfection,
protection, and rest;
and to enhance healing mechanisms. Common electives
include:
Disinfection of open skin (eg, scratches, abrasions,
etc)
Cryotherapy (never apply ice or severe cold directly on the
olecranon)
Cool packs
Ice massage
Vapocoolant spray and stretch of related trigger points
Compression
Pressure bandage
Aircast
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Mild pulsed ultrasound
Pulsed alternating current
Auriculotherapy
Meridian therapy
Spondylotherapy (upper thoracic)
Rest
Bed or chair rest
Foam/padded appliance
Sling
Immobilization
Brace
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional
supplementation.
2. Stage of Passive Congestion
The major goals are to control residual pain and swelling,
provide rest and
protection, prevent stasis, disperse coagulates and gels,
enhance circulation
and drainage, maintain muscle tone, and discourage adhesion
formation. Common
electives include:
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Indirect therapy (reflex therapy)
Spray-and-stretch related trigger points
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cool cryokinetic passive exercise
Meridian therapy
Spondylotherapy (upper thoracic)
Rest
Chair rest
Foam/padded appliance
Sling
Immobilization
Brace
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional
supplementation.
3. Stage of Consolidation and/or Formation of Fibrinous
Coagulant
The major goals are the same as in Stage 2 plus enhancing
muscle tone and
involved tissue integrity and stimulating healing processes.
Common electives
include:
Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch related trigger points
Cool cryokinetic active exercise
Moderate active range-of-motion exercises
Meridian therapy
Alternating stretching
Sinusoidal current
Ultrasound, continuous
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy (upper thoracic)
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
Foam/padded appliance
Sling
Immobilization
Semirigid appliance
Foam support
Indicated diet modification and nutritional
supplementation.
4. Stage of Fibroblastic Activity and Potential Fibrosis
At this stage, causes for pain should be corrected but some
local
tenderness likely exists. The major goals are to defeat any
tendency for the
formation of adhesions, taut scar tissue, and area fibrosis and
to prevent
atrophy. Common electives are:
Deep heat
Articular adjustment technics
Spondylotherapy (upper thoracic)
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch of related trigger points
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound, continuous
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Sling and light elastic cuff
Indicated diet modification and nutritional
supplementation.
5. Stage of Reconditioning
Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional
supplementation.
COMMON ARM TRAUMA
Rotator Cuff Injuries
Five deep muscles are around the glenohumeral joint. They
comprise the
rotator cuff. The infraspinatus and teres minor work as
external rotators of
the humerus. The subscapularis and teres major rotate the
humerus medially.
The supraspinatus pulls the humerus into the glenoid fossa and
abducts the humerus initially (10 ° –15 °)
before the deltoid becomes effective. In further abduction, the
supraspinatus
and deltoid stabilize the humerus during full abduction. The
mechanism of
rotator cuff injury may be a fall with outstretched hand, a
blow on the shoulder, throwing, or heavy lifting.
Stages. Three stages are commonly recognized and
related to age:
(1) Edema and hemorrhage resulting from overuse (eg, swimming,
tennis, baseball,
arm work) characteristically seen before age 25 but may be seen
at any age.
(2) With repeated episodes, the subacromial bursa becomes
fibrotic and
thickened. The patient is usually 25–40 years old. (3) This
stage is
characterized by wearing of the bone and rupture of the tendon
in individuals
over 40 years, associated with anterior acromial erosion and
spurs. However,
these stages fail to recognize the effect of a reflex-produced
ischemia so
often seen in practice.
Classes. Rotator cuff strain can be classified as
follows:
Grade I injury:
Minor pain and weakness; tenderness over upper end of
humerus,
weakness and loss of normal shoulder rhythm on flexion and
abduction.
Grade II injury:
Pain with moderate disability; exaggerated signs of
Grade I.
Unpalpable tear site.
Grade III injury:
Pain at tear site (partial or complete) with severe
disability;
weakness with inability to actively abduct shoulder. A tear is
possibly
palpable. Later signs of atrophy appear. A supraspinatus tear
is characterized
by a dull ache on rest which is aggravated by abduction. It is
usually sited
in the rotator cuff or common tendinous insertion, rather than
within the
tendon itself. Complete ruptures are rare in comparison to
partial
tears.
The degree of cuff injury is determined by the degree of
pain or weakness
on passive motion or active motion against resistance.
Differentiation must be
made from bicipital tenosynovitis by a positive Yergason's sign
and severe
pain on palpation. Roentgenograms are usually negative; but in
chronic cases,
the anterior edge of the acromion may show spur formation or a
displaced fracture of the tuberosity.
Clinical Features. On examination, the patient's arm is held to the
side and cannot be abducted actively without pain, but nearly a
full range of
passive movement can be obtained with care. The arc of pain is
generally
located between 45° –90
° as
the tuberosity of the humerus passes under the acromion
process. Pain may also
arise during adduction from 120°–170
° with subacromial crepitus, varying
amounts of weakness, and recurrent "bursitis" episodes. When the patient is asked to
raise his arm, the shoulder hunches in support, a short motion may be made,
but the arm quickly collapses to the side in pain.
While passive motions of the shoulder are unrestricted, pain
may be felt
when the humeral head presses under the acromial arch. When the
shoulder is
extended, the front and back of the humerus will be tender but
not as acute as
at the greater tubercle. Extreme tenderness is found where the
cuff inserts
into the tuberosities. A superior subluxation of the humerus is
often
associated. Associated supraspinatus tears (full or partial
rupture) are
characterized by a total loss of initial abduction. The tendon
of the
supraspinatus may be the site of peritendinitis or ectopic
calcification.
Subacute Cases. An important sign arises in 1–2
weeks after injury.
It is an area of thinning or depression at the fossae of the
supraspinatus and
infraspinatus (especially) muscles. If this is the site of
rupture, a "catch"
and clicking sound may be felt and heard at the site during
passive movements
if swelling is minimal.
Arm Drop Test. The patient's arm is held at
90° abduction and
the patient is
asked to hold that position without assistance. If this cannot
be done
actively for a few moments without pain, it indicates a torn
rotator cuff. In
lesser tears, the patient may be able to hold the abduction (a
slight tap on
the forearm will make it drop) and slowly lower it to his side,
but the motion
will not be smooth.
Patient Counsel. Both the amateur and professional
must avoid
stressful activity (eg, golf, tennis, throwing, swimming,
weight lifting, etc)
for several weeks (5–7). Return to full activity is a
conditioning process
that takes time and patience. Explain to the patient that
sensations of joint
noise (eg, snapping, grinding) are normal in this syndrome and
that they will
slowly disappear with treatment. During restoration, emphasis
will be on
prescribed low-weight high repetition exercise. A maintenance
program may be
necessary for 1–2 years to discourage recurring symptoms.
Management. The main early treatment for small tears
is rest and
support, assisted by cryotherapy. Any taping technique should
be designed to
assist the action of the rotator cuff tendons and the joint
capsule. This
requires strapping from just above the elbow to the neck.
Horizontal strips
should be laid "in line" at the base of the neck to cover the
entire shoulder
to stabilize the clavicle and scapula. Early rehabilitation
exercises should
emphasize flexion, extension, and abduction, and adduction in
the late stage.
Significant tears usually require surgery.
Deltoid Contusion and Strain
Because it is such a powerful abductor and used to some
degree in almost
all shoulder motions, acute and chronic disabilities of the
deltoid are
common. Strong contractions are known to produce tearing of its
attachments to
the humerus or clavicle solely from the intrinsic forces
produced.
As with most strains, pain arises with active motion but not
passive
motion. Point tenderness, swelling, and disability arise after
injury. Grade
III strains are not uncommon and require surgical repair if a
distinct rupture
can be palpated.
Anterior
deltoid strain is often seen in football following an attempted
one-arm
tackle. Symptoms arise slowly, often peaking 6-8 hours after
injury. Pain and
weakness increase on forward abduction. Evidence of swelling
and tenderness
appears in the anterior third of the muscle.
Middle
deltoid strain follows forceful abduction against resistance in
the lateral
plane. Symptoms arise slowly. Pain and weakness increase on
lateral abduction.
Evidence of swelling and tenderness appears in the mid-third of
the
muscle.
Posterior deltoid strain is the result of a posteriorly directed strain
such as seen in
swimmers using the butterfly stroke. Symptoms arise slowly.
Pain and weakness
increase on posterior abduction, and evidence of swelling and
tenderness
appears in the posterior third of the muscle.
Management. Cold packs, shoulder-cap strapping, and
an arm sling are
necessary during the first 2 days, followed by moist heat and
passive
manipulation. Active exercises should be conducted during a
warm shower. Full
activity can usually be allowed (with support) in 3–5
days.
A contributing spinal major will likely be found at C5.
