ELBOW JOINT INJURIES-

ASSESSMENT & TREATMENT

BY DR. SUSHMA IMMADI

MPT (SPORTS)
UNIVERSITY OF TEESSIDE, UK
INTRODUCTION:
The elbow is a difficult joint to examine
diagnose and treat (not a frequent site of
trauma and injury). Nevertheless the elbow is
becoming better understood as more athletes
participate in throwing or overhead sports
resulting in an increasing number of elbow
problems requiring treatment.
.
Overuse injuries in throwing or catching sports
create most chronic elbow problems (may
involve the ligaments, capsule, muscles or
Articular surfaces of the joint to impair
function). Particular sports cause specific
injuries around the elbow
TYPE OF SPORT CONDITION

1. GULF MEDIAL EPICONDYLITIS

2. TENNIS LATERAL EPICONDYLITIS

3. BASEBALL MCL INJURIES

VALGUS EXTENSION OVERLOAD
LITTLE LEAGUER’S ELBOW
OCD PANNER’S DISEASE
ULNAR NEURITIS/CUBITAL TUNNEL
ACUTE RUPTURE MCL
MEDIAL EPICONDYLITIS

4. GYMNASTICS OCD

5.JAVELIN ACUTE RUPTURE MCL

PARTIAL RUPTURE MCL
EPICONDYLITIS.
 ANATOMY & BIOMECHANICS

The elbow is a highly constrained hinge joint,

(its stability is maintained by ligamentous,
osseous and capsular structures) with a
slight degree of varus/valgus and rotational
laxity (3-5 degrees) throughout the flexion -
extension arc.
There are 3 articulations here
• Ulnohumeral - allows 0-150 degrees flexion.
• Radiocapitellar.
• Proximal Radio-ulnar joints (radiocapitellar
allows 75 degrees pronation and 85 degrees
supination).

Most daily activity is done through a 100 degree

arc of flexion and extension (usually 30- 130
degrees) Forearm rotation occurs in an arc of
100 degrees, (usually 50 degrees supination &
pronation). Any loss of this arc of movement
may limit one’s function.
Elbow Stability.
Ligamentous stability is provided by the medial and
lateral ligamentous complex. (The relative importance
of these ligaments depends on the position of the arm).

Medial Collateral Ligament: has 3 parts. The anterior

oblique ligament is the most important of these bands
originating from the medial epicondyle and inserting
onto the medial aspect of the coronoid process;
The anterior band is the primary constraint to VALGUS
instability and the radial head is of secondary
importance (clinically, this is noted in throwing as the
repetitive valgus stress can result in microtrauma and
attenuation of the anterior oblique ligament).
Lateral Collateral Ligament: has 3 parts and
offers varus stability (rarely stressed in the
athlete) The lateral ulnar collateral, the most
important of these ligaments plays an
important role in rotational instability, it
originates from the lateral epicondyle and
inserts onto the tubercle of the supinator crest
of the ulna; Its function is to prevent Varus and
Posterolateral rotatory instability of the elbow.
The capsule serves as an important constraint
to instability in full extension.
Neurological anatomy:
Neurological compression syndromes are common
here due to the closeness of the nerves.
The ulnar nerve is vulnerable within the cubital
tunnel, posterior to the medial epicondyle.
The median nerve is anterior deep within the
cubital fossa, the radial nerve is lateral and
branches in the cubital fossa
Ligament injuries and instability
Medial (ulnar) collateral ligament injuries (MCL)
From throwing sports where repetitive valgus
stress results in small tears in the anterior band
of the MCL and subsequent rupture.

Occurs in javelin throwers and baseball pitchers

(in throwing there is an enormous valgus stress
on the elbow during the late-cocking phase so
overloading the ligament leading to attenuation
and rupture).
Occasionally there is a single acute painful
throw or a fall onto the outstretched hand.

Examination reveals swelling and pain

(localized to the medial side) and occasionally
paraesthesia in the ulnar nerve distribution.
Valgus deformity and elbow
contracture may follow.
Valgus stress testing with the elbow at 30
degrees of flexion displays increased laxity and
pain.
Incongruity develops between the olecranon
process and its fossa with loose body formation
at the medial side of the olecranon.

