The Elbow and Forearm
Overview of the Elbow:
The elbow contains three articulations within a single joint capsule: the
ulno-humeral and radio-humeral joints and the proximal radio-ulnar joint.
The forearm and elbow motions respectively serve to rotate the forearm to
allow for maneuvering of the hand, and to lengthen and/or shorten the
distance of the hand to the upper body allowing for such functions as
grooming, eating, dressing, etc. (Lehmkuhl & Smith, 1983).
Functional Anatomy and Brief Biomechanical Considerations:
Elbow stability: The elbow is a relatively stable joint with two degrees of
freedom: flexion-extension at the ulno-humeral joint, and
pronation-supination at the proximal radio-ulnar articulation of the
forearm. The elbow is not prone to instability, however, it is less stable
with valgus stresses than to varus stresses.
The ulno-humeral joint: The trochlea of the humerus articulates with the
trochlear notch of the ulna. The strong structural stability of this joint
is derived from both its bony configuration and its collateral ligaments
(Lehmkuhl & Smith, 1983). The trochlea extends more distally than the
capitulum, therefore when the elbow is extended and the forearm supinated,
the forearm deviates laterally in relation to the humerus. This angulation
is called the carrying angle or cubital angle of the elbow. This angle is
usually between 10 and 25 degrees of valgus (Stralka & Brasel, 1994).
Cubitus valgus: excessive angulation of the forearm with respect
to the humerus is known as cubitus valgus (Hammer, 1991).
The radioulnar articulation: The proximal and distal articulations between
the radius and the ulna allow the radius to rotate in relation to the ulna.
The proximal radioulnar joint lies within the capsule of the elbow, with
the medial aspect of the head of the radius articulating with the radial
notch of the ulna.
Cubital varus: a decreased carrying angle, also known as a
"Gunstock Deformity", usually due to an improperly reduced
supracondylar fracture or epiphyseal abnormality during growth.
The cubital fossa: the triangular space located at the anterior aspect of
the elbow. This area contains the biceps tendon, the brachial artery and
its terminal branches, and parts of the median and radial nerves (Moore,
The Joint Capsule of the Elbow:
The capsule of the elbow completely surrounds the humero-radial/ulnar and
the radio-ulnar joints. Its anterior and posterior parts are thin and weak,
but its sides are strengthened by the collateral ligaments. The capsular
pattern of the elbow is flexion, then extension with more limitations of
flexion than extension.
Ligaments of the Elbow:
Instability of the elbow is not common, however, when it is present, it
occurs primarily with the valgus stress. Nature has compensated for this to
a certain extent, in that the medial collateral ligaments of the elbow are
stronger than the lateral collateral ligaments (Hammer, 1991).
Medial or ulnar collateral ligaments: Consist of anterior oblique and
posterior oblique bundles and a transverse ligament.
Anterior oblique bundle: offers medial stability through almost
total flexion and extension. This ligament maintains the elbow
against valgus instability to a greater extent than even the bony
configuration of the olecranon.
Lateral or radial collateral ligament: Originates from the lateral condyle
and inserts on the annular ligament of the radius. According to Hammer, the
elbow does not have a functional lateral collateral ligament (Hammer,
Posterior oblique bundle: offers medial stability in 60 to 135
degrees of flexion and extension.
Transverse ligament: this ligamentís contribution to stability is
negligible (Hammer, 1991).
Annular ligament: Forms a ring around the head of the radius and has firm
fibrous connections with the ulna and is anchored to the neck of the
radius. The head of the radius rotates this ring, which permits rotation
but prevents movement in other directions.
Muscles acting at the elbow and forearm have attachments all along the
upper extremity. Applying resistance while using midpositional muscle
positions will assist the therapist in isolating pathologies in specific
Soft Tissue Disorders of the Elbow
Dislocations, Subluxations, and Sprains: again, elbow instability due to
dislocation, subluxation, or sprain, is not a common problem.
Dislocations: when dislocations do occur, they are almost always posterior
and may be due to direct trauma, such as a fall on the outstretched arm, or
due to "structural fatigue" of the ligaments due to overuse (Hammer, 1991).
