Chapter 18: The Elbow and Forearm Complex

A freely mobile but strong and stable elbow complex is required for normal upper extremity function. The design of the elbow and forearm adds to the mobility of the hand in space by shortening and lengthening the upper extremity and by rotating the forearm. The muscles provide control and stability to the region as the hand is used for various activities, from eating, dressing, and grooming to pushing, pulling, turning, lifting, throwing, catching, and reaching for objects to coordinated use of equipment, tools, and machines.^39,50,65,68 Most activities of daily living require a 100° arc of flexion and extension at the elbow, specifically between 30° and 130° as well as 100° of forearm rotation, equally divided between pronation and supination.⁶⁵ Tasks, such as drinking and eating, primarily require elbow flexion, whereas a task, such as reaching to tie shoelaces, requires substantial elbow extension.

Injury or disease of boney, articular, or soft tissue structures of the elbow and forearm can cause pain and compromised mobility, strength, stability, and functional use of the upper extremity. Loss of active or passive elbow flexion interferes with grooming and eating, whereas loss of elbow extension restricts a person's ability to push up from a chair or reach out for objects. In general, loss of terminal flexion of the elbow contributes to greater limitation of function than loss of terminal extension.⁶⁵

The anatomical and kinesiological relationships of the elbow and forearm are outlined in the first section of this chapter. Chapter 10 presents information on principles of soft tissue healing and management; the reader should be familiar with that material before establishing a therapeutic exercise program to improve function of the elbow and forearm.

The distal end of the humerus has two articular surfaces: the trochlea, which articulates with the ulna, and the capitulum, which articulates with the head of the radius (Fig. 18.1). Flexion and extension occur between these two joint surfaces. The radius also articulates with the radial notch on the ulna and is called the proximal radioulnar joint. This joint participates in pronation and supination along with the distal radioulnar joint. The capsule of the elbow encloses the humeroulnar, humeroradial, and proximal radioulnar articulations. The distal radioulnar joint is structurally separate from the elbow complex even though its function is directly related to the proximal radioulnar joint.

Joints of the Elbow and Forearm

There are four joints involved in elbow and forearm function: the humeroulnar, humeroradial, proximal radioulnar, and distal radial ulnar joints.

Elbow Joint Characteristics and Arthrokinematics

The elbow is a compound joint with a lax joint capsule, supported by two major ligaments—the medial (ulnar) and lateral (radial) collateral—which provide medial and lateral stability, respectively.^44,67,68

Humeroulnar Articulation

Characteristics. The humeroulnar (HU) articulation is a modified hinge joint. The medially placed hourglass-shaped trochlea at the distal end of the humerus is convex. It faces anteriorly and downward 45° from the shaft of the humerus. The concave trochlear fossa on the proximal ulna faces upward and anteriorly 45° from the ulna (see Fig. 5.27). The primary motions at this articulation are flexion and extension.

Arthrokinematics. During flexion/extension the concave fossa slides in the same direction in which the ulna moves, so with elbow flexion, the fossa slides around the trochlea in an anterior and distal direction. With elbow extension, the fossa slides in a posterior and proximal direction.

There is also slight medial and lateral sliding of the ulna, allowing for full elbow range of motion (ROM); it results in a valgus angulation of the joint with elbow extension and a varus angulation with elbow flexion. When the bone moves in a medial/lateral direction, the trochlear ridge provides a convex surface, and the trochlear groove provides a concave surface—so with varus the ulna slides in a lateral direction and with valgus the ulna slides in a medial direction.

The arthrokinematics are summarized in Box 18.1.

Humeroradial Articulation

Characteristics. The humeroradial (HR) articulation is a hinge-pivot joint. The laterally placed, spherical capitulum at the distal end of the humerus is convex. The concave boney partner, the head of the radius, is at the proximal end of the radius. Flexion/extension and pronation/supination occur at this articulation.

Arthrokinematics. As the elbow flexes and extends, the concave radial head slides in the same direction as the bone motion, so with elbow flexion, the concave head slides anteriorly, and with elbow extension, it slides posteriorly. With pronation and supination of the forearm, the radial head spins on the capitulum (see Box 18.1).

Ligaments of the Elbow

Medial (ulnar) collateral ligament. The medial collateral ligament complex consists of bundles of fibers that may be differentiated into anterior, posterior, and transverse portions (Fig. 18.2 A). Various portions of the ligament are taut in different ROMs, providing medial support to the elbow against valgus stresses and limiting end-range elbow extension. The ligament also keeps the joint surfaces in approximation.^67,68 Activities, such as throwing and golfing, impose significant stresses on the medial collateral ligament complex.

Lateral (radial) collateral ligament. The lateral collateral ligament complex, a fan-shaped ligament on the lateral surface of the elbow, is composed of the lateral collateral ligament, the lateral ulnar collateral ligament, and the annular ligament.⁶⁸ This complex provides stability to the lateral aspect of the elbow against varus and supination forces, stabilizes the humeroradial joint, resists longitudinal distraction, and prevents posterior translation of the radial head (Fig. 18.2 B).

Forearm Joint Characteristics and Arthrokinematics

Both the proximal and distal radioulnar joints are uniaxial pivot joints that function together to produce pronation and supination (rotation) of the forearm.^44,67,68

Proximal (Superior) Radioulnar Articulation

The proximal radioulnar (RU) articulation is within the capsule of the elbow joint but is a distinct articulation.

Characteristics. The convex rim of the radial head articulates with the concave radial notch on the ulna and the annular ligament. This ligament encircles the rim of the radial head and stabilizes it against the ulna. The primary motion is pronation/supination.

Arthrokinematics. As the forearm rotates into pronation and supination, the convex rim of the radial head slides opposite the bone motion, so with pronation, the head slides posteriorly (dorsally) on the radial notch, and with supination, it slides anteriorly (volarly). It also slides in the annular ligament (see Fig. 18.2), and the proximal surface spins on the capitulum (see Box 18.1).

Distal (Inferior) Radioulnar Articulation

Characteristics. The distal RU joint is an anatomically separate joint at the distal end of the radius and ulna. The concave ulnar notch on the distal radius articulates with the convex notch on the head of the ulna. The distal RU joint, along with the proximal RU joint, participates primarily in pronation/supination.