Mobilize fixations
found in the shoulder girdle or involved upper extremity. After
relaxing the
tissues and adjusting the subluxated/fixated segments, deep
high-velocity
percussion spondylotherapy can be applied over segments C7–T4
for 3–4
minutes to stimulate pertinent vasomotor activity. Also treat
discovered
trigger points, especially those found in the deltoid,
supraspinatus, scaleni,
pectorals, upper and mid trapezius muscles, coracobrachialis,
infraspinatus,
and biceps. Supplemental processed brain extract and nutrients
B1, C, RNA,
calcium, and magnesium are recommended by nutritional
authorities.
Other helpful forms of treatment include cryotherapy and
massage with
eucalyptus oil in the early stage, followed by spray and
stretch, and tendon
friction massage of involved muscles. Helpful modalities during
rehabilitation
are moist heat or shortwave diathermy, ultrasound for deep heat
and cellular
massage, hot needle-spray showers, interferential therapy,
iontophoresis or
phonophoresis with proteolytic enzymes, local
vibration-percussion,
alternating current, or high-voltage therapy.
Shoulder cap taping or at least an arm sling may be
necessary in the early
stage to rest the joint and enhance healing. After the acute
stage, the
attending physician should demonstrate progressive therapeutic
exercises to
strengthen weakened muscles and/or stretch contractures.
The Bicipital Syndrome
In shoulder injury, after possible dislocation and fracture
have been
eliminated, special attention should be given to the bicipital
muscle because
it is the most powerful flexor of the elbow and a strong
supinator. Within the
shoulder area, proximal strains and tears along the long head's
course within
the bicipital groove to the glenoid rim are frequent.
Acute rupture of the biceps tendon results from forceful
contraction of the
biceps muscle or forceful movement of the arm with the biceps
contracted. The
injury may be avulsion of the tendon from the muscle belly
anywhere along its
course or be pulled free from its glenoid attachment. It is
often a crippling
problem in sports and certain occupations, often accompanied by
tenosynovitis.
The condition is often called "golfer's shoulder" but may occur
in almost any
sport.
Clinical Features. An acute tendon tear may be felt
by the patient
as a "snap," followed by swelling, tenderness, and ecchymosis
over the
bicipital groove and bulging of the biceps near the antecubital
fossa at the
lower half of the humerus. Pain is usually felt in the anterior
shoulder about
2 inches below the humeral head at the site of the thecal
tunnel. If the long
head is torn, the contracted muscle belly moves distally and
bulges even if
the short head is intact. This is an important sign in
differentiating a
proximal biceps problem from other shoulder problems. A hollow
in the upper
humeral area can be both seen and felt. Flexion and supination,
especially
against resistance, increase the bulging at the lower half of
the upper arm.
Strength of forearm supination decreases.
Yergason's Stability Test. The seated patient flexes
the elbow,
pronates his forearm, and attempts elbow flexion, forearm
supination, and
humeral external rotation against the resistance of the
examiner. The doctor
stabilizes the patient's elbow with one hand while offering
resistance to the
patient's distal forearm with his other hand during the
maneuver. Severe pain
in the shoulder is a positive sign of a bicipital tendon
lesion, a tear of the
transverse humeral ligament, or bicipital tendinitis.
Management. Bicipital injury with or without
tenosynovitis requires
careful strain therapy. Rest in an arm sling is necessary until
all symptoms
subside. Graduated exercises can be initiated once the tissues
appear stable
to clinical testing. Impatient pitchers must be advised against
"testing"
throws because progress may be completely destroyed. Steroid
injections are
rarely helpful in the athlete, although frequently employed by
habit by some
medical physicians. Complete tear or rupture requires surgical
approximation.
Loose-Tendon Syndrome. In some chronic bicipital disorders, the
tendon may appear slack and actually glide from side to side on
palpation
during repeated adduction and external rotation. To further
test this
condition, the examiner places the patient's affected forearm
on his knee.
Palpate the bicipital groove with one hand while the other hand
moves the
patient's elbow laterally and anteriorly while the patient
resists the
movement. If the tendon is slack, it will be felt to "jump"
during the motion.
Injury to the transverse humeral ligament is also often
involved.
Bicipital Tendon Dislocation
A stable biceps tendon may be displaced or at least
partially disrupted
from its groove and express symptoms of a bicipital syndrome.
This is due to
rupture or loosening of the transverse ligament which holds it
within the
bicipital groove.
Clinical Features. The disorder is often a
consequence of painful
strains, sprains, capsule tears, and contractures. The
subluxated tendon can
be felt and/or heard to snap as the patient forward flexes and
abducts his
arm, then returns it to its natural position. The patient is
unable to place
the ipsilateral hand on his sacrum. As time passes, motion
restrictions
indicate cuff degeneration. Yergason's test is positive on
resisted external
rotation.
Abbott-Saunders Test. This is a modification of
Yergason's test that
forces the biceps tendon against the lesser tuberosity, which
will stress an
unstable tendon. The arm of the seated patient is brought into
full abduction,
externally rotated, and then lowered to the patient's side. A
"click" felt or
heard, frequently accompanied by pain and a reproduction of
symptoms, is a
sign of subluxation or dislocation of the biceps tendon.
Adjustment Technic. To re-set a displaced bicipital
tendon, stand behind the sitting patient toward the side of involvement. If
the right shoulder is involved, place your left hand over the shoulder
cap and grasp the patient's right wrist with your right hand. The patient's arm
is allowed to hang loose, the elbow should be flexed about 45
°, and the arm
should be
abducted about 45°. Press the thumb of your left hand against the back of
the tendon,
and wrap your fingers under the short head of the biceps and
coracobrachialis
to compress the tendon of the biceps. Advise the patient that
the adjustment
is not painful and to relax the shoulder. With firm contact on
the shoulder
muscles, quickly bring the patient's flexed arm anterior and
medial to
internally rotate the humerus. This usually brings immediate
relief. If not, a
steady lateral (rarely medial) pressure is applied to the
slipped tendon while
the elbow is drawn posterior and held close to the chest until
the limit of
motion is reached. Then with continued pressure on the tendon,
abduct the
elbow, bring it forward, and return it to its original
position. Follow
adjustment with traction strapping, sling, and the usual
treatment of sprain
depending on the history. Efforts to elongate the tendon with
weight exercises
following the acute stage are very helpful. If the ligament is
severely torn,
it will not remain in place; surgery is required for permanent
correction.
Rupture of the Transverse Humeral Ligament
An important function of this ligament is to hold the long
head of the
biceps within its humeral groove. The mechanism of injury is
usually heavy
lifting, "Indian" arm wrestling, or a slip while carrying a
heavy object.
Injury occurs, especially in young adults, when the contracted
biceps meets an
overload.
Clinical Features. Extreme tenderness will be found
at the superior
aspect of the bicipital groove, with some tenderness along the
groove
distally. A slack tendon will be found on palpation of the
upper groove as the
humerus is abducted and internally rotated. A "jumping"
sensation from the
tendon is felt if the transverse ligament is partially torn. A
gliding
sensation is felt if the ligament is completely torn.
Management. Mild partial tears respond to strapping
and sling, and
the usual physiotherapeutic measures for sprain.
Supplementation with 140 mg
of manganese glycerophosphate six times daily speeds healing.
Severe ruptures
require surgical attention.
Brachialis Contusion and Strain
Brachialis strain is common in contact sports and industrial
accidents. The
muscle is continually subjected to bruises in football as it is
exposed to
contusion just below the epaulettes of the shoulder pad.
Clinical Features. In sprain of the proximal
radioulnar joint, there
is often a related injury to the brachialis anticus muscle with
contracture,
or, especially in children, a strip of periosteum may be torn
from the
anterior aspect of the humerus followed by callus formation and
blocked joint
motion. The athlete or well-developed laborer will present a
large muscle
belly on the anterolateral aspect of the upper arm that is
easily found
between the deltoid and the lateral head of the triceps.
Management. Treat for acute sprain with cryotherapy
and pressure,
and follow with typical physiotherapeutic procedures such as
heat and
progressive exercises. See strain/sprain template.
Bicipital Tendinitis
The synovia of the bicipital groove is a common site of
chronic
peritendinous inflammation. It is frequently a complication of
bicipital
rupture (long head) or displacement of the tendon from the
groove.
Clinical Features. Pain is aggravated on abduction
and extension,
and tenderness is localized over the inflamed tendon. Symptoms
mimic
supraspinatus tendinitis, but the pain is referred distally in
the area of the
biceps insertion to the radius. Tenderness is found along the
anterior
shoulder in the bicipital groove. Pain is increased if the
patient abducts,
flexes, and internally rotates the shoulder. When the patient
flexes the arm
and supinates the wrist against resistance, a positive sign is
pain within the
anterior medial upper humerus area.
Lippman's Test. Ask the sitting patient to flex the
elbow on the
involved side and rest the forearm in the lap. Palpate the
tendon of the long
head of the biceps, which is located about 3 inches distal from
the
glenohumeral joint. Attempt to displace the tendon laterally or
medially from
its groove. Pain, reduplication of other symptoms, and a
palpable displacement
of the tendon from its groove signifies tenosynovitis with
instability.