Dislocations are classified as posterior, anterior, recurrent, and
divergent (Stralka & Brasel, 1994). Posterior dislocations of the ulna on
the humerus are by far the most common. Anterior dislocations are almost
always associated with fractures of the olecranon. Recurrent dislocations
account for only 1 to 2% of elbow dislocations and result from insufficient
healing of the capsular and ligamentous restraints, which allows
dislocation with forces much less than those responsible for the initial
injury. In divergent dislocations, the radius becomes displaced from the
ulna. This type of dislocation is associated with severe trauma and is a
rare injury. With dislocations, fractures are of concern, as are injuries
to nerves, arteries, muscles, and ligaments.
Dislocation/subluxation of the radial head: Radial head
dislocation/subluxation is commonly known as "nursemaidís elbow", and is
seen in children. This condition is the result of a sudden pull or jerk on
the childís arm, resulting in dislocation or subluxation of the radial head
from the annular ligament (Salter, 1983). This pathology can be confirmed
via the radial apprehension test.
Sprains: The elbow is more prone to instability with valgus forces, and
activities such as repetitive throwing or hammering can cause chronic
valgus insufficiency/sprain of the medial collaterals. Repetitive valgus
stress creates microtears in the ligament(s), which can lead to the
formation of scar tissue, bone spurs, etc., which can ultimately result in
rupture of the ligament. Check for primary ligamentous instability: stress
the ligament in 20-30 degrees of flexion. Surgery for medial collateral
ligament is usually performed if the personís livelihood is affected by the
sprain. If medial collateral ligament is of secondary importance, many
times the physician will not surgically intervene, and will simply allow
scar formation to augment stability.
Tendinitis and Muscle Strains:
- Complications of sprains: fractures associated with the dislocation,
injury to the ulnar nerve, rupture of the anterior joint capsule,
and/or rupture of collateral ligaments.
- Treatment: surgical intervention may be necessary with some period of
immobilization. Strengthening of the triceps, and early motion should
be initiated as soon as appropriate.
Grade III strain of the triceps tendon: varying methods of reattachment.
The person may be immobilized at 30 degrees flexion for 3-4 weeks, then
dynamic splinting performed, with movements greater than 100 degrees of
flexion prohibited for approximately 6 weeks, then progressive ROM can be
Distal biceps tendinitis: irritation due to lifting, repetitive
hyperextension of the elbow with pronation, or repetitive
pronation-supination movements. The most involved site is the distal belly
and musculotendinous regions.
Grade III biceps strain: requires surgical connection, which is dependent
of the location of the rupture. Avulsion fractures are easiest, tears
occurring in the belly are more difficult. The elbow is immobilized at 45
to 90 degrees for 3-4 weeks, then gentle active motion is performed. At 8
weeks - 2 months, begin progressive stretching and strengthening. Full
extension is difficult to reacquire; dynamic splinting may be very
Brachialis strains: because the brachialis crosses the elbow as muscle, not
as tendinous tissue, it is prone to hemorrhage when injured and has a high
potential for significant scar formation. An occasional complication of
brachialis strains is myositis ossificans. The brachialis is frequently
prone to contractures post-injury.
- Treatment for strains and tendinitis: Dependent on the grade of
strain. For grade I and lower grade II strains, determination of the
etiology of the injury is critical. Rest or modified activity, along
with anti-inflammatory modalities and medication will foster healing.
Friction massage in the subacute and latter phases of healing is also
beneficial. Severe grade II and grade III strains require surgery,
followed by a period of immobilization, then gentle, active motion,
then progressive stretching and strengthening.
Lateral epicondylitis/tennis elbow: irritation of the common origin of the
wrist extensors, primarily the extensor carpi radialis brevis, due usually
to actions that are stressful to wrist extension and repetitive in nature.
This pathology is confirmed by Cozenís test/ test for lateral
epicondylitis: resisted wrist extension while palpating the lateral
epicondyle. A positive sign is indicated by pain in the area of the lateral
epicondyle of the humerus.
Medial epicondylitis/golferís elbow: less common than lateral epicondylitis
involving irritation of the medial epicondyle, and associated with
activities that stress wrist flexion and active pronation, such as baseball
pitching, golf swings, or the pull through phase of swimming strokes
(Stralka & Brasel, 1994). The flexor carpi radialis and pronator teres are
commonly involved, with this condition occurring most often in middle-aged
patients involved in baseball, golf, or swimming, or in occupations that
require a strong hand grip and an adduction movement of the elbow.