Arthrokinematics. As the forearm rotates, the concave radius slides in the same direction as the physiological motion. It slides anterior (volar) with pronation and posterior (dorsal) with supination (see Box 18.1).

Muscle Function at the Elbow and Forearm

Muscles in the elbow region not only affect the function of the elbow and forearm, but also wrist and finger function.

Primary Actions at the Elbow and Forearm

Elbow Flexion

Brachialis. The brachialis is a one-joint muscle that inserts close to the axis of motion on the ulna, so it is unaffected by the position of the forearm or the shoulder; it participates in all flexion activities of the elbow.^67,68

Biceps brachii. The biceps is a two-joint muscle that crosses both the shoulder and elbow and inserts close to the axis of motion on the radius, so it also acts as a supinator of the forearm. It functions most effectively as a flexor of the elbow between 80° and 100° of flexion. For the optimal length-tension relationship, the shoulder extends to lengthen the muscle when it contracts forcefully for elbow and forearm function.^67,68

Brachioradialis. With its insertion a great distance from the elbow on the distal radius, the brachioradialis mainly functions to provide stability to the joint. However, it also participates as the speed of flexion motion increases and a load is applied with the forearm from mid-supination to full pronation.^67,68

Elbow Extension

Triceps brachii. The long head of the triceps brachii crosses both the shoulder and elbow; the other two heads are uniaxial. The long head functions most effectively as an elbow extensor if the shoulder simultaneously flexes. This maintains an optimal length–tension relationship in the muscle.^67,68

Anconeus. The anconeus muscle stabilizes the elbow during supination and pronation and assists in elbow extension.^67,68

Forearm Supination

Supinator. The proximal attachment of the supinator at the annular and lateral collateral ligaments may function to stabilize the lateral aspect of the elbow. Unlike the biceps brachii, its effectiveness as a supinator is not influenced by the elbow position.⁸⁰

Biceps brachii. The biceps muscle acts as a supinator if the elbow simultaneously flexes or if resistance is given to supination when the elbow is in extension.¹⁰

Brachioradialis. The brachioradialis contributes to pronation and supination only as an accessory muscle when resistance is provided to the motion.¹⁰ It cannot function alone as a rotator or stabilizer of the forearm joints when other forearm muscles are paralyzed.

Forearm Pronation

Pronator teres. The pronator muscle pronates as well as stabilizes the proximal radioulnar joint and helps approximate the humeroradial articulation.⁶⁸

Pronator quadratus. The pronator quadratus is a one-joint muscle and is active during all pronation activities.

Relationship of Wrist and Hand Muscles to the Elbow

Many muscles that act on the wrist and hand are attached on the distal portion (epicondyles) of the humerus. This allows for effective movement of the fingers and wrist, whether the forearm is in pronation or supination. The muscles provide stability to the elbow but contribute little to motion of the elbow. The position of the elbow affects the length-tension relationship of the muscles during their actions on the wrist and hand.⁶⁸ See Chapter 19 for information on the function of the wrist and hand.

Wrist flexor muscles. The flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis and profundus originate on the medial epicondyle.

Wrist extensor muscles. The extensor carpi radialis longus and brevis, extensor carpi ulnaris, and extensor digitorum originate on the lateral epicondyle.

Referred Pain and Nerve Injury in the Elbow Region

For a detailed description of referred pain patterns and injuries to the peripheral nerves coursing through the elbow and forearm region, see Chapter 13. Table 13.1 summarizes the muscle involvement and functional loss that occur with each of the nerve injuries.

Common Sources of Referred Pain into the Elbow Region

Symptoms referred from the C5, C6, T1, and T2 nerve roots cross the elbow region but are not usually isolated in the elbow.

Nerve Disorders in the Elbow Region

Ulnar nerve. The ulnar nerve courses posteromedial to the olecranon process in the cubital tunnel, which is the most common site for compression of this nerve in the elbow region.

Radial nerve. The radial nerve pierces the lateral muscular septum anterior to the lateral epicondyle and passes under the origin of the extensor carpi radialis brevis and then divides into a superficial and deep branch. Entrapment of the deep branch may occur under the edge of the extensor carpi radialis brevis, or injury may occur with a radial head fracture. The superficial branch may receive direct trauma as it courses along the lateral aspect of the radius.

Median nerve. The median nerve courses the elbow region deep in the cubital fossa, medial to the tendon of the biceps and brachial artery, where it is well protected. The nerve then progresses between the ulnar and humeral heads of the pronator teres muscle and dips under the flexor digitorum profundus muscle. Entrapment may occur between the heads of the pronator muscle, mimicking carpal tunnel syndrome.

In order to make sound clinical decisions when treating patients with elbow and forearm disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting structural and functional impairments, activity limitations, and participation restrictions (functional limitations and possible disabilities). In this section, pathologies and surgical procedures are presented and related to the corresponding preferred practice patterns (groupings of impairments) described in the Guide to Physical Therapist Practice³ (Table 18.1). Conservative and postoperative guidelines for managing these conditions are described in this section.

Joint Hypomobility: Nonoperative Management

Related Pathologies and Etiology of Symptoms

Pathologies, such as rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), and degenerative joint disease (DJD), as well as acute joint reactions after trauma, dislocations, or fractures affect this joint complex. Postimmobilization contractures and adhesions develop in the joint capsule and surrounding tissues any time the joint is immobilized in a cast or splint. This typically occurs after dislocations and fractures of the humerus, radius, or ulna. The reader is referred to Chapter 11 for background information on arthritis and fractures.

Common Structural and Functional Impairments

Acute stage. When symptoms are acute, joint effusion, muscle guarding, and pain restrict elbow flexion and extension, and there usually is pain at rest. If pronation and/or supination are restricted after an acute injury, other conditions, such as fracture, subluxation, or dislocation, may be present.²³ These conditions require medical intervention.

Subacute and chronic stages. A capsular pattern usually exists in the subacute or chronic stages of tissue healing. Elbow flexion is more restricted than extension. There is a firm end-feel and decreased joint play. In long-standing arthritis of the elbow, pronation and supination also become restricted with a firm end-feel and decreased joint play in the proximal RU joint.²³ Arthritis of the distal RU joint results in pain on overpressure.