Gilcrest's Sign. Ask the patient to lift a 5-lb
weight (eg,
dumbbell) overhead and then to externally rotate the arm and
slowly lower it
to the lateral horizontal position. Pain and/or reduplication
of symptoms
during this maneuver (with or without tendon displacement from
the groove)
suggests instability of the long head of the biceps and
probable
tenosynovitis.
Management. Check for lower cervical, 1st rib, and
upper thoracic
subluxations. Mobilize any fixations found in the glenohumeral,
acromioclavicular, and sternoclavicular joints, and the
scapulothoracic
"articulation." A trigger point is frequently found just above
or over the
ipsilateral scapula. Supraspinatus and infraspinatus muscle
spasms are often
associated. In the acute stage, cold is indicated.
Interferential therapy or
ultrasound combined with pulsating high-voltage galvanism is
reported to be
especially beneficial in degenerative tendinitis. Apply
strapping for 3–5
days. An arm sling should be used for relieving the tendon of
weight for 7–10
days from injury. Progressive exercises such as circumduction,
pendulum
exercises, two-hand rod swinging, and lateral and front finger
wall-walking
may begin at home as soon as symptoms subside. Treat
essentially as a severe
sprain. Magnesium and vitamin C supplementation may assist
healing. The
beneficial use of acupuncture and DMSO has been supported.
Contributing spinal majors will likely be found at C5–C6,
and any
fixations found should be mobilized -especially those in the
shoulder girdle,
involved upper extremity, upper thoracics, ribs, and scapula.
After relaxing
the tissues and adjusting the subluxated/fixated segments, it's
helpful to
apply deep high-velocity percussion spondylotherapy over
segments C7–T4 for
3–4 minutes.
Other helpful forms of treatment include massage with
eucalyptus oil, in
the early stage, and tendon friction massage of involved
muscles. Helpful
modalities during rehabilitation are moist heat or shortwave
diathermy,
ultrasound for heat and massage at the cellular level, hot
needle-spray
showers, iontophoresis or phonophoresis with proteolytic
enzymes, local
vibration-percussion, alternating current, or high-voltage
therapy. Taping or
at least an arm sling may be necessary in the early stage to
rest the joint
and enhance healing. After the acute stage, demonstrate
progressive
therapeutic exercises to strengthen weakened muscles and/or
stretch
contractures. Supplemental processed brain extract and
nutrients B1, C, RNA,
calcium, and magnesium are recommended by several authorities.
Counsel the
patient to avoid appropriate antivitamin and antimineral
factors.
Supraspinatus Tendinitis
Supraspinatus tendinitis is often a part of rotator cuff
injury and/or a
complication of supraspinatus strain. The typical history is a
complaint of
shoulder ache occurring on rest and aggravated by abduction. It
is painful to
sleep on the affected side. The pain may be referred distally
as far as the
deltoid insertion. A differentiating feature is the pain is
restricted to
movement only within a certain point of the arc (painful arc
syndrome) because
the acromion process affects the tendon area only during part
of its
excursion. Point tenderness will be found over the site of
inflammation. The stages of supraspinatus tendinitis are shown in Table 5.
Table 5. The Stages of Supraspinatus Tendinitis
Stage |
Pathophysiologic Picture |
Symptoms |
1
|
Hyaline degeneration of the
tendon's collagen,
with calcific deposits beginning to form. |
Ache, muscle
soreness. |
2
|
Hyperemia develops and calcium
deposits begin
to enlarge. |
Pain on motion. |
3
|
Tendon engorgement and
swelling.
|
Pain on abduction near 70 degrees
Painful arc syndrome. |
4
|
Inflammation of surrounding
bursa.
|
Same as 3 but greater pain with
less
motion. |
5
|
Rupture of tendon and bursal
sac.
|
Same as above. |
6
|
Adhesive capsulitis, with
severely limited
range of motion. |
Frozen
shoulder. |
Inflamed peritendinous supraspinatus tissues are frequently a part of
subdeltoid or subacromial bursitis. Also note that the area of the
supraspinatus tendon is a common site of referred pain from the
gallbladder, right diaphragm (eg, hiatal hernia), and heart.
Supraspinatus Press Test. With the patient in the
relaxed seated
position, apply strong thumb pressure directed toward the
midline in the soft
tissues superior to the midpoint of the scapular spine. The
production of pain
signifies an inflamed supraspinatus muscle (eg, strain,
rupture,
tendinitis).
Shoulder Abduction Stress Test. Ask the patient to
abduct the arm
laterally to the horizontal position with the elbow extended
while you apply
resistance. If this causes pain in the area of the insertion of
the
supraspinatus tendon, acute or degenerative shoulder tendinitis
is
suggested.
Codman's Sign. This is a variation of the shoulder
abduction stress
test and the arm drop test. If the patient's arm can be
passively abducted
laterally about 100° without pain, remove support so that the position is
held actively by
the patient. This produces sudden deltoid contraction. If a
rupture of the
supraspinatus tendon or strain of the rotator cuff exists, the
pain elicited
will cause the patient to hunch the shoulder and lower the
arm.
Impingement Syndrome Test. Place the patient supine
with the arms
resting loosely at the sides. The elbow on the involved side is
then flexed to
a right angle and the arm is rotated internally so that it
rests comfortably
on the patient's upper abdomen. Place one hand on the patient's
shoulder and
your other hand on the patient's elbow. Apply a compressive
force to push the
humerus against the inferior aspect of the acromion process and
the
glenohumeral fossa. Pain and/or a reduplication of symptoms
indicates an
impingement syndrome of the supraspinatus and/or bicipital
tendon. This is
sometimes called the locking position test.
Management Considerations. Treatment is similar to
that for
bicipital tendinitis. Initial cold followed by ultrasound,
spray-stretch
trigger point therapy, interferential therapy, transverse
muscle massage,
meridian therapy, and neurolymphatic reflexes have all been
reported to
relieve the associated pain. During rehabilitation, graded
active and passive
shoulder exercises, vitamin C, and proteolytic enzymes are
helpful.
General Rotator Cuff Tendinitis
When tendinitis is diffuse throughout the rotator cuff, the
pain is poorly
defined in the area of deltoid insertion and often more
prominent at night. As
in a typical rotator cuff lesion, a painful arc appears on
abduction between
60° and
120°. The tendons
and muscles of the rotator cuff are tender throughout.
Pitching and Related Injuries
Shoulder girdle muscle forces must act through four
relatively unique
joints (glenohumeral, scapulothoracic, acromioclavicular,
sternoclavicular) to
achieve the normally graceful coordination required of shoulder
motion.
Because of this, alterations of the throwing mechanism about
the shoulder
produce a clinical picture that can be difficult to diagnosis
and effectively
treat.
It has been estimated that two of every three professional
baseball pitchers have an elbow abnormality. Arm and forearm hypertrophy
is typical.
Hypertrophy of the humerus is invariably demonstrated in
roentgenography, and
traction spurs and loose bodies of bone within the elbow joint
are frequent.
Most loose bodies are found in the olecranon fossa, near the
epicondyle, and
near the tip of the coronoid process -where ulnar nerve
irritation is likely.
In 50% of professional pitchers, flexion contracture of the
elbow is present.
In addition to pitching, outfield throwing and batting mishaps
account for
similar sports injuries.
Avulsion and displacement of the medial epicondyle may
complicate
supracondylar fracture, or they may occur in association with
soft-tissue
trauma alone. Biceps spasm after 5 minutes of pitching strongly
suggests an
avulsion. Finger numbness following pitching suggests a
scalenus anticus
syndrome from a cervical or 1st rib condition. Avulsion and
displacement of
the epicondyle are common between 7 and 17 years of age and
vary from slight
epicondylar separation to complete avulsion and displacement
into the elbow
joint.
Predisposing Mechanics of the Arm During Elevation. The position of the clavicle and the suspension of the upper
extremity are
determined by the integrity of the capsule of the
sternoclavicular joint and
its associated ligaments, while the vertical stability of the
upper extremity
at the glenohumeral joint is determined by the strength of the
capsule's
superior aspect and the coracohumeral ligament. During the
first half of arm
abduction in a pitch, all components of the rotator cuff are
active and, along
with the deltoid, produce compressive and shear forces at the
surface of the
glenoid cavity. These forces peak at 90
° elevation. At
150° elevation,
they are usually absent. During the last phase of elevation,
EMG studies show
the infraspinatus and teres minor tendons maintain their high
level of
activity to provide necessary external rotation for complete
elevation of the
arm.