Bursitis: of the various bursae of the elbow, the two olecranon bursae (the
subcutaneous olecranon and the subtendinous olecranon bursa) are the only
bursae of clinical significance (Moore, 1980).
- Treatment: Should address the etiology, with the goal to restore
normal, pain-free use of the extremity and to prevent recurrence.
Treatment in the acute phase includes ice application, rest, and
gentle active wrist movement to minimize loss of extensibility of the
muscle and tendon. If appropriate instructions are given, and the
patient faithfully follows the outlined program, progression to a more
chronic status should occur over a period of a few days (Hertling &
Kessler, 1996). Treatment in the chronic phase includes advising
patients in gradually resuming activities with adaptations to minimize
stresses on wrist extensors or flexors, ultrasound and friction
massage to promote maturation at the site of healing, strength and
mobility training, and the use of anti-inflammatory agents.
Subcutaneous olecranon bursitis is the most common bursitis at the elbow,
and is usually due to repeated excessive friction on a hard surface. It
presents as a edematous area at the elbow.
Subtendinous olecranon bursitis is much less common, but may result from
excessive friction between the triceps tendon and the olecranon.
Entrapment Syndromes: often the clinical findings of entrapment are similar
to those of the epicondylitis lesions (Hammer, 1991). The specific etiology
of the entrapment may be due to a crush injury, repetitive motion resulting
in chronic irritation from muscular hypertrophy, fascial thickenings, bony
or vascular anomalies, or hypermobile nerves. Therapists must recognize
that entrapment/compression can occur at a number of sites for a number of
nerves. Entrapment symptoms depend on the type of nerve affected and the
amount of compression.
- Treatment of bursitis should address the cause. Ice,
anti-inflammatories, and other modalities can be used; protection of
the area may prove helpful.
Ulnar nerve entrapment: in the elbow region, the most common site of
entrapment is at the cubital tunnel. Signs and symptoms include paresthesia
of the 4th and 5th digits, weak/clumsy interossei muscles, positive Tinel
sign, and positive elbow flexion test. Surgery may be performed to
transpose/redirect the nerve. Usually the elbow is splinted at 30 degrees
for a week before surgery to "calm down" the nerve.
Transposition/redirection often involves an epicondylectomy with re-routing
of the nerve under the flexor-pronator muscles. The elbow is usually
immobilized for 3 weeks, then gentle AROM initiated at 3 weeks. At 6 to 8
weeks, the patient is returned to light-to-moderate activity.
Radial nerve entrapment/posterior interosseous syndrome: The most frequent
site of compression is at the arcade of Frohse, the arch formed by the
proximal edge of the supinator. Symptoms include weakness of the extensors
of the forearm and functional wrist drop, so the patient has difficulty or
is unable to stabilize the wrist for proper hand function. Irritation of
the radial nerve or the posterior interosseous nerve may mimic lateral
epicondylitis (Hammer, 1991).
Median nerve entrapment: there are two types of median nerve entrapment:
pronator syndrome: compression of the median nerve between the
two heads of the pronator teres. Frequently due to repetitive
forceful forearm pronation or due to direct trauma. There is
usually a vague, fatigue-like complaint of pain and numbness on
the proximal volar forearm. Pronator syndrome sensory changes may
mimic carpal tunnel syndrome, which the therapist would want to
rule out by the test of the median nerve.
Fractures of the Elbow and Forearm: can be quite complicated, with factors
such as difficulties of diagnosis of the fracture and maintenance of
reduction, neurovascular complications, malunion, and post-injury
anterior interosseous syndrome: the anterior interosseous portion
of the median nerve supplies only the motor fibers to the flexor
pollicis longus, the flexor digitorum profundus of the second and
third fingers, and the pronator quadratus. The nerve may be
compressed at its origin 5 to 8 cm distal to the lateral
epicondyle or farther distally. Involvement of this nerve is
ruled-in using the pinch-grip test.