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• Difficulty turning a doorknob or key in the ignition

• Difficulty or pain with pushing and pulling activities, such as opening and closing doors

• Restricted hand-to-mouth activities for eating and drinking and hand-to-head activities for personal grooming and using a telephone

• Difficulty or pain when pushing up from a chair

• Inability to carry objects with a straight arm

• Limited reach

Joint Hypomobility: Management—Protection Phase

See 'Guidelines for Management Related to the Stages of Tissue Healing' in Chapter 10, Box 10.1.

Educate the Patient

• Inform the patient regarding the anticipated length of acute symptoms and teach methods of joint protection and how to modify activities of daily living. For example, the patient should avoid activities that involve lifting or pushing off with the involved upper extremity.

• Instruct the patient to avoid excessive fatigue by performing exercises frequently during the day but limiting the number of repetitions during each bout (set) of exercises.

Reduce Effects of Inflammation or Synovial Effusion and Protect the Area

• Immobilization in a sling provides rest to the part, but complete immobilization can lead to joint hypomobility, contractures, and limited motion; therefore, frequent periods of controlled movement within a pain-free range should be performed.

• Gentle grade I or II joint distraction and oscillation techniques in the resting position may inhibit pain and move synovial fluid for nutrition in the involved joints (see Chapter 5 for principles of application and techniques).

Maintain Soft Tissue and Joint Mobility

• Passive or active-assistive ROM within limits of pain, including flexion/extension and pronation/supination

• Multiple-angle muscle setting of elbow flexors, extensors, pronators, supinators, and wrist flexors and extensors in pain-free positions

Maintain Integrity and Function of Related Areas

• Shoulder, wrist, and hand ROM and activities should be encouraged within the tolerance of the individual.

• If edema develops in the hand, the arm should be elevated whenever possible. Apply massage as described in Chapter 25.

Joint Hypomobility: Management—Controlled Motion Phase

If joint hypomobility exists, ROM is increased by utilizing joint mobilization techniques as well as passive stretching and muscle inhibition techniques following the principles described in Chapters 4 and 5. Box 18.2 highlights several important precautions if joint restrictions are related to trauma.

Increase Soft Tissue and Joint Mobility

Initiate stretching cautiously and note the joint and tissue response. Vigorous stretching should not be undertaken until the chronic stage of healing. As noted in Box 18.2, high-intensity stretching of the elbow flexors is contraindicated following trauma because of the potential for development of heterotopic bone formation.

• Passive joint mobilization techniques. Because several articulations are involved with each motion at the elbow, it is important to identify which of the articulations have reduced joint play prior to applying grade III sustained or grade IV oscillation techniques. For specific techniques to use, see Figures 5.28, 5.29, 5.30, 5.31,5.32, 5.33 and their descriptions in Chapter 5. Progress each technique by positioning the joint at the end of its available range before applying the mobilization technique.

• Manipulation to reduce a "pushed elbow." Proximal subluxation of the radius may result from falling on an outstretched hand. The radial head is pushed proximally in the annular ligament and impinges against the capitulum. This injury sometimes accompanies a fracture of the distal radius (Colles' fracture) or scaphoid and is not identified as an impairment until after the fracture has healed and the cast is removed. It is often overlooked because there is considerable soft tissue and joint restriction caused by the period of immobilization. Bilateral palpation of the joint spaces reveals the decreased space on the involved side. There may be limited flexion or extension of the elbow, limited wrist flexion, and limited pronation.

• Manipulation to reduce a "pulled elbow." Distal subluxation of the radius is usually seen as an acute injury in children and is sometimes labeled "tennis elbow" when it occurs in adults. It occurs as a result of a forceful pull on the hand such as would occur when a child jerks away from a parent or caregiver or a person tries to pick up a heavy object with a jerking motion on the handle. The force causes the radius to move distalward with respect to the ulna. The head of the radius is unable to slide proximally in the annular ligament when supination is attempted, resulting in the person holding the forearm in pronation. Either supination is restricted, or the patient guards against the motion.

• Manual stretching and self-stretching. Use manual stretching and inhibition techniques to increase the flexibility of any periarticular tissues that are restricting mobility. Use of a cuff weight placed around the distal forearm with the patient carefully positioned for an effective stretch provides a low-intensity, long-duration stretch and is an alternative to manual passive stretching (see Fig. 18.7 in the exercise section). If elbow ROM does not steadily improve after acute symptoms have subsided, the patient may need to begin wearing an adjustable, dynamic splint that applies a low-intensity stretch force over an extended period of time. These stretching interventions are described in Chapter 4.

• Home instructions. Teach the patient self-stretching maneuvers followed by active exercise that utilizes the new range. Suggestions are provided in the last section of this chapter.

Improve Joint Tracking of the Elbow

A mobilization with movement (MWM) technique consisting of a lateral glide combined with the active movement of flexion or extension and pain-free passive overpressure may improve articular surface tracking by allowing the muscles to move the joint in a pain-free manner.⁶⁶ (Refer to the principles of MWM in Chapter 5.)

• Patient position and maneuver: Supine with elbow either flexed or extended to the end of the available range. A mobilization belt is secured around the proximal forearm and your hips. Stabilize the distal humerus at the olecranon process with one hand and support the forearm with the other. Apply a gentle lateral glide to the proximal ulna with the belt by moving your hips. Have the patient produce an active elbow flexion or extension movement and apply a passive overpressure stretch at the end of the range (Fig. 18.3). This should not elicit any pain.

Improve Muscle Performance and Functional Abilities

Initiate active and low-load resistance exercises in open- and closed-chain positions to develop control, muscular endurance, and strength in the muscles of the elbow and forearm. As the patient improves, adapt the exercises to progress toward functional activities. Specific exercises are described in the exercise section of this chapter. Include the shoulder girdle, wrist, and hand in the exercise program as their flexibility and strength has an influence on the recovery of elbow function.

Joint Hypomobility: Management—Return to Function Phase

Improve Muscle Performance

Progress strengthening exercises as the joint tissue tolerates. Teach the patient safe progressions and exercise strategies that promote return to function. To prepare the joints and muscles for specific tasks, use exercises that replicate the repetitions and demands of daily activities, such as pushing, pulling, lifting, carrying, and gripping.

Restore Functional Mobility of Joints and Soft Tissues

If restrictions remain, use vigorous manual or mechanical stretching and joint mobilization techniques.

Promote Joint Protection

Chronic arthritic conditions may require modification of high-load activities to minimize deforming stresses on the involved joints.

