Physiotherapy Management of the Elbow: Difference between revisions
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== Differential Diagnosis of Elbow Pain == | == Differential Diagnosis of Elbow Pain == | ||
Lateral elbow pain is the most common site for pain to be felt at the elbow.<ref name=":3">Brukner P. [ | Lateral elbow pain is the most common site for pain to be felt at the elbow.<ref name=":3">Brukner P. [http://www.softtissuetherapyonline.com/wp-content/uploads/2009/10/FreeChapter.pdf Brukner & Khan's Clinical sports medicine.] North Ryde: McGraw-Hill; 2012.</ref> Lateral epicondylalgia or tennis elbow is a common cause of lateral elbow pain but it is not the only cause. There are many conditions that can cause pain and dysfunction at the elbow and a systematic differential diagnosis is important to identify all contributing and predisposing factors. | ||
Lateral Elbow Conditions | Lateral Elbow Conditions | ||
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=== Shoulder, Cervical Spine and Thoracic Spine === | === Shoulder, Cervical Spine and Thoracic Spine === | ||
The cervical and thoracic spine have been shown to influence elbow pain. In a study, by Berglund et al in (2008), 70% of subjects with lateral elbow pain also experienced pain in their cervical and thoracic region whereas the asymptomatic group only reported 16%.<ref>Berglund KM, Persson BH, Denison E. [ | The cervical and thoracic spine have been shown to influence elbow pain. In a study, by Berglund et al in (2008), 70% of subjects with lateral elbow pain also experienced pain in their cervical and thoracic region whereas the asymptomatic group only reported 16%.<ref>Berglund KM, Persson BH, Denison E. [https://www.sciencedirect.com/science/article/pii/S1356689X07000471 Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain]. Manual therapy. 2008 Aug 1;13(4):295-9.</ref> | ||
Weakness of the scapular muscles, particularly serratus anterior as well as lower and middle traps, have been shown to be a significant risk factor in the development of elbow pathology.<ref name=":4">Suzuki H, Swanik KA, Huxel KC, Kelly JD, Swanik CB. [https://pdfs.semanticscholar.org/2248/53e3a6c76d4811299bf28c1c471f24889c8c.pdf Alterations in upper extremity motion after scapular-muscle fatigue]. Journal of Sport Rehabilitation. 2006 Feb 1;15(1):71-88.</ref> Fatigue in these muscles can alter the biomechanics of upper limb activity and thereby cause dysfunction at the elbow.<ref name=":4" /> A study conducted in 2012 by Lucado et al found that female tennis players with lateral epicondylalgia showed greater weakness in their wrist extensors and lower trapezius muscles compared to asymptomatic players.<ref>Lucado AM, Kolber MJ, Cheng MS, Echternach Sr JL. [ | Weakness of the scapular muscles, particularly serratus anterior as well as lower and middle traps, have been shown to be a significant risk factor in the development of elbow pathology.<ref name=":4">Suzuki H, Swanik KA, Huxel KC, Kelly JD, Swanik CB. [https://pdfs.semanticscholar.org/2248/53e3a6c76d4811299bf28c1c471f24889c8c.pdf Alterations in upper extremity motion after scapular-muscle fatigue]. Journal of Sport Rehabilitation. 2006 Feb 1;15(1):71-88.</ref> Fatigue in these muscles can alter the biomechanics of upper limb activity and thereby cause dysfunction at the elbow.<ref name=":4" /> A study conducted in 2012 by Lucado et al found that female tennis players with lateral epicondylalgia showed greater weakness in their wrist extensors and lower trapezius muscles compared to asymptomatic players.<ref>Lucado AM, Kolber MJ, Cheng MS, Echternach Sr JL. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2012.4095 Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia]. journal of orthopaedic & sports physical therapy. 2012 Dec;42(12):1025-31.</ref> This study contained a relatively small sample size and as such does not represent a direct causal relationship but rather factors to consider in the diagnosis and management of elbow pathology. | ||
Compensatory movements at the elbow can occur as a result of dysfunction at other joint complexes in the body. An example being if there is a loss of glenohumeral lateral rotation range of motion there may be an increase in forearm supination or valgus as a compensatory strategy.<ref name=":5">Sahrmann S. [https://books.google.com/books?hl=en&lr=&id=hAZT-VFiTUoC&oi=fnd&pg=PP1&dq=Sahrman+2010+Shirley+associates&ots=Kw7uCyrMz0&sig=74Q2c6HsVDrYCpM8aaTiyZhN7hM Movement system impairment syndromes of the extremities, cervical and thoracic spines-e-book]. Elsevier Health Sciences; 2010 Nov 19.</ref> Alternatively, a loss of glenohumeral internal rotation range of motion may result in an increase in forearm pronation.