Initiating Mechanisms in Throwing. The act of throwing includes an initially smooth sequence of
elevation,
abduction, and external rotation of the upper arm that quickly
leads to a
sudden, forceful forward flexion, anterior abduction, and
internal rotation of
the shoulder associated with elbow, wrist, and finger
extension. Crucial to
the initial motion is the integrity of the rotator cuff. The
cuff muscles are
well beneath overlying muscles, thus difficult to palpate and
differentiate.
Because the path of the ulnar nerve is quite close to the
medial epicondyle,
strenuous pitching can easily result in traumatic ulnar
neuropathy. Cases
often present with paresthesias associated with fragmentation
and partial
avulsion of the medial epicondyle.
The biceps tendon whips against the outer edge of its groove
when "round
house" curves are thrown, initiating an inflammation and
degenerative process
("glass arm" syndrome). The injury is essentially a localized
tendinitis from
intrinsic overload particularly at the subscapularis insertion
on the lesser
tuberosity. This produces disability on elevation and external
rotation of the
arm in the early stages of throwing. A cause is found in
overstretch of the
subscapularis at the end of "draw back," which is instantly
interrupted by a
sudden force on the tendon as the throw is made. Examination
reveals limited
motion and pain on abduction and external rotation of the
shoulder. Pain is
increased when active internal rotation is resisted, and
tenderness will be
found over the lesser tuberosity.
For purposes of analysis, Tullos/King divide the throwing
mechanism into
three separate and independent stages, each of which is
associated with
specific shoulder injuries:
The cocking phase. During wind-up, the shoulder is
brought into
extreme external rotation, abduction, and extension. The
biceps, triceps, and
internal and external rotators are highly tensed. Thus, a
professional
baseball pitcher invariably exhibits abnormal external humeral
rotation and
subnormal internal rotation. Overstress makes the proximal arm
vulnerable to
biceps tendinitis, triceps tendinitis, and humeral
subluxation.
The acceleration phase. The actual throwing phase
is a two-stage
process: (a) With the forearm and hand stationary, the shoulder
is brought
forward, the elbow is put in extreme valgus strain as the
muscular forces
multiply on the shaft of the humerus, and the elbow is
stabilized by the
flexors of the forearm. (b) In the second stage, the forearm is
rapidly
whipped forward by internal shoulder rotation produced by
severe contraction
of the pectoralis major and latissimus dorsi. This stage ends
when the hand is
near ear level and the ball is released. Overstress makes the
shoulder complex
vulnerable to pectoralis and latissimus tendinitis, along with
the effects of
the mechanical forces on the humerus.
The follow-through phase. The last phase begins as
the ball is
released near head level and ends when the pitch is completed.
Its major
function is involved with deceleration of the arm and forearm
and, usually,
some type of ball rotation. Great stress is applied at that
time to the
glenohumeral joint and its adjacent tissues. See Table 6.
Table 6. Features of Typical Throwing Injuries
Throwing Phase |
Especially Vulnerable Structure |
Picture |
Cocking |
Biceps, long head |
Tendinitis; localized pain in
the anterior
shoulder and bicipital groove, aggravated by resisted forearm
supination. |
|
Triceps, long head |
Tendinitis; pain in the
posterior aspect of
the shoulder, which radiates to axilla or deltoid
area. |
|
Rotator cuff |
Impingement syndrome during abduction and external rotation involving entrapment against either the
acromion or coracoacromial ligament. |
|
Humerus |
Abduction subluxation during internal or external rotation. |
|
Axillary artery |
Occlusion by the pectoralis minor when the arm is brought into hyperabduction, extension, and extreme external
humeral rotation, leading to intimal damage and subsequent thrombosis.
|
|
Subdeltoid bursa |
Bursitis and the development of fibrous adhesions. |
Acceleration |
Pectoralis major |
Strain, tendinitis, rupture. |
|
Latissimus dorsi |
Strain, tendinitis, rupture. |
|
Humerus |
Fatigue fractures, coracoid process avulsion, epiphysitis in the young |
Follow-through |
Glenohumeral joint |
Posterior capsulitis or tear;
traction
spurs. |
|
Quadrilateral area |
Strain, myositis ossificans;
occlusion of the
posterior humeral circumflex vessel. |
Triceps Brachii Calcification
Repetitive stretching of the posterior elements of the shoulder in baseball
pitchers frequently causes an inflammation of the posterior capsule tissues of
the shoulder. This can result in an osteotendinous calcification at the
infraglenoid area where the long head of the triceps originates. Once
calcification forms, the pitching follow-through is very painful. Management
is similar to that of supraspinatus calcification.
Roentgenography.
Throwing injuries can be complex -acute trauma inserted
within a framework
of old scars. Anterior abnormalities may be found with the long
head of the
biceps tendon within the intertuberous groove or the
supraspinatus. In rupture
of the biceps brachii, a mass of soft tissue may appear at the
anterior or
anterolateral aspect of the mid or lower humerus. The long head
of the triceps
originating from the scapula at the infraglenoid tubercle may
present an
avulsion throwing injury detectable on roentgenography.
Less common throwing injuries include avascular necrosis of
the head of the
radius; thrombosis of the axillary artery; stress fracture of
the olecranon
process, the first rib (usually the contralateral midrib), and
the front tips
of the lower three ribs; and humeral fracture. Fracture of the
humerus, a
spiral fracture of the mid or lower third of the shaft
(sometimes comminuted),
appears to be associated with the sudden stopping of the
throwing movement by
the deltoid. While it is most common in the unconditioned
baseball player, it
is sometimes seen in softball, javelin, shot put, and
handball.
Fracture of the proximal humeral epiphyseal cartilage is
sometimes seen in
adolescent baseball pitchers. Radiographs may show irregular
ossification of
the capitellum, abnormalities of the medial epicondyle,
accelerated closure of
the epiphyseal cartilage, or fragmentation of the medial
epicondylar epiphysis
from avulsion injury.
In heavy throwing sports such as shot put, hammer throw, and
javelin, tears
of the interscapular, scapulocostal, and rotator cuff muscles
are often seen.
In javelin activity, overstress may lead to elbow abnormalities
such as bony-
surface irregularities, soft-tissue calcification,
para-articular
ossification, capitellar erosion, rupture of the collateral
ligaments, and
intra-articular loose bodies at the lateral epicondyle and
olecranon area.
Bursal or tendon ossification are best shown in coned-down
views taken during
external and internal rotation.
ARTICULAR THERAPY
Most subluxations in the elbow area will offer dramatic
relief on
correction. Generally, the adjustment is made with a quick
short thrust to
minimize the pain (and time) of relocation. It is essential
that the patient's
muscles be relaxed or correction will be inhibited and
extremely painful.
Naturally, quick thrusts are contraindicated in arthritic and
sclerotic
conditions or if adhesions are advanced.
Techniques to Release Humeroulnar Hypomobility
Internal and external rotation of the head of the radius on
the head of the ulna and capitulum of the humerus and internal and external
rotation of the olecranon of the ulna on the trochlea of the humerus are
spinning actions that are readily reflected in standard procedures for evaluating
passive ranges of motion.
Freeing Restricted Distraction. The humeroulnar joint can be jammed
by a fall on the outstretched hand or simply by severe para-articular muscle
spasm. It is sometimes seen in patients whose occupations require repeated
violent pushes with the heel of the extended hand (eg, football linemen,
carpenters). Almost any type of axial traction will help to relieve this
condition. A common procedure is to first place the patient supine, and sit at
the side of the table on the involved side (obliquely facing the patient).
Abduct the patient's shoulder to 90°, flex the elbow to 90°, and pronate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the
humerus, grasp the under surface of the proximal forearm with
both hands, slightly abduct the forearm so that more pressure will be
applied to the ulnar than the radius, and apply axial traction toward your body.
Slowly stretch to patient tolerance, hold, and gradually release. Repeat several
times.
Freeing Restricted Medial-Lateral Tilt. Place the patient supine,
and sit or stand at the side of the table on the involved side (obliquely
facing the patient). The patient's involved limb should be resting loosely at
the side, near the body, with the elbow extended and the wrist supinated. This
is a two-phase procedure:
The first maneuver is to stabilize the patient's distal forearm with your
medial hand and grasp the lateral surface of the patient's proximal ulnar
with your active (lateral) hand. This position allows you to apply a horizontal
shearing force across the humeroulnar joint, from the lateral to the medial.
Slowly apply force to patient tolerance, hold, and gradually release. Repeat
several times.
The second maneuver is just the reverse. Stabilize the patient's distal
forearm with your lateral hand and grasp the medial surface of the patient's
proximal ulnar with your active (medial) hand. This position allows you to apply a
horizontal shearing force across the humeroulnar joint, from the medial to
the lateral. Slowly apply force to patient tolerance, hold, and gradually
release. Repeat several times.