Joint Surgery and Postoperative Management

Intra-articular or extra-articular surgical intervention is often necessary for management of severe fractures or dislocations that affect the joints of the elbow and surrounding soft tissues. These injuries may require open reduction with internal fixation or arthroscopic or open excision of bone fragments. In adults, the most common fracture in the elbow region is a fracture of the head and neck of the radius. This type of fracture accounts for approximately one-third of all elbow fractures.^9,71 This injury usually occurs when a person falls on an outstretched hand when the elbow is extended, causing a posterior dislocation and fracture of the radial head coupled with injury of elbow ligaments.³¹

If the proximal radius is displaced and the radial head fracture is comminuted, either open or occasionally arthroscopically assisted reduction with internal fixation or a radial head excision (resection) with or without prosthetic implant are surgical options.^31,59,60,71 It has been suggested that rigid internal fixation (screws or plate fixation) of radial head fractures is indicated in the young, active adult, whereas excision of the radial head is more appropriate for the low-demand patient or if the fracture is severely comminuted and fixation is not possible.⁴⁰ Box 18.3 summarizes the advantages and disadvantages of surgical options for management of displaced fractures of the radial head. Radial head fractures in children, however, are relatively uncommon. When they do occur, closed reduction is preferred.⁷⁸

Small osteochondral defects of one or more of the articular surfaces of the elbow complex occur in the skeletally mature and immature individual (often in the throwing athlete) as the result of repetitive trauma. Such defects, depending on their size, characteristics, and location, may require surgical intervention, such as removal or internal fixation of a fragment, microfracture, or autologous osteochondral or chondrocyte implantation, if nonoperative measures have been ineffective.⁷²

Early-stage or long-standing joint disease (RA, JRA, post-traumatic arthritis) associated with synovial proliferation and destruction of articular surfaces of the elbow joints and leading to pain, limitation of motion, and impaired upper extremity function also may need to be managed with extra-articular or intra-articular surgery. For example, with early-stage RA in which synovial proliferation is present but joint surfaces are still in good condition, arthroscopic or open synovectomy is the procedure of choice for relief of pain if medications have not controlled the disease.^14,32,43,47 Occasionally, advanced arthritis is managed surgically by interposition arthroplasty (only in the young patient on a selective basis),^21,32,73 resection of the radial head with or without prosthetic implant and concomitant synovectomy,^20,28,56,60 or arthrodesis (as a salvage procedure).⁷³ However, today, the most common surgical procedure used to manage severe destruction of the elbow joint is total elbow arthroplasty.^{14,20,21,32,48,61,73} Table 18.2 summarizes how the severity of joint disease and the extent of soft tissue involvement influence the choice of surgical procedure for the elbow complex.^14,21,28,32

The goals of surgery of the elbow joint complex and postoperative rehabilitation include^21,73: (1) relief of pain, (2) restoration of boney alignment and joint stability, and (3) sufficient strength and ROM to allow functional use of the elbow and upper extremity. Surgical procedures done to relieve pain and improve elbow stability tend to be more successful than procedures done solely to increase ROM. Heterotopic bone formation, which leads to joint stiffness, is often a complication of elbow fractures, dislocations, and elbow joint surgery.⁵⁷ Therefore, the single goal of improving ROM is rarely an indication for surgery.²¹

Radial Head Excision or Arthroplasty

Indications for Surgery

The following are frequently cited indications for radial head excision or arthroplasty.

• Severely comminuted fracture or fracture-dislocations of the head or neck of the radius that cannot be reconstructed and stabilized with internal fixation^54,56,59,71

• Chronic synovitis and mild deterioration of the articular surfaces associated with arthritis of the HR and proximal RU joints resulting in joint pain at rest or with motion, possible subluxation of the head of the radius, and significant loss of upper extremity function^21,28,60

CONTRAINDICATIONS: Radial head excision is contraindicated in the growing child.⁷⁸ Excision without replacement of the radial head is not an appropriate option in the presence of a damaged lateral ulnar collateral ligament complex.⁵⁶ As with other joints, arthroplasty also is contraindicated with active infection.

Procedure

Background

Selection of procedure. Depending on the integrity of the ligaments and stability of the elbow complex, a radial head excision may be selected or implant arthroplasty may be the better choice. The use of a prosthetic implant is indicated when there is clinical instability of the elbow as the result of disruption of the supporting ligaments.^49,56,60

Implant designs, materials, and fixation. Radial head implants originally were flexible and made of silicone (Silastic^® material).^21,60 However, this material is no longer used because it has been associated with fatigue failure, particulate debris, and the development of adverse biological reactions, specifically inflammatory arthrosis (synovitis) of the HU joint.⁸⁴ Currently used implants are one-piece or two-piece (modular) designs that more closely replicate the normal biomechanics of the elbow and are made of metal (cobalt-chrome and titanium), ceramics, or ultra-high molecular weight polyethylene.^36,56,59,60 The use of pyrolytic carbon as an implant material also is being investigated.⁵⁶ However, the optimal radial head implant has yet to be designed and fabricated. Cemented or cementless fixation is an option with total elbow arthroplasty (TEA).

Overview of Operative Procedure

A lateral or posterolateral triceps-sparing incision at the elbow and forearm is made into the joint (arthrotomy) just anterior to the lateral collateral ligament. The radial head is exposed, and a radial osteotomy is performed at the level of the annular ligament to resect the head. For a severe fracture, some of the neck of the radius also may need to be excised. When exposing the operative field, effort is made not to detach intact ligaments. A concomitant synovectomy is done if proliferative synovitis is present (typically seen in RA and JRA).

If an implant is to be inserted, the medullary canal of the radius is prepared to accept the stem of the prosthesis. If the elbow is unstable, ligamentous structures are repaired. If the lateral ulnar collateral ligament (LUCL) is insufficient, it may be reinforced with a palmaris longus autograft or allograft. To prevent injury to the ulnar nerve or if symptoms of compression are present, ulnar nerve transposition is also performed.^28,56,59,60

Complications

Intraoperative complications. Damage to the posterior interosseous nerve is a concern during surgical excision of the radial head regardless of whether a radial head replacement is included in the procedure.⁵⁶ If an implant is inserted, malpositioning or inaccurate sizing can cause postoperative pain and HR instability, compromise ROM, and eventually contribute to premature implant wear.