<ref name=":5" /> These compensatory movements can result in problems occurring at the various elbow structures. Treating the local elbow pain will not resolve symptoms as the primary problem of reduced shoulder mobility needs to be addressed to reduce the increased stress at the elbow. | Compensatory movements at the elbow can occur as a result of dysfunction at other joint complexes in the body. An example being if there is a loss of glenohumeral lateral rotation range of motion there may be an increase in forearm supination or valgus as a compensatory strategy.<ref name=":5">Sahrmann S. [https://books.google.com/books?hl=en&lr=&id=hAZT-VFiTUoC&oi=fnd&pg=PP1&dq=Sahrman+2010+Shirley+associates&ots=Kw7uCyrMz0&sig=74Q2c6HsVDrYCpM8aaTiyZhN7hM Movement system impairment syndromes of the extremities, cervical and thoracic spines-e-book]. Elsevier Health Sciences; 2010 Nov 19.</ref> Alternatively, a loss of glenohumeral internal rotation range of motion may result in an increase in forearm pronation.<ref name=":5" /> These compensatory movements can result in problems occurring at the various elbow structures. Treating the local elbow pain will not resolve symptoms as the primary problem of reduced shoulder mobility needs to be addressed to reduce the increased stress at the elbow. | ||
=== The Role of the Central Nervous system === | === The Role of the Central Nervous system === | ||
As in any pain condition, the central nervous system plays an important role in elbow pain and dysfunction. Depression and anxiety have been associated with upper extremity complaints and should be considered when managing elbow conditions.( | As in any pain condition, the central nervous system plays an important role in elbow pain and dysfunction. Depression and anxiety have been associated with upper extremity complaints and should be considered when managing elbow conditions.<ref>Degen RM, MacDermid JC, Grewal R, Drosdowech DS, Faber KJ, Athwal GS. [https://www.jospt.org/doi/full/10.2519/jospt.2016.6265 Prevalence of symptoms of depression, anxiety, and posttraumatic stress disorder in workers with upper extremity complaints]. journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):590-5.</ref> Central sensitisation can be a cause of hyperalgesia and altered pain processing at the elbow.<ref name=":6">Coombes BK, Bisset L, Vicenzino B. [https://research-repository.griffith.edu.au/bitstream/handle/10072/140975/CoombesPUB1411.pdf?sequence=1 Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors.] The Clinical journal of pain. 2015 Jan 1;31(1):30-5.</ref> This centrally mediated process is important to identify as standard peripheral biomechanical based treatment may not be as effective in patients presenting with symptoms of central sensitisation. Patients with central sensitisation potentially experience short-term and long-term pain as well as increased disability.<ref name=":6" /> Cold hyperalgesia as a means of identifying central sensitisation in the elbow could be a useful diagnostic test to identify altered pain processing.<ref name=":6" /> A study conducted by Maxwell and Sterling in 2013 on patients with neck pain showed that a Numeric Pain rating scale of greater than 5 after the application of ice to the neck is a good indicator of cold hyperalgesia.<ref>Maxwell S, Sterling M. [https://www.sciencedirect.com/science/article/pii/S1356689X12001750 An investigation of the use of a numeric pain rating scale with ice application to the neck to determine cold hyperalgesia]. Manual therapy. 2013 Apr 1;18(2):172-4.</ref> More research in this field specific to the elbow is required. | ||
== References == | == References == | ||
Revision as of 07:18, 7 April 2020
Introduction[edit | edit source]
Physiotherapy has an important role to play in the management of pain and dysfunction around the elbow joint. Physiotherapists have a functional knowledge of the complicated 3-joint elbow complex as well as its associated anatomy. They can apply this knowledge to the various structures around the elbow as well as distant from the elbow that can contribute to a person's symptoms.
A physiotherapist can perform a detailed assessment of the elbow and identify all contributing factors as well as co-morbidities associated with the person's symptoms. This assessment will help them develop a multi-modal treatment approach that is individualised to the specific problems and contributing factors found in the assessment.
The Complex Anatomy of the Elbow[edit | edit source]
The elbow joint is where the distal humerus meets the proximal radius and ulna bones. It is known as a trochleogingylomoid joint as it can flex and extend as a hinge (ginglymoid) joint as well as pivot around an axis (trochoid motion) known as pronation and supination.[1][2] It is an extremely congruent joint and is inherently stable with injuries at the elbow resulting in an inheritably unstable joint.[3]
Joints[edit | edit source]
The humerus, radius and ulna articulate to form 3 joints that make up the elbow.