X-ray’s may show osseous bodies in the MCL or

fluffy calcification at the tip of the olecranon.
Treatment is rest, activity modification,
NSAIDs and physiotherapy.

If posteromedial pain continues then

arthroscopy is necessary to debride the
osteophytes.
If there is chronic MCL laxity or instability
then surgical reconstruction is necessary.
Acute rupture of the MCL
Isolated tears of the anterior oblique ligament
may occur in javelin throwers.

The mechanism is almost pure valgus stress with

the elbow flexed at 60-90 degrees. There is
severe pain and a pop on the medial side of the
elbow.
Ulnar nerve symptoms may occur with
ecchymosis about the elbow (48 hours later). If
the diagnosis is in doubt stress tests or stress x-
rays are useful . Acute repair of the ligament is
necessary.
Valgus extension overload:

Seen in pitchers during the acceleration phase.

(In the early phase of acceleration excessive
valgus stress is applied to the elbow causing
impingement).
This results osteophyte formation posteriorly
and posteromedially which can cause
chondromalacia with loose body formation.
The pitcher presents with pain on pitching (early
in the game) and are not able to let go of the
ball.
Pain over the olecranon fossa occurs in valgus
and extension.
X-rays show a posterior osteophyte at the tip of
the olecranon (on lateral views).

Treatment (should be started early) is

increasing functional strength, heat application
and ultrasound. An osteophyte needs surgical
excision)
Posterolateral rotatory instability
Differentiate from a frank elbow dislocation.
Caused by a laxity or disruption of the ulnar
part of the lateral collateral ligament which
then allows a transient rotatory subluxation of
the ulnohumeral joint (and secondary
dislocation of the radio-humeral joint).
There maybe preceeding trauma (dislocation
or sprain from a fall on an outstretched hand).
Previous surgery, radial head excision or lateral
release for a tennis elbow, maybe the cause of
instability.
There is a history of a recurring click, snap,
clunking, locking of the elbow and a sense of
instability that ones elbow is about to dislocate.

Such stability episodes occur with a loaded

extended elbow and supinated forearm.

Examination, often unremarkable, should

include the ‘Lateral Pivot Shift’ (Posterolateral
rotatory apprehension test)
The elbow is extended overhead and the
forearm fully supinated;

A valgus and supination force is then slowly

applied to the elbow going from the extended
to flexed position;

This results in subluxation of the ulno-humeral

joint and radiohumeral joint ).
On X-ray the joint will look normal (unless
taken with the joint subluxed) so the diagnosis
is made from history and after above test.

When symptomatic surgery is required (re-

attach the avulsed lateral ulnar collateral
ligament or reconstructing it (with a tendon
graft).
Tennis elbow (lateral epicondylitis)

A lateral tendinitis which involves the origin of

Extensor Carpi Radialis Brevis.
It is related to activities that increase tension
and stress on the wrist extensors and supinator
muscles not all activities include tennis.

It occurs between the ages of 35-55 years with

pain localized to the lateral epicondyle
especially after a period of unaccustomed
activity (such as tennis 3-4 times a week).
The pain is worsened by movements such as
turning a door handle or shaking hands
Examination reveals pain localized to the lateral
epicondyle and distally.

Typically aggravated by passive stretching the

wrist extensors or actively extending the wrist
with the elbow straight
X-rays are often normal (to exclude OA, LB or
tumour).
A bone scan will show increased uptake about
the lateral epicondyle.
An ultrasound or MRI will show degeneration
within the belly of ECRB.
The differential diagnosis includes:

posterior interosseus nerve entrapment ( has a

more distal localization of the pain and
associated weakness);
Radial tunnel syndrome (pain distal and
exacerbated by resisted extension of long digit,
i.e. ECRB);