Postoperative complications. Postoperatively complications of excision with or without implant may include delayed wound closure, infection, limited ROM of the elbow and/or forearm, cubital laxity, persistent pain, and a sense of instability. Slight proximal migration of the radius may occur if resection does not include implantation of a prosthetic radial head. This complication may or may not be associated with elbow or wrist pain. Following excision for a severe radial head fracture, osteoarthritis of the HR joint also may develop over time.^56,59

As with all types of implant arthroplasty, aseptic loosing or long-term implant wear and breakage are complications that may occur, necessitating revision arthroplasty. Although not unique to elbow surgery, complex regional pain syndrome may develop in rare instances.

Postoperative Management

The goals and interventions, the rate of progression, and the length of the rehabilitation program, as well as final outcomes, are highly dependent on the extent of damage to soft tissues from injury or chronic inflammation, the integrity of repaired soft tissues particularly the supporting ligaments of the elbow complex, the philosophy of the surgeon, and the patient's expectations of the surgery and response to treatment.

Immobilization

The elbow is immobilized continuously in a well-padded posterior resting splint in a position of 90° of flexion and mid-position of the forearm after surgery.^59,60 When elbow motion is permissible (often as early as 1 to 3 days after surgery or longer if significant reconstruction of ligaments was necessary), the splint is removed for exercise but is replaced after exercise and worn at night for an extended period of time to protect healing tissues. If the stability of the elbow is in question, the patient may need to wear a dynamic (hinged) splint for ROM exercises.

Exercise: Maximum Protection Phase

Goals and interventions. The first phase of rehabilitation, which extends for about the first 6 weeks after surgery, focuses on patient education that emphasizes wound care, control of pain and peripheral edema, and exercises to offset the adverse effects of immobilization while protecting repaired soft tissues that maintain the stability of the elbow. The arm is elevated for comfort and to control edema distally. The following goals and exercise-related interventions typically are included in this initial phase.^{9,51,59,60,91}

• Maintain mobility of unoperated joints. Active ROM exercises of the shoulder, wrist, and hand immediately after surgery.

• Maintain mobility of the elbow and forearm. When permitted, have the patient remove the splint several times daily for self-ROM (passive or active-assisted) of the elbow and forearm within pain-free ranges. Active ROM is allowed within a week after exercises are initiated. As noted previously, some patients must wear a hinged splint for additional stability during ROM exercises.

• Minimize muscle atrophy. Submaximal, pain-free, multiple-angle setting exercises of elbow and forearm musculature.

Exercise: Moderate and Minimum Protection Phases

Goals and interventions. The intermediate phase of rehabilitation begins when wound healing is satisfactory and active movements of the elbow are relatively pain-free. This phase and the final phase of rehabilitation are characterized by continued efforts to restore nearly full or at least sufficient ROM for functional activities while maintaining stability of the elbow. Exercises to improve upper extremity strength and muscular endurance and use of the involved elbow for light functional activities are introduced and progressed.⁹

NOTE: It is important to note that some surgeons and therapists prefer to improve strength and muscular endurance solely through ADL without the use of specific resistance exercises.^51,59,60

• Increase ROM, particularly if contractures were noted preoperatively.

  • Gentle (low-intensity) manual stretching, hold-relax techniques (PNF stretching), or self-stretching

  • Grade II joint mobilization techniques initially, followed by grade III mobilizations after 6 weeks when the joint capsule is well healed

CONTRAINDICATION: When applying joint mobilization techniques, do not perform valgus/varus stretches in terminal extension/flexion, particularly if the radial head was not replaced with a prosthetic implant or if the integrity of the supporting ligaments and stability of joints are questionable.

• Low-load, long-duration, dynamic splinting or alternating use of static splints in maximum flexion and extension

• Improve functional strength and muscular endurance.

• Low-load resistance exercises (maximum 1 to 2 lb), emphasizing high repetitions

• Use of the operated upper extremity for light ADL

Resumption of recreational and work-related activities. Patient education is a key element of helping the patient return safely to physical activities. Following excision of the radial head with or without a prosthetic implant, a patient must permanently refrain from high-demand or high-impact, work-related or recreational activities regardless of the underlying pathology that necessitated surgery.⁵¹ Be certain the patient knows to avoid using the involved upper extremity for moving or holding heavy objects or refrain from participating in recreational activities that impose significant stress across the elbow complex, such as racquet sports.

Total Elbow Arthroplasty

When nonoperative management or previous surgical procedures have been unsuccessful, total elbow arthroplasty (TEA) has been considered a treatment option primarily for the older individual (over 60 to 65 years of age) with debilitating, late-stage elbow arthritis whose physical demands are relatively low.^11,73 However, since the first cemented TEA was introduced several decades ago,²⁴ the indications for this procedure have broadened considerably as the design of prosthetic implants and surgical techniques have evolved.⁸⁸ TEA is now considered for the younger patient. One resource, for example, has suggested that any individual, older than age 30, might be an appropriate candidate for TEA depending on their expected postoperative demands.³² A long-term followup of patients, who had undergone TEA at or before the age of 40 for various types of elbow arthritis, showed that 93% continued to have good to excellent outcomes at a mean duration of 91 months after surgery.¹⁶

In addition to management of advanced arthritis, TEA now is considered a preferred surgical alternative to open reduction and internal fixation for management of severely comminuted, intra-articular distal humeral fractures sustained by elderly patients.^53,75

Indications for Surgery

The following are currently accepted indications for TEA.

• Debilitating pain and loss of functional use of the upper extremity as the result of moderate to severe joint pain and articular destruction of the HU and HR joints.^{11,21,32,73,75} Underlying diseases managed with TEA include RA (by far the most common pathology),^28,34,61,63 JRA,²⁰ and post-traumatic degenerative arthritis or primary OA.^32,62,77

• Gross instability of the elbow^{11,31,41,74,75}

• Acute comminuted, intra-articular fracture^18,53 and nonunion fracture of the distal humerus^58,64

• Failed interposition arthroplasty or radial head resection⁷⁶

• Marked bilateral limitation of motion of the elbows^21,22,58

CONTRAINDICATIONS: Absolute and relative contraindications for TEA are identified in Box 18.4.^{11,22,32,48,61,75} It is important to note, however, with the exception of active infection, there is lack of agreement as to which contraindications are absolute versus relative.