Techniques to Release Proximal Radioulnar Hypomobility
Freeing Restricted Distraction. This method is a variation on that
for a jammed humeroulnar joint. Place the patient supine, and sit at the side
of the table on the involved side (obliquely facing the patient). Abduct the
patient's shoulder to 90°, flex the elbow to 90°, and supinate the forearm. Place the medial side of your knee in the patient's antecubital fossa to stabilize the
humerus, grasp the upper surface of the proximal forearm with both hands, slightly adduct the
forearm so that more pressure will be applied to the radius than the ulna, and
apply axial traction toward your body. Slowly stretch to patient tolerance,
hold, and gradually release. Repeat several times.
Freeing Restricted A-P Glide. Place the patient supine, sit at the
side of the table on the involved side, and face the head of the table. Abduct
the patient's shoulder to 90°, flex the elbow to 90°, supinate the
forearm, and lift the arm so that the patient's hand points toward the
ceiling. Place your thumb (lateral side) on the head of the radius (which serves as
a fulcrum) and cup the patient's elbow with the palm of your stabilizing hand. With your
active hand (medial), move the patient's distal forearm toward the shoulder
(elbow flexion). Once resistance is felt, slowly apply force to patient
tolerance and release. This is essentially a rocking-type motion. Repeat
several times. The patient must completely relax the arm as any contraction of
the patient's biceps against your thumb produces pain.
Freeing Restricted Pronation (Internal Rotation). Place the patient
supine, and sit at the side of the table on the involved side (obliquely
facing the patient). Abduct the patient's shoulder to 90°, flex the
elbow to 90°, and supinate the forearm. Place your medial knee in the patient's
antecubital fossa to stabilize the humerus, grasp under the patient's distal forearm with both
hands, pronate the patient's forearm to tolerance by rotating your hands, and
apply axial traction toward your body. Slowly stretch to patient tolerance,
hold, and gradually release. Repeat several times, progressively increasing
the degree of pronation possible.
Posterior-Medial Radial Head Subluxation-Fixation Release
This "pulled elbow" injury results from the radial head being jerked from
under the annular (orbicular) ligament, manifesting pain and tenderness in the
area of the radial head. A "snap" is usually heard and felt at the time of
trauma. The injury was once called "nursemaid's elbow" because it was
frequently found after young children were quickly lifted up by
the wrist or
hand when the child's elbow was extended and the forearm was
pronated. This
classic form rarely occurs after the age of 6 years.
Significant Features. Motion is severely limited in
pronation and
supination, but flexion and extension are normal. The arm is
held motionless
at the side in slight flexion and pronation, and pain is fairly
localized at
the elbow. X-ray films are usually negative. This type of subluxation is
commonly associated with tennis elbow, lateral elbow pain,
restricted anterolateral radial-head motion, and wrist trauma.
Adjustment Technic. When adjustment is indicated,
hold the patient's affected elbow with one hand so that your thumb rests on the
back of the head
of the involved radius. With your other hand, grasp the
patient's hand and
move the forearm into a position of slight flexion at the
elbow, full forearm
pronation, and full flexion at the wrist. The adjustment
(Mills' movement)
consists of fully extending the patient's elbow while
maintaining pronation
and flexion of the wrist. The maneuver is made gently but quite
sharply; thus,
it is essential that the patient's elbow muscles are relaxed.
The maneuver
does not usually cause pain in a normal elbow, but there is
sharp pain quickly
followed by relief when a "tennis elbow" is freed. After
correcting
malposition, treat the condition as a severe sprain and offer
rest in a
flexion sling for several days.
Alternative Technic. An alternative procedure to
re-establish a
slipped radial head is to grasp the hand of the sitting patient
and extend the
patient's wrist. Support the elbow firmly with your contact
hand. Flex the
patient's elbow to a right angle. Maintain axial compression
along the radius,
and firmly alternate forearm supination and pronation in a
"screwing" manner
until the head of the radius slips back into its normal seat.
The thumb of
your hand holding the patient's elbow can be used to apply
manual pressure
against the head of the radius. A click can usually be felt and heard on
replacement, which is followed by immediate relief.
Anterior Olecranon Subluxation-Fixation Release
Subluxation of the olecranon anteriorly is often found associated with
hyperextension sprains and restricted posterior olecranon motion.
Adjustment Technic. Stand on the involved side and face the sitting
patient. Slightly abduct the patient's arm, and flex the elbow.
Grasp your
medial (active) hand around the patient's distal forearm. Cup
the medial
aspect of your lateral (stabilizing) hand deep within the
antecubital fossa,
and wrap your fingers around the proximal aspect of the
patient's forearm so
that your thumb points upward. Make a short brisk thrust with
your contact
hand toward the patient's shoulder, using your stabilizing hand
as a fulcrum
to bring the olecranon out of its depressed position.
Posterior Olecranon Subluxation-Fixation Release. This type of subluxation is associated with elbow or wrist
trauma,
epicondyle and bursa tenderness, triceps weakness, and
restricted anterior
olecranon movement.
Adjustment Technic. Stand on the affected side of the
supine patient
so that you face cephalad. Extend the patient's elbow, and
slightly externally
rotate the patient's forearm. Cup the patient's elbow with your
medial hand,
and place your thumb against the epicondyles for leverage. With
your lateral
hand, grasp the patient's lower forearm. A short, brisk, thrust
(downward) is
made toward the tabletop on the distal forearm as your medial
hand applies
mild counterpressure upward.
Superior Olecranon Subluxation-Fixation Release
Subluxation of the ulna superiorly is related to elbow or wrist trauma. It
is often a consequence of a falling person protecting the head by an
outstretched hand, resulting in the proximal aspect of the ulna
being jammed
against the distal aspect of the humerus.
Adjustment Technic. The patient sits next to a narrow
table and is instructed to lean forward to slightly forward-abduct the arm
and extend the forearm horizontal to the table's surface. The elbow should
never be fully extended as this subjects the tip of the olecranon process to
injury. Stand on
the opposite side of the table and face the patient. With your
contact hand,
grasp the patient's lower forearm and slightly rotate it
externally. Place the
web of your other hand around the patient's lower anterior
humerus and extend
your elbow to stabilize the patient's arm. Apply traction with
your contact
hand, and then make a short quick pull to bring the ulna
inferiorly (toward
your body).
Alternative Technic. Stand on the affected side of the supine
patient. Abduct the patient's arm, and flex the elbow. Grasp the patient's
lower forearm with both hands, with emphasis on the ulnar aspect, and place
your knee in the patient's antecubital fossa for stabilization.
Traction is
applied, followed by a strong upward pull.
Lateral Olecranon Subluxation-Fixation
This type of subluxation is often related to elbow or wrist trauma that is
followed by lateral elbow pain, triceps weakness, a decreased distance between
the olecranon and the lateral epicondyle, and/or restricted olecranon motion.
Adjustment Technic. Face cephalad on the affected
side of the prone
patient. Abduct the patient's involved arm, extend the elbow,
and internally
rotate the extremity. Apply a soft pisiform contact with your
medial hand on
the lateral aspect of the patient's olecranon, and stabilize
the patient's
lower forearm with your other hand. A short brisk thrust is
made caudally to
shift the olecranon medially as your stabilizing hand pronates
the lower
forearm.
Medial Olecranon Subluxation-Fixation Release
Subluxation of the olecranon medially is often seen in association with
wrist or elbow trauma that is followed by ulna nerve paresthesias, medial
elbow pain, triceps weakness, a decreased distance between the
olecranon and
the medial epicondyle, and/or restricted lateral olecranon
joint motion.
Adjustment Technic. Face cephalad on the affected
side of the supine
patient. The patient's arm is slightly abducted with the elbow
extended. The
heel of your medial contact hand should be placed over the
medial aspect of
the patient's olecranon, while your stabilizing hand grasps the
patient's
forearm. The patient's involved elbow is then gently brought
into full
extension. A short thrust is then made from the medial to the
lateral with
your contact hand while your stabilizing hand applies lateral
to medial
pressure.
Alternative Technic. The positions for both doctor
and patient are
similar to those described above, but the doctor stands more
parallel to the
patient's arm when applying this technic. Abduct the patient's
arm so that the
arm is in front of you, pronate the patient's wrist, and extend
the elbow.
Firmly grasp the patient's olecranon with the 1st and 2nd
finger of your
contact hand, and stabilize the patient's distal forearm with
your other hand.
A short brisk pronating medial to lateral pull and full elbow
extension is
then made with your contact hand as your stabilizing hand tends
to supinate
the patient's forearm.
Reducing and Managing Simple Dislocations
Reduction of uncomplicated posterior elbow dislocations can
usually be
performed without anesthesia if they are presented soon after
they occur and
spasm has not become severe.
Classic Reduction Technic. All that might be
necessary is gentle
steady longitudinal traction on the wrist of the supine
patient, with
countertraction on the shoulder. This countertraction is easily
accomplished
by a long towel looped around and under the patient's arm pit, with the loose
ends of the towel held cephalad by an assistant while the doctor performs the
reduction. Slight manual extension pressure may be necessary to unlock the
olecranon during wrist traction.
