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SPORTS INJURIES IN UPPER EXTREMITY.

ELBOW COMPLEX

Dr Riafat Mehmood
 ELBOW
Explain what you know about elbow?

Key facts about the elbow joint.

Type of joint , Bones , Ligaments , Blood supply,
Movements

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 THE ELBOW STRUCTURE
• The elbow is a hinge joint that helps
connect the three bones of the arm,
including the radius and ulna of the forearm
and humerus of the upper arm. The bones
are held together by ligaments.
• The primary ligament is the medial
collateral ligament (MCL) on the inside of
the elbow and the lateral collateral ligament
(LCL) on the outside.
• Several muscles that surround the joint are
responsible for the movement.
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 LIGAMENTS AND OTHER STRUCTURES

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 MUSCLES
OF THE ELBOW
AND FOREARM

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 ANATOMICAL
RELATIONSHIPS

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 BIOMECHANICS OF
ELBOW

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PROXIMAL RADIOULNAR ARTICULATION

•:

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 Why carrying angle of elbow is more in females?

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 KINEMATICS

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• primarily of the gliding type and that with the extremes of flexion
extension (the final 5°–10° of both flexion and extension), the axis of
rotation changed and the gliding/sliding joint motion changed to a
rolling-type motion.

• the ulnohumeral joint could be assumed to move as a uniaxial

articulation except at the extremes of flexion-extension.

• Pronation and supination take place primarily at the humeroradial

and proximal radioulnar joints with the forearm rotating about a
longitudinal axis passing through the center of the capitellum and
radial head and the distal ulnar articular surface.

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 ELBOW STABILITY

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• Baseball pitchers are frequently at risk for MCL injury due to the
repetitive valgus stress placed on their elbows by the nature of the
throwing motion.
• increased valgus torque at the elbow is associated with late trunk
rotation, reduced shoulder external rotation, and increased elbow
flexion
• in extension, resistance to valgus stress is shared equally by the MCL,
capsule, and joint articulation. In flexion, the primary resistor to
valgus stress is the MCL
• In flexion, the elbow articulation remains the primary restraint to
varus stress followed by the anterior capsule and LCL, respectively,
with the LCL contributing only 9%

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ELBOW INJURIES/ ELBOW PAIN IN
SPORTS

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 ELBOW INJURIES IN SPORTS

• Injuries are an integral part of all sports activity.

• Overuse and improper use of the joints are the main causes of injuries
in sportsmen.
• Sports injuries types,
Macro -traumas
Micro -traumas

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• ELBOW PAIN IN SPORTS
• Lateral elbow pain (outside)
• Medial elbow pain (inside)
• Posterior elbow pain (back)
• Acute elbow injuries (sudden
onset)
• Forearm Pain

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• LATERAL ELBOW PAIN (OUTSIDE)

• Tennis elbow –

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MEDIAL ELBOW PAIN

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 POSTERIOR ELBOW

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ELBOW INJURIES:
HOW THEY
HAPPEN
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 ELBOW INJURIES: HOW THEY HAPPEN

• Most elbow injuries that are caused by repetitive strain, either from
athletic injuries or other forms of overuse.

• Repetitive strain injuries occur when you repeat an activity over and over
again, with little time off between sessions to allow the body to heal. Over
time, the joints or muscles involved in the activity can become inflamed or
aggravated due to overuse. Symptoms like pain, swelling, stiffness, or
weakness may begin gradually and worsen over time.

• Among athletes, overhead throwers who use significant force and speed
are the ones most likely to complain of elbow injury (think baseball
pitchers or football players).
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• Overuse from sports. Performing repetitive motions can lead to strain and
inflammation in the tendons and ligaments in the inside and outside of the
elbow joint — especially if the motions are weight-bearing or involve exerting
a force to counteract another force (swinging a club, hitting or throwing a ball,
or pushing against water when swimming laps).

• Throwing sports like football and baseball are particularly infamous for causing
injuries along the inner side of the elbow.

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Clinical Presentation

Pain and symptoms localized in or around elbow.

May present with neurological symptoms local or distant to elbow.

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 ELBOW INJURIES IN THROWING
SPORTS

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• A 23-year-old man is experiencing valgus instability of the elbow after
many consecutive seasons of pitching. Which anatomical structure is
likely injured and during which phase of the throwing cycle depicted
in Figure A will his symptoms be most likely reproduced?

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 ELBOW ASSESSMENT

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Clinical Presentation

Pain and symptoms localized in or around elbow.

May present with neurological symptoms local or distant to elbow.

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 SUBJECTIVE HISTORY

• Exact location of pain.