Procedure

Background

The complex structural relationships among the HU, HR, and proximal RU joints have made developing a prosthetic elbow joint a challenging task. Following introduction and use of early cemented elbow replacements,²⁴ incremental improvements in design, materials, fixation, and surgical technique have contributed to increasingly predictable and successful outcomes.^21,73 Elbow replacement systems include a humeral and an ulnar implant (Fig. 18.4), and some designs also include replacement of the head of the radius.^48,58,61

Implant design and selection considerations. Early designs were hinged (linked, articulated) and fully constrained metal-to-metal humeral and ulnar implants that allowed only flexion and extension of the elbow joint.^21,32,73 These designs made no allowances for normal varus and valgus and rotational movements, and hence, the implants rapidly loosened at the bone-cement interface. Metal fatigue at the linkage of the prosthetic components and joint dislocation also were common complications.^7,35 As more accurate information about the biomechanical characteristics of the elbow joint became known, the design of prosthetic replacements evolved. In addition to an arc of flexion and extension, contemporary designs provide 5° to 10° of varus and valgus and a small degree of rotation (Fig. 18.5).⁶¹

The designs of total elbow replacement can be classified into two broad categories: linked (articulated) and unlinked (nonarticulated).⁷ Rather than being fully constrained, as the early components were, linked humeral and ulnar implants are now loosely constrained and, as such, are referred to as semiconstrained designs.^34,58,61,77 Designs classified as unlinked are composed of two separate, nonarticulated implants and are often called resurfacing replacements.^7,22,32,48 The most recent advance in implant design is the hybrid prosthesis, which can be inserted as either a linked or unlinked replacement system. Use of a hybrid replacement enables the surgeon to determine the more appropriate design based on intraoperative observations and evaluation.⁷

The criteria for use of a linked or unlinked TEA are based in part on the characteristics of these designs with respect to stability. Linked designs derive inherent stability from one or two pins, which couple the humeral and ulnar components.⁵⁸ In addition, some semiconstrained designs have an anterior flange to enhance joint stability and decrease the risk of posterior dislocation.⁶¹ Unlinked implant systems, although sometimes referred to as nonconstrained,³² actually have varying degrees of constraint built into their designs based on the degree of congruency of the articulating surfaces.^22,48 The less constraining the articular surfaces of the implants, the more reliant the replacement system is on the surrounding soft tissues, particularly the collateral ligaments, for joint stability.

Overall, linked designs, because of their inherent stability, are considered appropriate for use with a broader spectrum of patients, including those with unstable elbows, than unlinked designs.³² Although both linked and unlinked designs derive some degree of stability from the supporting capsuloligamentous structures and elbow musculature, the integrity of these soft tissues is far more critical for successful use of unlinked than linked designs.^7,58

In addition to considerations related to stability, the etiology and extent of joint destruction, the degree of deformity, the quality of the available bone stock, and the training and experience of the surgeon are factors that influence the type of replacement system used.

Materials and fixation. A stemmed titanium humeral component that has a cobalt-chrome alloy articulating surface interfaces with a high-density polyethylene articulating surface of a stemmed ulnar component.^7,21 Currently, prosthetic components are cemented in place with polymethyl methacrylate, an acrylic cement. Some designs also have a porouscoated extramedullary flange for osseous ingrowth. To date, all-cementless fixation has not yet been developed for total elbow arthroplasty.^21,73

Operative Overview

The following is a brief overview of typical elements involved in a TEA.^{11,22,32,48,58,61,77} A longitudinal incision is made at the posterior aspect of the elbow, either slightly lateral or medial to the olecranon process. The ulnar nerve is isolated, temporarily displaced, and protected throughout the procedure. The distal attachment of the triceps is detached and reflected laterally with a triceps-reflecting approach or split longitudinally and retracted along the midline with a triceps-splitting approach.^22,61 The more recently developed triceps-sparing (triceps-preserving) approach is also an option. It involves incisions on the medial and lateral aspects of the elbow joint. This approach preserves the attachment of the triceps tendon on the olecranon but makes insertion of the implants more technically challenging.^8,32

As the procedure progresses, ligaments and other soft tissues are released as necessary; the posterior aspect of the capsule is incised and retracted; and the joint is dislocated. In preparation for the implants, small portions of the distal humerus and proximal ulna are resected. Depending on the status of the radial head, the integrity of the collateral ligaments, and the design of the prosthesis, the head of the radius may or may not be excised. Then the intramedullary canals of the humerus and ulna and possibly the radius are prepared, and trial components are inserted. The available ROM and stability of the prosthetic joint are checked intraoperatively and x-rays are taken to confirm proper alignment of the implants. The components are then cemented in place, and the capsule and any ligaments that had ruptured prior to surgery or were released during the procedure are repaired to the extent possible or necessary based on the design of the prosthesis and the quality of the structures. If detached or split, the extensor mechanism is securely reattached or meticulously repaired. Following possible anterior transposition and careful placement of the ulnar nerve in a subcutaneous pocket, the incision is closed, and a sterile compressive dressing and posterior and/or anterior splint are applied to immobilize the elbow and forearm. The arm is elevated to control peripheral edema.

Complications

Although the incidence of complications has declined steadily over the past few decades as selection of patients, prosthetic design, and surgical technique have improved, complications after TEA continue to occur more frequently than after total hip, knee, or shoulder arthroplasty.^8,88

Complications are categorized as intraoperative and postoperative—early or late (before or after 6 weeks).⁷⁰

Intraoperative complications. Intraoperative complications, such as fracture and component malpositioning, can significantly affect short- and long-term outcomes. Ulnar damage or irritation, either transient or permanent, also can occur intraoperatively from handling or during the early weeks after surgery from compression as well,^8,35,70,88 typically causing paresthesia but not weakness.^32,75

Postoperative complications. Deep infection, a concern after any surgery, is reported to occur in an average of 3.3% (±2.9%) of cases following current-day TEA.⁸⁸ This rate is higher for TEA than large joint arthroplasties, owing to the thin layer of soft tissues covering the elbow joint and because the majority of patients undergoing TEA have inflammatory arthritis and a compromised immune system due to medication.^75,88

Other postoperative complications, including joint instability, wound healing problems, and triceps insufficiency, are of particular concern during the early and intermediate phases of rehabilitation. Despite continuing improvements in implant design and fixation and surgical techniques, some complications develop several months or even years after surgery. These complications include aseptic (biomechanical) loosening of the prosthetic implants over time at the bone-cement interface (the most common long-term complication and reason for revision arthroplasty), periprosthetic fracture, and mechanical failure or premature wear of the components.^{8,30,32,75,88}

It is important for a therapist to be familiar with the incidence and possible causes of complications after TEA in order to effectively structure and progress a postoperative rehabilitation program that decreases at least some of the risk factors associated with these complications. The incidence and characteristics of selected postoperative complications (joint instability, triceps insufficiency, prosthetic loosening) after TEA and factors that contribute to these complications are summarized in Box 18.5.^{8,35,70,74,75,88} Precautions to reduce the risk of these and other complications are addressed in the following section on postoperative management.