Parvin's Method. An alternative procedure is conducted with the patient prone. The involved limb is allowed to hang so that the fingers point toward the floor. A 5-lb weight can be applied to the patient's padded wrist by tape or manual downward traction can be used. After several minutes, when any spasm has subsided, gently place your medial hand in the
involved antecubital fossa and grasp the patient's wrist with your lateral hand. Gently lift the patient's wrist upward to produce elbow flexion. This simple maneuver will often reduce the dislocation.
General Management Direction. After reduction, the elbow should be
immobilized for 3 weeks in a molded posterior plastic splint at 90° flexion. This
time should be sufficient for adequate ligamentous and capsular healing to take place before
mild unsupported activity is resumed. Gentle passive stretching and active range-of-motion exercises should be initiated after the splint is removed. Motion should never be forced because it will only lead to greater swelling and joint stiffness. Moist heat can be applied by the patient at home at least once daily for 20–30 minutes and continued until residual stiffness resolves. It may take several months for full recovery to occur, and a minor nondisability stiffness may remain.
ELBOW TRAUMA
Common Elbow Contusions and Strains
There may be an injury to the upper radioulnar articulation
by sudden overpronation or oversupination that is followed by pain over
the articulation
with limitation of rotation. Normally, the olecranon bursa is
not palpable; in
bursitis, it will feel boggy and thick. Trigger points are
usually found just
below the horizontal midline of the antecubital fossa over the
proximal radius
and ulna. When the joint proper is involved, motion is limited
chiefly in
extension and may persist indefinitely. An associated injury of
the brachialis
anticus muscle with later contracture is common. In children,
it has been
previously described that a strip of periosteum may be torn
from the anterior
humerus, followed by bone formation and blocked joint motion.
Local myositis
ossificans may also develop in the tendon of the brachialis
anticus. Some
cases will be complicated by ulnar neurapraxia.
Management. During the early stage, rest in a sling
for 3–4 days is
required for the acute symptoms to subside. Thereafter,
physical therapies
with passive and progressive active exercises are recommended.
Diathermy is
especially helpful in absorption of joint effusion. Rarely is
joint aspiration
necessary.
Distal Bicipital Strain
Strains of the bicipital attachment to the ulna are not
common. They occur
in elbow hyperextension injuries and in overenthusiastic
weight-lifting
efforts. The course of the tendon is tender on palpation.
Management consists
of rest in a sling for a few days along with standard sprain
therapy.
Olecranon Bursitis
Smooth mobility of the elbow is provided by the olecranon
bursa. Besides a
direct blow, this fluid-filled pouch is exposed to injury when
the elbow is
repeatedly pressed against a firm surface. Excessive intrinsic
forces also may
cause inflammation, synovial thickening, and the formation of
excessive fluid.
Repetitive friction of extensor tendons may initiate the
inflammatory process.
Thus, olecranon bursitis is often a part of the clinical
picture of
epicondylitis (medial or lateral), forearm strains, and
traumatic inflammation
of the elbow.
Posterior elbow swelling, pain, and tenderness exhibit.
Active flexion and
extension are restricted. Most cases of olecranon bursitis will
heal
spontaneously in a few days once the irritating factor is
removed, but proper
clinical management speeds the process and prevents secondary
infection from
converting the inflammation into an abscess.
Diagnosis. A typical protocol is to motion palpate
the elbow and the
spine and relate findings with the patient's complaints.
Confirm findings with
appropriate orthopedic and neurologic tests. Check pertinent
tendon and
superficial reflexes, and grade the reaction. Check involved
joint motion and
muscle strength against resistance, and grade resistance
strength. Interpret
resisted motion signs.
Management. Treat with cold. Check for elbow motion
restrictions and
gently mobilize fixations if such maneuvers are not too
painful. Follow with
compression and elevation for 1 or 2 days. Contributing spinal
majors will
likely be found at C5–T1. Also release fixations found at the
nonacute elbow,
shoulder, or wrist. After relaxing the tissues and adjusting
the
subluxated/fixated segments, it helps to apply deep
high-velocity percussion
spondylotherapy over segments C7–T4 for 3–4 minutes.
The adjunctive therapy commonly recommended includes
interferential
therapy, transverse friction massage at the periphery of the
elbow area,
acupuncture, and surge stimulation to reduce the swelling.
Refer for
aspiration if necessary, but crisscross taping in elbow
extension usually
brings quick relief after primary therapy has been applied. In
mild moderate
cases, an elastic ankle support can be worn with the heel
opening placed on
the antecubital fossa.
Recurrent swelling is common, and protective elbow padding
is necessary
long after symptoms subside. Rehabilitative procedures should
be designed to
improve the strength of wrist extensors, flexors, abductors,
and adductors.
Stressful elbow flexion and extension should be avoided.
Monitor carefully for
possible signs of secondary cellulitis.
Discovered treat trigger points should be treated,
especially those found
in the triceps, extensors, and serratus posterior muscles.
Supplemental
nutrients B1, B6, C, niacin, P, manganese, and zinc are
recommended by several
authorities. Counsel the patient to avoid appropriate
antivitamin and
antimineral factors.
Other helpful forms of treatment include contrast baths
during the acute
stage, iontophoresis with proteolytic enzymes or hyaluronidase,
alternating
current for passive exercise and pain control, or high-voltage
therapy. When
swelling and tenderness have disappeared, the attending doctor
should
demonstrate therapeutic exercises to strengthen weak muscles
and/or stretch
contractures.
Traumatic Arthritis
Injury to the proximal radioulnar articulation occurs by
sudden
overpronation or excessive supination. The injury is followed
by joint pain
and restricted rotation. The clinical picture resembles a
combination of
tennis elbow and forearm strain, but take care not to overlook
the possibility
of a spontaneously reduced dislocation of the head of the
radius.
Forced movement beyond the normal range of joint motion in
any position may
produce a rupture in the capsule and its supporting ligaments.
If this occurs,
the capsule will be tender and likely distended with blood.
Movement in the
direction of injury will aggravate the pain, and motion will be
voluntarily
restricted.
Management. Associated spinal majors will likely be
found at C6–C7.
Also release fixations found at the nonacute elbow, shoulder,
or wrist. After
relaxing the tissues and adjusting the subluxated/fixated
segments, it's
beneficial to apply deep high-velocity percussion
spondylotherapy over
segments C7–T4 for 3–4 minutes. Because of its poor
vascularity, never apply
ice massage to the elbow. Treat trigger points discovered,
especially those in
the anconeus, triceps, brachialis, brachioradialis, and
extensor and pronator
muscles. Supplemental nutrients B1, B6, C, niacin, P, copper,
manganese, zinc,
and rutin are recommended by authorities. Counsel the patient
to avoid
appropriate antivitamin and antimineral factors.
Other helpful forms of treatment include rest, temporary
support, contrast
baths, comfrey ointment, and spray-and-stretch therapy during
the acute stage,
followed by moist heat or shortwave diathermy, ultrasound,
interferential
therapy, iontophoresis with hydrocortisone, alternating current
for passive
exercise and pain control, high-voltage therapy, or tendon
friction massage of
involved muscles. When pain and tenderness subside, the
attending physician
should demonstrate and prescribe therapeutic exercises to
strengthen weak
muscles and/or stretch contractures.
Common Elbow Sprains
Forced motion beyond full extension, abduction, or adduction
ruptures the
capsular apparatus and its reinforcing ligaments from their
attachment to the
humerus, radius, and ulna. The capsule is tender and frequently
distended with
blood. Movement in the direction of injury aggravates the pain,
and there is
some restriction at extreme ranges.
Articular or extra-articular injuries to the elbow without
fracture are not
uncommon and are peculiarly resistant to treatment. There may
be a primary or
secondary injury to the upper radioulnar articulation by sudden
overpronation
or oversupination, followed by pain over the articulation and
limited
rotation. Overlooking radial-head dislocation is a common
orthopedic
error.
Biomechanics Involved. The proximal forearm, elbow
joint, and distal
humerus are frequently injured when the mechanism of trauma is
a fall on the
outstretched hand. When the elbow is extended, the upper
extremity acts as a
mechanical brace that transmits force from the point of hand
contact to the
neck and trunk. An axial compression combined with a bending
motion to sharply
dorsiflex the wrist produces a force couple that compresses the
wrist dorsally
and stretches the ventral soft tissues. If a portion of this
strut is weakened
by age, for instance, where bone is weaker than the involved
ligaments and
tendons, this weakness determines the type of injury. Thus,
falls on the
outstretched hand usually involve the wrist of the elderly and
the distal
humerus of the young.
When a fall is made on the outstretched hand, several
mechanisms are
effected:
(1) axial compression forces throughout the limb;
(2)
bending
moments at the wrist, elbow, and shoulder joints;
(3) torsion
about the long
axis of the limb; and
(4) violent lateral flexion of the
cervical spine. The
moment of axial loading (impact force X lever arm) must be resisted by the elbow
tissues to
prevent failure. If the elbow holds, the force not absorbed is
transmitted to
the shoulder.