OA/LB/ Tumour. It will resolve over a 10-12

month period but there is a 30% recurrence
therefore treat comprehensively with rest,
Activity modification, NSAIDs, heat, ultrasound,
Phonophoresis with 10% hydrocortisone cream,
brace (counterforce effect), eccentric muscle
strengthening, modify tennis handle (usually
too large) or tennis stroke (occurs in back hand
stroke).
Injection of cortico-steroid (no more than 3,
just below ECRB, anterior and distal to the
epicondyle), and then surgery (symptoms >12
months, release and excise ECRB, note Nirschl
scratch effect). Return to sport when strength
80% back or after 4 to 6 months.
SPECIAL TESTS OF THE ELBOW
JOINT:
1. Ligament instability tests (valgus & varus
stress tests):
Aim of the test: Identifies collateral ligaments laxity or
restriction.
Patient position: Patient is sitting or supine.
Entire upper limb is supported & stabilized and elbow placed
in 20°-30° of flexion. Valgus force placed through elbow
tests ulnar collateral ligament.
Varus force placed through elbow tests radial collateral
ligament
Positive sign: Primary finding is laxity, but pain may be noted
as well.
2. Tests for Epicondylitis:

Aim of the test:

To identify lateral or medial epicodylitis

A. Lateral Epicondylities/Tennis Elbow (Cozen) Test:

Patient position: Patient is sitting with elbow in 90° &

supported, resist wrist extension, wrist radial deviation
& forearm Pronation with fingers fully flexed (fist)
simultaneously.
B. Medial epicondylities/Golfer Elbow test

Patient position: Patient is sitting with elbow in

90° & supported, passively supinate forearm,
extend elbow & wrist.

Positive sign: Pain at Lateral epicondyle for tennis

elbow & at medial epicondyle for golfer elbow
3. Pronator teres syndrome test:
Aim of the test:
Identifies a median nerve
entrapment within pronator teres.

Patient position: Patient sitting with elbow in 90°

flexion & supported.
Resist forearm pronation and elbow extension
simultaneously.

Positive sign: Reproduces a tingling or paresthesia

within median nerve distribution.
4. Tinel's sign:

Aim of the test: Identifies dysfunction of ulnar

nerve at olecranon.

Patient position: patient is sitting, tap region

where the ulnar nerve passes through cubital
tunnel.

Positive sign: Reproduces a tingling sensation in

ulnar distribution.
5. The use of Polk’s test may help the clinician
to diagnostically differentiate between 
Lateral Epicondylitis en Medial Epicondylitis, 2
of the most common causes of elbow pain.
Polk’s test also helps to definitively indentify
the method of lifting that is best to be
avoided by the patient [1].

The mechanism of the Polk’s test is very

straightforward. When the hand grasps an
object, tension is placed on both the flexors
and the extensors of the wrist.
The motion of lifting an object, aggravates the
tension on the primary affected muscle group
with resulting mechanical strain at the
inflamed musculotendinous attachment site .

Technique
With the patient seated and the elbow flexed, the
patient is instructed to lift an object of
approximately 2.5 kg. An appropriately weighted
sand bag, hand weight, heavy purse or thick book
will usually suffice for the purpose of the test

The test is performed in 2 separate phases;

Phase 1: Diagnosis of lateral Epicondylitis

The patient grasps the object with the palm

facing the floor (pronation of the forearm) and
is instructed to attempt to lift it up the object.
Pain produced in the elbow, typically in the
region of the lateral epicondyle, upon this
manoeuvre is suggestive of Lateral Epicondylitis
.
In the absence of lateral Epicondylitis However,
the patient usually performs this manoeuvre
quite easy and without pain.
Phase 2: Diagnosis of Medial Epicondylitis

This phase involves the seated patient , with a

flexed elbow. The patient is instructed to grasp
the object with the palm up (supination of the
forearm) and attempt to lift the object.
Elbow pain, usually in the region of the medial
Epicondyle, produced with this manoeuvre is
suggestive of Medial Epicondylitis.
In the absence of medial epicondyilits, the
patient performs this manoeuvre quite
comfortably.
Other Techniques to Diagnose Lateral
Epicondylitis
Maudsley’s test = Resisted third digit extension
Cozen’s test = Resisted wrist extension with
radial deviation and full pronation
Chair lift test = Lifting the back of a chair with a
three-finger pinch (thumb, index long fingers)
and the elbow fully extended