Postoperative Management

The overall goal of rehabilitation after TEA is to achieve pain-free ROM of the elbow joints as well as strength of the upper extremity sufficient for functional activities while minimizing the risk of early or late postoperative complications. This goal is best achieved with an individualized rehabilitation program based on a thorough examination of each patient's postoperative status.

Immobilization

As noted previously, a soft compression dressing is applied at the close of surgery. A well padded posterior or anterior splint is used to immobilize the elbow and maintain stability and protect structures as they heal. Recommendations for the positions and duration of immobilization vary.

Position. The position of immobilization is based on a number of factors, including the surgical approach, the implant design, and which soft tissues were repaired and require protection.^6,22,28,51 If, for example, a triceps-reflecting approach was used for a linked TEA, full or almost full elbow extension typically will be selected to protect the reattached triceps tendon and a neutral position of the forearm.^6,22,58,61 In contrast, with an unlinked TEA, which typically requires repair of the lateral ligament complex because of preoperative damage or release for operative exposure of the joint, the position of immobilization is a moderate degree of flexion with limitation of full forearm supination to lessen stress on the repaired ligaments.^6,70 If a patient had a significant preoperative elbow flexion contracture that was surgically released, an anterior splint may be selected with the elbow placed in the available amount of extension. An extended position is also indicated if symptoms of ulnar neuropathy are present to alleviate pressure in the cubital tunnel.^58,61,70

Duration. The period of continuous immobilization after surgery, which is kept as short as possible to avoid stiffness, also varies widely, ranging from 1 to 2 days to several weeks. This time period depends on the design of the prosthesis, the surgical approach, the integrity of ligamentous structures, intraoperative observations by the surgeon, and the integrity of the skin and subsequent wound healing. In general, unlinked/resurfacing designs, which have little inherent stability, require a longer period of immobilization than linked/semiconstrained designs.^8,28,51

If there is increased risk of delayed wound healing because of poor skin quality or a patient's history of diabetes, smoking, or use of steroids, the elbow may be continuously maintained in extension for 10 to 14 days postoperatively to limit stress on the posterior incision.^58,61,70 Even after it is permissible to remove the splint for exercise or self-care, the patient is advised to continue to wear the splint at night for protection for up to 6 weeks.^6,51 If there was a preoperative flexion contracture, an adjustable splint that maintains the elbow in extension is worn periodically during the day for a prolonged stretch, and a static (resting) splint is worn at night to hold the arm in a comfortably extended position. This regimen may be followed for 8 to 12 weeks postoperatively to prevent recurrence of the contracture.^51,58,61

Exercise Progression

The progression of a postoperative exercise program after TEA varies considerably based on many factors. Key factors and their impact on postoperative rehabilitation are identified in Table 18.3.^6,22,51,91 The rehabilitation process proceeds most rapidly when a triceps-sparing approach is used to insert a linked replacement in a patient whose incision is healing well. On the other end of the spectrum, in which rehabilitation must progress most cautiously, is the use of a triceps-reflecting approach for an unlinked replacement, requiring release and repair of the lateral ligament complex in a patient with poor skin quality.

Just as the progression of exercise is based on the unique features of each patient's surgery, precautions are determined in a similar manner. It is particularly important for the therapist to know the status of repaired soft tissues to incorporate the necessary precautions into the exercise program. Information in the operative report and close communication with the surgeon are the best sources for these details. Specific precautions for exercise and functional use of the operated upper extremity are summarized in Box 18.6.^{6,11,51,58,75,91} Patient education about these precautions should occur throughout the rehabilitation program. A patient's adherence to precautions ensures more positive outcomes and lessens the likelihood of short- or long-term postoperative complications related to exercise and use of the operated arm for functional activities.

Exercise: Maximum Protection Phase

The focus during the first phase of rehabilitation, which extends approximately over a 4-week period, includes control of inflammation, pain, and edema with use of medication as needed, application of cold and regular elevation of the operated arm. Emphasis is also placed on careful inspection of the wound, protection of repaired soft tissues as they begin to heal, and early ROM exercises to offset the adverse effects of immobilization without jeopardizing the stability of the prosthetic joint. Assisted ROM as tolerated and within the ranges achieved intraoperatively typically is initiated 2 to 3 days after linked TEA and a few days later after unlinked TEA if the elbow is stable.^6,51,91

Goals and interventions. The goals and exercise interventions during this first phase include the following.^{6,19,25,48,51,58,61,91}

• Maintain mobility of the shoulder, wrist, and hand.

  • Active ROM of these regions during the immediate postoperative period. This is particularly important for the patient with RA or JRA involving these joints.

• Regain motion of the elbow and forearm.

  • After a linked TEA or if the elbow is stable after an unlinked TEA, start with gentle self-assisted elbow flexion/extension and pronation/supination with the elbow comfortably flexed and the forearm in mid-position, progressing to active ROM as tolerated. As acute symptoms subside, have the patient maintain the end-range position to apply a very low-intensity stretch.

  • If the triceps mechanism was reflected and repaired, limit assisted flexion to 90° to 100° for the first 3 to 4 weeks to avoid excessive stretch on the repaired triceps tendon. Perform active elbow flexion/extension in a seated or standing—rather than supine—position for the same time frame to avoid antigravity extension, which also could cause excessive stress to the reattached triceps mechanism and subsequent insufficiency.^6,19,51 While sitting and standing, elbow extension is gravity-assisted; extension is controlled by an eccentric contraction of the elbow flexors.