Common Types of Elbow Sprain
Hyperextension Sprain. Severe hyperextension sprain
strongly
resembles posterior dislocation of the elbow. Swelling and
tenderness will be
found at the joint capsule (posteriorly), bicipital tendon,
olecranon fossa,
lateral and medial collateral ligaments, and attachments of the
flexors at the
medial condyle. Pain is relieved by flexion and increased on
attempted
extension. If the joint proper is involved, extension is
chiefly limited, and
it may persist for weeks or years.
Hyperabduction Sprain. Tenderness is found below the
medial
epicondyle, suggesting sprain of the ulnar collateral ligament.
Pain is
increased by forcing the elbow into valgus stress.
Hyperadduction Sprain. Tenderness is located below
the lateral
epicondyle, indicating sprain of the radial collateral
ligament. Pain is
increased by forcing the elbow into varus stress.
Ligament Stability Tests
Elbow Abduction-Adduction Stress Test. To roughly
judge the
stability of the medial and lateral collateral ligaments of the
elbow, hold
the patient's wrist with one hand and cup your stabilizing hand
under the
patient's distal humerus. After the patient has slightly flexed
the elbow,
(1)
push medially with your active hand and laterally with your
stabilizing hand,
then
(2) push laterally with your active hand and medially with
your
stabilizing hand. With the fingers of your stabilizing hand,
note any joint
gapping felt during either the valgus or varus maneuver.
Painful instability
indicates torn ligaments.
Elbow Extension-Flexion Stress Test. Passively extend
and flex the
patient's elbow. Painful instability suggests sprain or
destructive joint
disease, while discomfort with limited motion suggests
contractures or
degenerative arthritis.
Forearm Pronation-Supination Stress Test. Passively
pronate and
supinate the patient's forearm. Painful instability suggests
sprain or
destructive joint pathology, while discomfort with limited
motion points to
contractures or degenerative arthritis.
Tennis Elbow (Lateral Epicondylitis)
"Tennis elbow" is a vague term. It generally refers to any
painful elbow
condition of traumatic origins (not limited to tennis)
occurring about the
external epicondyle of the humerus, especially the tendinous
origins of the
forearm extensors. The syndrome incorporates a group of
associated conditions,
especially epicondylitis or radiohumeral bursitis. It is
usually caused by
repeated violent elbow extension combined with sharp twisting
supination or
pronation of the wrist against resistance thus its association
with tennis.
The result is severe contraction stress of the
extensor-supinator muscle
insertions of the forearm. The supinator has its tendinous
origin just behind
the common extensor tendon.
The overt clinical picture is synovitis, subperiosteal
hematoma,
fibrositis, and/or partial rupture of the fibrous origin of
muscles and
ligaments at the affected epicondyle, with some associated
periostitis. Radial
nerve entrapment may be involved. If the medial epicondyle is
sore, the
flexor-pronator muscles and medial ligaments are involved
(golfer's elbow).
However, the lateral epicondyle area is affected seven times
more often than
the medial epicondyle.
Clinical Features. Hasemeir describes the typical
symptomatic
picture as pain over the outer or inner side of the elbow,
distal to the
affected epicondyle. The pain may be severe and radiate when
the patient
extends his arm. The pain is usually sharp and lancinating on
exertion, but it
may be dull, aching, and constant. Squeezing an object with the
fingertips is
painful (writer's cramp). Tenderness, abnormal warmth, and
swelling are found
over the affected epicondyle, and limited passive movement on
extension can
often be found. Grip strength as well as supination and
pronation strength are
affected.
In medial epicondylitis (golfer's elbow) and lateral
epicondylitis (tennis
elbow), Palo points out that simple palpation over the involved
epicondyle
will elicit a painful response from the patient. The definitive
tests involve
stretching or stressing the involved joint.
Palo reinforces Southmayd's reason tennis elbow is slow to
heal. It has to
do with the myology of the joint.
"The forearm muscles are attached to what most physicians
call a tendon.
But in reality they are attached to a muscle origin. A true
tendon slides. It
has a sheath and is bathed in synovial fluid, which both
nourishes and
lubricates. The muscle origin of the forearm muscles has none
of these. In a
few instances, I have operated on the muscle origin. It is like
cutting into
gritty tissue. It has the worst blood supply of any structure
in the body. The
incision gives forth only a drop or two of blood. It is this
infinitesimal
blood supply which slows the healing process when the muscle
origin is ripped
or torn."
Kaplan's Test. This is a two-phase test:
(1) The
sitting patient is
given a hand dynamometer and instructed to extend the involved
upper limb
straight forward and squeeze the instrument as hard as
possible. Induced pain
and grip strength are noted.
(2) The test is then repeated
except that this
time you firmly encircle the patient's forearm with both hands
(placed about
1–2 inches below the antecubital crease). Induced pain and
grip strength are
noted. If the second phase of the test shows reduced pain and
increased grip
strength when the muscles of the proximal forearm are
compressed, lateral
and/or medial epicondylitis is indicated.
Mills' Test. The patient makes a fist; flexes the
forearm, wrist,
and fingers; pronates the forearm, and then attempts to extend
the elbow
against your resistance. This stretches the extensors and
supinators attached
to the lateral epicondyle. Pain at the elbow during this
maneuver is a general
indication of radiohumeral epicondylitis (tennis elbow).
Cozen's Test. With the patient's forearm stabilized,
the patient is
instructed to make a fist and extend the wrist. Cup the
patient's elbow with
your stabilizing hand and the top of the patient's fist with
your active hand,
and attempt to force the wrist into flexion against patient
resistance. A sign
of tennis elbow is a severe sudden pain at the lateral
epicondyle area.
Management. For appropriate adjustment procedure,
refer to
posteromedial subluxation of the radial head that has been
described
previously. Check for elbow, shoulder, wrist, lower cervical,
1st rib, and
upper thoracic subluxations/fixations. In chronic cases, the
correction of
local elbow lesions will often be designed to relieve fixation
produced by
probable scar tissue in the vicinity of the lateral
epicondyle.
Contributing spinal majors will likely be found at C5–T1.
Also release
fixations found at the nonacute elbow, shoulder, or wrist.
After relaxing the
tissues and adjusting the subluxated/fixated segments, it's
helpful to apply
deep high-velocity percussion spondylotherapy over segments
C7–T4 for 3–4
minutes. Treat trigger points discovered, especially those
found in the
triceps, supraspinatus, anconeus, brachioradialis, extensors,
and supinator
muscles.
Physiologic Therapeutics. Apply cold (eg, packs, ice
massage),
spray-and-stretch isolated trigger points as described below,
secure forearm
muscles with a short strap placed about 1-1/2 inches below the
antecubital
crease (splint in severe cases), and rest the joint with a
sling. A firm but
not tight strap applied around the circumference of the forearm
just below the
antecubital crease will afford protection to the injured
tissues and relief
during healing. An elastic bandage offers little therapeutic
value.
After the acute stage, transverse friction massage,
interferential therapy,
auriculotherapy, positive galvanism, diathermy, or ultrasound,
along with
progressive exercises are the common adjunctive procedures
used. Underwater
ultrasound is recommended by several authorities. Caution the
patient that
return to activity immediately on fading of symptoms invites
recurrence. Other
helpful modalities include iontophoresis with salicylate,
alternating current
for passive exercise and pain control, and high-voltage
therapy.
Several nutritionists recommend protein, vitamin C with
bioflavinoids,
manganese, and zinc to speed the healing process. Supplemental
nutrients B6,
niacin, P, copper, and rutin are also suggested. Counsel the
patient to avoid
appropriate antivitamin and antimineral factors.
When swelling and tenderness have disappeared, demonstrate
therapeutic
exercises to strengthen weak muscles and/or stretch
contractures. Squeezing a
rubber ball helps recuperation. Graduated restoration to
painless function
under stress conditions is necessary before full activity is
resumed.
Strengthening wrist extensors is important.
Golfer's Elbow (Medial Epicondylitis)
A severe strain opposite to that of tennis elbow may be
found at the origin
of the flexor pronator muscles at the medial epicondyle with
associated sprain
of the medial ligament. This injury is often called "golfer's
elbow."
Subperiosteal hematoma and periostitis are often involved. Poor
warm-up is
usually the predisposing cause in golf or bowling, but taking a
divot too deep
during chipping is sometimes the precipitating factor.
Medial Epicondyle Test. The patient flexes the wrist
with the
forearm in supination. The doctor then attempts to force the
patient's wrist
into extension against patient resistance. Pain originating at
the medial
epicondyle is a sign of medial epicondylitis. This test is
sometimes called
the reverse Cozen's test.
Management. The classic adjustment is to extend the
wrist and
fingers and supinate the forearm while the elbow is fully
extended.