Ulnohumeral Joint
The ulnohumeral hinge joint is responsible for flexion and extension. The spool-shaped trochlea of the humerus articulates with the greater sigmoid arch of the proximal ulna.[1]
Radiocapitellar Joint
The radiocapitellar joint is where the radius and humerus articulate. It is partly responsible for pronation and supination. The capitellum of the lateral distal humerus is a spherical structure onto which the concave surface of the proximal radial head articulates.[2]
Proximal Radioulnar Joint
The proximal radioulnar joint is a trochoid joint responsible for pronation or supination of the forearm. The peripheral edge of the radial head articulates with the radial notch of the ulna.[2]
Carrying Angle
The carrying angle is measured when the elbow is in full extension and supination. It is an angle measured along the long axis of the humerus and ulna. In men, it is approximately 11-14° and women 13-16°. Is it appropriately named as it allows our arms to clear our hips as we walk and allows objects to be carried.
Movements at the Elbow[edit | edit source]
Flexion and Extension
Flexion and Extension occurs at the ulnohumeral joint. Normal range of movement is from 0-140° but only 30°-130° is required for most ADLs[1]
Pronation and Supination
The radiocapitellar joint and proximal radioulnar joint are responsible for pronation and supination. Normal ROM is considered approximately 180° (80-90 pronation and 90 supination). 100° of movement (50° pronation and 50° supination) is considered adequate for most ADLs. If pronation ROM is lost this can be compensated by using shoulder abduction. But, there is no compensatory action for supination and as such a loss of supination ROM can pose a greater disability than a loss of pronation ROM.[1]
Ligaments and Capsule[edit | edit source]
There are 2 main ligament complexes at the elbow namely the Medial and Lateral Collateral.
Medial Collateral Ligament Complex (MCLC)
The MCLC is comprised of the anterior bundle, posterior bundle and transverse ligament (the ligament of Cooper). The anterior bundle is considered to be the most important stabiliser of the elbow and provides valgus and posteromedial stability.[2] The anterior bundle is further divided into the anterior and posterior bands. The anterior band is more taught in extension and relaxes into flexion and the posterior band is taught in flexion and releases in extension.[2] This makes the anterior band more vulnerable to valgus stress when the elbow is extended and the posterior band of the AMCL more vulnerable to valgus stress when the elbow is flexed.[1]
Lateral Collateral Ligament Complex (LCLC)
The LCLC is the primary stabiliser against varus and external rotation stresses. The lateral ulnar collateral ligament, the radial collateral ligament and the annular ligament form the LCLC.[3] The lateral ulnar collateral ligament is important in maintaining posterolateral rotatory stability as well as stabilising against varus stresses.[3] The radial collateral ligament also contributes to posterolateral rotational stability. The Annular ligament surrounds the radial head but does not attach to it. It is am important stabiliser of the proximal radioulnar and radiocapitellar joint.[3]
Joint Capsule
The joint capsule of the elbow surrounds all 3 joints[3][2]. There are thickening medially and laterally of the joint capsule that blend with the MCLC and LCLC respectively and contributes to stability of the elbow.[2][3]
Musculature[edit | edit source]
There are 4 main muscle groups at the elbow. The anterior bicep group, the posterior tricep group, the lateral extensor-supinator group and the medial flexor-pronator group
Each muscle group applies a compressive load to the elbow joint when they contract.[1][2]
- Primary Elbow Flexors
- Brachialis
- Biceps brachii
- Brachioradialis
- Secondary Elbow Flexors
- Pronator teres
- Extensor carpi radialis longus
- Flexor carpi radialis (at elbow angles 50 degrees or more)
- Primary Elbow Extensors
- Triceps
- Anconeus
- Secondary extensors
- Flexor Carpi ulnaris
- Extensor carpiulnaris
- Pronation
- Pronator teres
- Pronator quadratus
- Supination
- Mainly Biceps
- Assistance from supinator
- Lesser degree finger and wrist extensors
Differential Diagnosis of Elbow Pain[edit | edit source]
Lateral elbow pain is the most common site for pain to be felt at the elbow.[4] Lateral epicondylalgia or tennis elbow is a common cause of lateral elbow pain but it is not the only cause. There are many conditions that can cause pain and dysfunction at the elbow and a systematic differential diagnosis is important to identify all contributing and predisposing factors.
Lateral Elbow Conditions
- Lateral Epicondylalgia
- Osteochondral Fractures of the capitellum
- Osteochondritis Dissecans
- Synovial Plica
- LCL tear/ strain
- Fractures of the Radial Head
- Loose Bodies
- OA radiohumeral joint
- Synovitis RH joint
- Radial tunnel syndrome
- Posterior interosseous Nerve entrapment
Medial Elbow Conditions
- Medial Epicondylalgia
- MCL strain/ rupture
- Ulnar Nerve Entrapments
- Medial olecranon fossa impingement
Posterior Elbow Conditions
- Avulsion fractures of the olecranon
- Olecranon spurs
- Olecranon posterior impingement
- Triceps tendinopathy/ rupture
- Olecranon Bursitis
- Postero/lateral dislocation
Anterior Elbow Conditions
- Biceps insertion tendinopathy rupture
- Brachialis Strain/ Tear
- Degenerative joint changes
- Adult annular ligament
Factors Contributing to Elbow Pain [edit | edit source]
Elbow pain does not occur in isolation. Many structures can refer pain to the elbow and others can contribute to the development of elbow pain and dysfunction.[4] It has been shown in various studies that structures distant to the elbow contribute to the development of elbow pain and dysfunction. These can be from a variety of dysfunctions namely neural, myofascial, joint-related or even centrally mediated.