• Timeline- When are the patients reported symptoms at their
worst?
• Mechanism of the injury- In the case of a traumatic event, the
mechanism of injury helps guide the diagnosis.
• Presence of numbness or tingling?
• Aggravating / reliving
• Medications?
• Past Medical History.
• Diagnostic Testing/Imaging?

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OBJECTIVE HISTORICAL QUESTION

• Do your symptoms change (better or worse) with any movements of the neck or
shoulder?

• Does your elbow ever “slip out” or feel unstable?

• Does the pain change with gripping activities?

• Do you ever experience numbness of tingling in the hand?

• Was the elbow hyper extended during the time of injury?

Do you relate the symptoms to a throwing activity?

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 ENVIRONMENTAL AND PERSONAL
FACTORS

During the initial examination, environmental and

personal factors should be addressed.
These issues could affect healing and return of function
after an elbow injury.

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 SPECIAL QUESTIONS

Red and Yellow Flags- Conditions that may require referral to appropriate
health care provider.
RED FLAGS
• Infection/Inflammation
• Malignancy
• Fracture/Dislocation (Positive Elbow Extension Test)
• Inflammatory Arthritides
• Abnormal Vitals
• Abnormal Vascular/Neurological Exam
• Heterotopic Ossification (Post-Surgical Consideration)
• Inappropriate progress from treatment made after surgery
YELLOW FLAGS
• Psychosocial factors
Passive coping
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 ELBOW
EXAMINATION

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 PALPATION

• Medial/lateral epicondyle.
• Olecranon and olecranon fossa.
• Radial head.
• Ulnar Collateral Ligament (UCL) of the elbow.
• Soft tissue in upper arm and forearm/wrist for pain
provocation, heat, swelling.

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 ULNAR NERVE TEST

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 GOLFER’S ELBOW:

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 ULNAR NERVE SCREENING WASTING

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 INTRINSIC EXAMINATION

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 MEDIAN NERVE

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 FUNCTIONAL TESTS

• Determination of an asterisk sign-(What activity increases symptoms?)

• Pain-Free Grip Strength.
• Push-off Test: The push off test can be used to quantify a person’s ability to
bear weight through the upper extremity. This can help identify
functional/occupational limitations.
• Functional Impairment Test-Hand, Neck, Shoulder Arm
• Standardized physical test. Assesses gross activities of the upper extremity.
Validation in elbow conditions has not yet been completed.

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NEUROLOGIC ASSESSMENT
• Reflexes: C5-C7
• Myotomes: C5-T1
• Dermatomes: C5-T1

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 SPECIAL TESTS

CUBITAL TUNNEL SYNDROME:

• Elbow Flexion Test

• Tinel's Sign
• Ulnar Nerve Compression Test

LATERAL EPICONDYLALGIA:

• Passive elbow extension, pronation, wrist flexion (Mill's Test)

• Resisted wrist extension with radial deviation (Cozen's Test)
• Resisted middle finger extension (Maudley's Test)
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• Tinel's sign ?
• Phalen's test?

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LIGAMENTOUS TESTS:

• Varus Stress Test

• Valgus Stress Test
• Moving Valgus Stress Test

NEURODYNAMIC TESTS:

• Median nerve bias: Upper Limb Neurodynamic Test 1

• Radial nerve bias: Upper Limb Neurodynamic Test 2b
• Ulnar nerve bias: Upper Limb Neurodynamic Test 3

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• 1. In a sitting position, place your right
forearm on the table palm down with
your elbow flexed as necessary (Fig).
Using your left hand, push against the
radial side of the right forearm just
proximal to the wrist until the right
palm is facing up (Fig.B). The right
forearm remains relaxed.
• a. What joint motion is occurring in
the right forearm?
• b. What muscles are being stretched?

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2. Sit in a chair that has armrests and place your hands on
them. Do a chair push-up, lifting your buttocks off the
seat.
a. What joint motion is occurring in the right elbow?
b. What type of contraction is occurring?
c. What muscles are being strengthened?
d. Is this an open- or closed-kinetic-chain activity?

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3. Stand with your right arm extended straight up
toward the ceiling. Using your left hand, push
your right hand down behind your head (Fig.).
Allow your elbow to bend.

a. What joint motion is occurring in the right

elbow?
b. What muscles are being stretched?

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• .Stand with your right hand next to your right shoulder,
and hold a small weight. Move your hand to anatomical
position.
• a. What joint motion is occurring in the right elbow?
• b. What type of contraction (isometric, concentric, or
eccentric) is occurring?
• c. What muscles are being strengthened?
• d. Is this an open- or closed-kinetic-chain activity?

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