Contributing spinal majors will likely be found at C5–T1. Also
release
fixations found at the nonacute elbow, shoulder, or wrist.
After relaxing the
tissues and adjusting the subluxated/fixated segments, it helps
to apply deep
high-velocity percussion spondylotherapy over segments C7–T4
for 3–4
minutes. Treat trigger points discovered, especially those
found in the
triceps, pronators, and pectoral muscles. Supplemental
nutrients C, B6,
niacin, P, copper, manganese, zinc, and rutin are recommended
in the
literature. Counsel the patient to avoid appropriate
antivitamin and
antimineral factors.
Other helpful forms of treatment include contrast baths and
spray-and-stretch therapy during the acute stage, followed by moist heat
or shortwave
diathermy, ultrasound, interferential therapy, iontophoresis
with salicylate,
alternating current for passive exercise and pain control,
high-voltage
therapy, or tendon friction massage of involved muscles.
Exercises for Elbow Epicondylitis. An excellent exercise for lateral epicondylitis, medial
epicondylitis,
related strains, or weak wrist dorsiflexors is to
have the patient
sit, loop the middle of a length of surgical tape or a
Theraband under the
ipsilateral foot and grasp the taut ends of the tubing in the
hand, palm down.
The wrist is then dorsiflexed against the resistance of the
tubing to the
point of fatigue where rapid rhythm fails. A mild burning
sensation in the
posterior forearm muscles is often perceived. After a period of
rest, the
exercise is repeated. Three successive bouts several times a
day is
recommended. The subject will advance to heavier resistance
(eg, hand dumbbell).
This exercise is also effective in wrist flexor/pronator tendinitis. The only difference is the tubing is grasped
first with the
palm up and later with the palm facing medially.
Pitcher's Elbow
Background for this disorder has been described earlier. Its
chronic form
is similar to golfer's elbow but associated with baseball
pitchers. It is
caused by elbow extension and snapping pronation or supination
as the pitcher
throws a "slider" or "breaking curve." Degenerative changes are
essentially on
the medial epicondyle, thus indicating pronator strain. It can
be considered
an elbow "whiplash" injury where the olecranon impinges the
fossa at the
distal humerus. Loose bodies from cartilage flaking, trochlea
osteophytes,
medial ligament ossicles, and olecranon chips are frequently
related.
Little League Elbow
Displacement and fragmentation of the medial condyle in
youthful baseball
pitchers (Little Leaguer's elbow) have a high incidence.
"Little league elbow"
is a general term for "pitcher's elbow" in youth. The term
basically refers to
elbow sprain complicated by an avulsion of the ossification
center of the
medial condyle, a nonunion fatigue fracture through the
olecranon growth
plate, osteochondritis, or loose bodies, or a combination of
such factors. The
syndrome may at first resemble either diffuse lateral or medial
epicondyle
inflammation. Avulsions, osteochondritis dissecans of the
capitulum, and
proximal forearm muscle strain may also be involved. The
primary lesion will
determine whether the onset is abrupt or gradual.
Javelin Elbow
When the javelin is thrown or a similar action is made the
olecranon pivots
medially in the trochlea and its tip is forced against the edge
of the fossa
during the extreme forearm pronation and elbow extension
necessary. This may
result in repeated sprain from amateur "round house" throws
complicated by
fracture fragments, calcification, and spur development along
the course of
the medial collateral ligament of the elbow. Transient ulnar
nerve paralysis
and "pitcher's" symptoms are early indications. In some cases,
a "golfer's
elbow" syndrome is seen from flexor-origin strain.
Direct Peripheral Nerve Trauma
Musculospiral Contusion.
The path of the radial nerve in the musculospiral groove,
which courses
along the lateral distal-third of the humerus, is relatively
superficial and
not infrequently the site of contusion. The clinical picture
("dead arm") is
sudden radiating pain throughout the distal radial distribution
and extensor
paralysis. Damage is rarely permanent, and symptoms usually
ease within a few
minutes. Local ice massage and standard nerve-contusion
management are usually
adequate. If symptoms persist, neurologic consultation should
be
considered.
Radial Nerve Compression at the Elbow.
This nerve compression syndrome features pain and disturbed
sensation in
the area of distribution of the nerve's superficial branch and
is thus
frequently confused with de Quervain's disease. If the deep
branch is
involved, pain is at or below the lateral epicondyle. On
palpation, the nerve
trunk is tender near the origin of the extensors, and active
extension of the
fingers initiates or aggravates pain. If the elbow is extended
and the middle
finger is actively extended against resistance, pain is acutely
increased
because the extensor carpi radialis inserts at the base of the
third
metacarpal. If conservative therapy fails to afford relief,
referral for
exploratory surgery should be considered.
Ulnar Nerve Compression at the Elbow.
The ulnar nerve is injured just slightly less in incidence
than radial
nerve trauma. The damage is usually at the inner side of the
elbow where it is
quite vulnerable in its superficial position along the elbow's
posteromedial
aspect. After severe damage, a characteristic "claw hand" can
result with
sensory loss at the medial side of the hand.
Cubital Tunnel Syndrome. Ulnar nerve compression at
the elbow is
called cubital tunnel syndrome or tardy ulnar nerve palsy. It
is often the
result of trauma or compression of the ulnar nerve at the elbow
when the
medial ligament ruptures during elbow dislocation. It may also
be involved if
the medial epicondyle becomes fractured. Disability and pain
occur along the
ulnar aspect of the forearm and hand. Early signs are inability
to separate
the fingers and disturbed sensation of the 4th and 5th digits.
Interosseous
atrophy is usually evident. Light pressure on the cubital
tunnel initiates or
aggravates the pain. Nerve conduction studies help to confirm
the diagnosis.
The cause can be repetitive trauma, and response to
conservative therapy is
often poor unless the source of irritation can be removed.
Surgery may stop
the progressive neuropathy, but it does not guarantee return of
normal
neurologic function.
Management. Associated spinal majors will likely be
found at C5–T1.
Also release fixations found at the nonacute elbow, shoulder,
or wrist. After
relaxing the tissues and adjusting the subluxated/fixated
segments, it helps
to apply deep high-velocity percussion spondylotherapy over
segments C7–T4
for 3–4 minutes. Treat trigger points discovered, especially
those found in
the anconeus, triceps, brachialis, brachioradialis, and
extensor and pronator
muscles. Supplemental nutrients B1, B6, C, niacin, P,
manganese, zinc, and
rutin are recommended. Counsel the patient to avoid appropriate
antivitamin
and antimineral factors.
Helpful modalities include contrast baths, interferential
therapy,
iontophoresis with magnesium, alternating current for passive
exercise and
pain control, or high-voltage therapy. When the acute stage has
passed, the
attending physician should demonstrate therapeutic exercises to
strengthen
weak muscles and/or stretch contractures.
Palsy of the Arm
Bilateral paralysis of several muscles of the arm is most
often
nontraumatic, occurring in anterior poliomyelitis and toxic
neuritis (eg,
alcoholic, lead). Unilateral paralysis is most often seen with
lower cervical
spine trauma; hemiplegia, with unilateral face and leg
involvement; hysteria;
cerebral cortex lesions (eg, space-occupying masses,
thrombosis, embolism,
softening); progressive muscular atrophy; neurosis, traumatic;
and pressure
neuritis (eg, crutch, tumor). When occurring in infants, the
cause may be
injury from a forceps delivery.
Rapid atrophy suggests neuritis or an acute spinal cord
lesion (eg,
poliomyelitis). If it arises centrally from the thumb, the
common cause is
progressive muscular atrophy. In such atrophic conditions, the
direct etiology
is something interfering with the nourishing functions that
should flow along
the nerve -thus distinguishing it from common disuse atrophy.
Slowly
progressing atrophy can usually be attributed to a thoracic
outlet syndrome,
hysteria, or hemiplegia or another type of cerebral lesion.
Management.
Contributing spinal majors will likely be found at C5–T1.
Mobilize
fixations found in the shoulder girdle or involved upper
extremity. After
relaxing the tissues and adjusting the subluxated/fixated
segments, apply deep
low-velocity percussion spondylotherapy over segments C7–T4
for 1–2 minutes.
Treat trigger points discovered, especially those found in the
arm, shoulder
girdle, and posterior neck. Supplemental nutrients B-complex,
inositol,
calcium, potassium, and magnesium are recommended. Counsel the
patient to
avoid appropriate antivitamin and antimineral factors.
Helpful modalities include moist heat or shortwave
diathermy, ultrasound
for heat and massage at the cellular level, hot needle-spray
showers,
interferential therapy, iontophoresis with iodine, local
vibration-percussion,
alternating current for passive exercise, or high-voltage
therapy. Once
passive exercise effects some degree of active motion, the
attending doctor
should demonstrate progressive therapeutic exercises to
strengthen weakened
muscles and/or stretch contractures.
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