Shoulder, Cervical Spine and Thoracic Spine[edit | edit source]
The cervical and thoracic spine have been shown to influence elbow pain. In a study, by Berglund et al in (2008), 70% of subjects with lateral elbow pain also experienced pain in their cervical and thoracic region whereas the asymptomatic group only reported 16%.[5]
Weakness of the scapular muscles, particularly serratus anterior as well as lower and middle traps, have been shown to be a significant risk factor in the development of elbow pathology.[6] Fatigue in these muscles can alter the biomechanics of upper limb activity and thereby cause dysfunction at the elbow.[6] A study conducted in 2012 by Lucado et al found that female tennis players with lateral epicondylalgia showed greater weakness in their wrist extensors and lower trapezius muscles compared to asymptomatic players.[7] This study contained a relatively small sample size and as such does not represent a direct causal relationship but rather factors to consider in the diagnosis and management of elbow pathology.
Compensatory movements at the elbow can occur as a result of dysfunction at other joint complexes in the body. An example being if there is a loss of glenohumeral lateral rotation range of motion there may be an increase in forearm supination or valgus as a compensatory strategy.[8] Alternatively, a loss of glenohumeral internal rotation range of motion may result in an increase in forearm pronation.[8] These compensatory movements can result in problems occurring at the various elbow structures. Treating the local elbow pain will not resolve symptoms as the primary problem of reduced shoulder mobility needs to be addressed to reduce the increased stress at the elbow.
The Role of the Central Nervous system[edit | edit source]
As in any pain condition, the central nervous system plays an important role in elbow pain and dysfunction. Depression and anxiety have been associated with upper extremity complaints and should be considered when managing elbow conditions.[9] Central sensitisation can be a cause of hyperalgesia and altered pain processing at the elbow.[10] This centrally mediated process is important to identify as standard peripheral biomechanical based treatment may not be as effective in patients presenting with symptoms of central sensitisation. Patients with central sensitisation potentially experience short-term and long-term pain as well as increased disability.[10] Cold hyperalgesia as a means of identifying central sensitisation in the elbow could be a useful diagnostic test to identify altered pain processing.[10] A study conducted by Maxwell and Sterling in 2013 on patients with neck pain showed that a Numeric Pain rating scale of greater than 5 after the application of ice to the neck is a good indicator of cold hyperalgesia.[11] More research in this field specific to the elbow is required.
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthopedic Clinics of North America. 2008 Apr 1;39(2):141-54.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Alcid JG, Ahmad CS, Lee TQ. Elbow anatomy and structural biomechanics. Clinics in sports medicine. 2004 Oct 1;23(4):503-17.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Smith JM, Bell JE. Anatomy of the Elbow. InThe Unstable Elbow 2017 (pp. 3-11). Springer, Cham.
- ↑ 4.0 4.1 Brukner P. Brukner & Khan's Clinical sports medicine. North Ryde: McGraw-Hill; 2012.
- ↑ Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Manual therapy. 2008 Aug 1;13(4):295-9.
- ↑ 6.0 6.1 Suzuki H, Swanik KA, Huxel KC, Kelly JD, Swanik CB. Alterations in upper extremity motion after scapular-muscle fatigue. Journal of Sport Rehabilitation. 2006 Feb 1;15(1):71-88.
- ↑ Lucado AM, Kolber MJ, Cheng MS, Echternach Sr JL. Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia. journal of orthopaedic & sports physical therapy. 2012 Dec;42(12):1025-31.
- ↑ 8.0 8.1 Sahrmann S. Movement system impairment syndromes of the extremities, cervical and thoracic spines-e-book. Elsevier Health Sciences; 2010 Nov 19.
- ↑ Degen RM, MacDermid JC, Grewal R, Drosdowech DS, Faber KJ, Athwal GS. Prevalence of symptoms of depression, anxiety, and posttraumatic stress disorder in workers with upper extremity complaints. journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):590-5.
- ↑ 10.0 10.1 10.2 Coombes BK, Bisset L, Vicenzino B. Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors. The Clinical journal of pain. 2015 Jan 1;31(1):30-5.
- ↑ Maxwell S, Sterling M. An investigation of the use of a numeric pain rating scale with ice application to the neck to determine cold hyperalgesia. Manual therapy. 2013 Apr 1;18(2):172-4.