Humerus: Intercondylar and condylar fractures of the humerus offer a poor
prognosis for restoration of full elbow range of motion due to difficulty
maintaining good reduction of the fragments, and due to post-traumatic
arthritis when articulating surfaces are involved. Medial and lateral
epicondylar fractures are usually the result of avulsion fractures of the
Olecranon fractures: usually due to significant injury, with some
degree of instability as a result. Because a fracture of the
olecranon is intra-articular, it requires open reduction and
internal fixation unless the fracture is "absolutely anatomic".
Tension band wiring is the most effective fixation (Reid, 1992).
Monteggia fracture: combination injury of fracture of the
olecranon or proximal ulna with associated dislocation of the
radial head due to a fall on the outstretched hand. The
importance of this fracture is that the radial head dislocation
can often be overlooked.
Colleís fracture: fracture of the distal radius, usually due to
falls on the outstretched hand, commonly seen in older people,
Galeazzi fracture: a fracture of the distal one-third of the
radius with associated rupture of the distal radial-ulnar joint,
also involving the interosseous membrane.
- Treatment considerations for fractures:
- internal fixation, via screws, pins, plates;
- external fixation via Kirschner wires through fragments, Hoffman device;
- excision of the bone fragments;
- closed reduction: not seen as much. The rehabilitation technique of
choice is the one that allows the earliest joint motion.
Injury to the elbow and forearm can often lead to post-injury stiffness.
The structures that may become stiff vary, but almost always stiffness is
associated with immobilization and/or guarding of the injured arm near the
trunk. The history is important to determine a time frame of events that
indicates the date of injury, subsequent surgeries (if any), duration of
mobilization, and date of removal of supports or splints. Also want to
determine whether there have been previous attempts at remobilization, and
to identify the factors that may contribute to stiffness. Factors
contributing to stiffness may be extrinsic, intrinsic, a combination of
extrinsic and intrinsic, or acquired.
Extrinsic stiffness: involves extra-articular structures, which include:
periarticular muscle contractures, shortening of the collateral ligaments
due to fibrosis, and stiffening of the joint capsule.
Intrinsic stiffness: caused by intra-articular structures, such as loose
bodies or articular incongruities that interfere with mechanical motion.
"Acquired" stiffness: as a result of arthritis, burns, paralysis, sepsis.
Evaluation of the Elbow and Forearm:
- Treatment of the stiff elbow: Since most capsular elbow restrictions
are those that follow immobilization after injury, they will rarely be
found in an acute stage, since the acute inflammatory process subsides
during the period of immobilization (Hertling & Kessler, 1996),
however, the best treatment for the stiff elbow is early motion
following injury. In the chronic stage, ultrasound may be used
followed by stretching, with stretching incorporated into the home
exercise program as indicated. The home program should also include
exercises to increase flexibility, endurance, and eccentric control
(Hertling & Kessler, 1996). Splinting of the elbow may be used to
protect the part, with passive/static splints being used at night and
active/dynamic splints being used during the day. Surgery to improve
motion should be considered a last resort, and may involve a
manipulation under anesthesia or an anterior capsulotomy.
The evaluation should be reflective of the general orthopedic evaluation,
including a thorough chart review, pertinent history, and physical
examination, proceeding from a general approach to a specific approach.
Although a personís diagnosis may be specific to the elbow, it is important
that the therapist not be so focused on the elbow joint that other areas of
involvement may be missed. It is extremely important for the occupational
or physical therapist to assess the impact that the elbow pathology has had
on the personís life roles. Once the general evaluation has been performed,
then tests specific to the elbow can be administered.
Differential Tests of the Elbow include:
- Valgus Stress Test / Test of Ulnar Collateral Ligament
- Varus Stress Test / Test of Radial Collateral Ligament
- Radio-ulnar Instability / Apprehension Test
- Test of the Wrist Extensors / Tennis Elbow Test (Cozenís Test)
- Test of the Wrist Extensors / Tennis Elbow Test (method 2)
- Test of the Wrist Flexors / Medial Epicondylitis (Golferís Elbow) Test
- Ulnar Nerve Stretch / Elbow Flexion Test
- Tinelís Sign
- Test of the Median Nerve / Test for Pronator Teres Syndrome
- Test of the Anterior Interosseus Nerve / Pinch-grip Test
- Upper Limb Tension Tests
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