  • If a linked replacement was implanted using a triceps-sparing approach, there is little to no risk of early postoperative instability or disruption of the triceps mechanism. Therefore, active ROM in all planes of motion is permissible immediately.

NOTE: Some sources recommend that after linked arthroplasty involving a triceps-reflecting approach—and if secure reattachment of the triceps tendon was achieved—ROM exercises progress as tolerated without restriction.^31,61

• Minimize atrophy of upper extremity musculature.

  • Gentle, pain-free muscle-setting exercises of elbow musculature (against no resistance) while in the splint and later, multiple-angle setting exercises when the splint can be removed.

  • Low-intensity, isometric resistance exercises of the shoulder, wrist, and hand.

  • Use of the hand for light functional activities as early as 1 to 2 weeks postoperatively if a linked replacement was inserted but several weeks later after an unlinked TEA.^58,61

Exercise: Moderate and Minimum Protection Phases

By about 4 to 6 weeks postoperatively, soft tissues have healed sufficiently to withstand increasing stresses. By 12 weeks, barring complications, only minimum protection is necessary; therefore, a patient typically can resume most functional activities with some imposed restrictions (see Box 18.6). However, the recommended timeline for return to a reasonably full level of activity varies from 6 weeks^22,48,58 to 3 to 4 months.^6,25,51

Goals and interventions. The focus of rehabilitation during the intermediate and final phases is to improve ROM to the extent achieved intraoperatively, regain strength and endurance of elbow musculature, and use the operated arm for gradually demanding functional activities. However, these goals must be reached without disrupting repaired soft tissues and compromising the stability of the prosthetic elbow. Strength and muscular endurance usually continue to improve up to 6 to 12 months postoperatively by cautious use of the operated arm for functional activities.

Patient education, especially with regard to the resumption of functional activities, is ongoing until the patient is discharged from therapy. The following goals and interventions are added during the moderate and minimum protection phases of rehabilitation.^6,25,51

• Increase ROM of the elbow.

NOTE: It is the opinion of the authors that use of joint mobilization techniques to increase ROM of the elbow or forearm is inappropriate after TEA, particularly with linked implants or if the stability of the elbow is questionable. If selected as a stretching technique, it should be implemented only after specific consultation with the surgeon to determine its appropriateness. It is a more prudent choice to forego full elbow motion than to jeopardize the stability of the joint.

• Low-intensity, manual self-stretching.

• Low-load, long-duration dynamic splinting,^13,38,51,83 as described and illustrated in Chapter 4 (see Fig. 4.13), or alternating use of static splints, each fabricated in maximum but comfortable extension and flexion.

PRECAUTIONS: Emphasize end-range extension before end-range flexion to protect the posterior capsule and the triceps mechanism. If symptoms of cubital tunnel syndrome are present (aching along the medial forearm and hand, paresthesia, or hyperesthesia due to compression or entrapment of the ulnar nerve), avoid prolonged or repeated end-range positioning or stretching to increase elbow flexion.^2,11

• Regain functional strength and muscular endurance of the operated extremity.

NOTE: Some sources advocate progressive use of the operated upper extremity to regain strength and muscular endurance rather than an exercise program.^31,48,58,61

• Resisted, multiple-angle isometric exercises at 5 weeks if not initiated previously.

• Light ADL (initially <1 lb of weight) performed with the arm positioned along the side of the trunk and the elbow flexed. If a triceps-reflecting approach was used, incorporate activities that require elbow flexion before elbow extension. Initially modify activities to avoid those that require lifting with the elbow extended and pushing motions, such as pushing up from a chair or using a walker, axillary crutches, or a cane.

• Dynamic, open-chain resistance exercises no earlier than 6 weeks and often later using a light-weight (1 lb) or light-grade elastic resistance. Emphasize gradually increasing repetitions rather than resistance.

• Repetitive lifting during exercise and functional activities limited to 1 lb for the first 3 months and 2 lb for the next 3 months. Permanently limit repetitive lifting to no more than 5 lb and a single lift to no more than 10 to 15 lb.^{6,22,48,51,58,61} (See Box 18.6 for additional restrictions to strengthening exercises and functional activities.)

• Low-load, closed-chain activities, such as wall push-ups after 6 weeks or later (when the triceps mechanism and posterior capsule have healed).

• Upper extremity ergometry.

CONTRAINDICATIONS: High-load progressive resistive exercise (PRE), heavy lifting during home- and work-related activities, and recreational activities that place high-loads or impact on the upper extremities (e.g., racquet and throwing sports or golf) are not allowed after TEA. These activities must be permanently avoided to reduce the risk of complications, such as elbow instability, implant loosening, and polyethylene wear.^{6,17,25,48,51,61}

Myositis Ossificans

The terms myositis ossificans and heterotopic or ectopic bone formation are often used interchangeably to describe the formation of bone in atypical locations of the body. Some resources^39,54,57 use the term myositis ossificans to denote only ossification of muscle. More often, the term is used generally to characterize heterotopic bone formation in the muscle-tendon unit, capsule, or ligamentous structures. In this text, the terms myositis ossificans and heterotopic bone formation are used synonymously.

Etiology of Symptoms

Although not a common phenomenon, the sites most frequently involved are the elbow region and thigh. In the elbow, heterotopic bone formation most often develops in the brachialis muscle or joint capsule as the result of trauma, such as a comminuted fracture of the radial head, a fracture-dislocation (supracondylar or radial head fracture) of the elbow, or a tear of the brachialis tendon.^23,39,57,59 Patients with neurological impairments, specifically traumatic brain injury or spinal cord injury, and patients with burns to the extremities are also prone to develop this complication.⁵⁷ It also may develop as the result of aggressive stretching of the elbow flexors after injury and a period of immobilization.²³

Myositis ossificans is distinguished from traumatic arthritis of the HU joint in that passive extension is more limited than flexion; resisted elbow flexion causes pain; flexion is limited and painful when the inflamed muscle is pinched between the humerus and ulna; and resisted flexion in mid-range causes pain in the brachialis muscle. Palpation of the distal brachialis muscle is tender.^23,39 After the acute inflammatory period, heterotopic bone formation is laid down in muscle between, not within, individual muscle fibers or around the joint capsule within a 2- to 4-week period. This makes the muscle extremely firm to touch. Although this condition can permanently restrict elbow motion, in most cases, the heterotopic bone, is largely reabsorbed over several months, and motion usually returns to near normal.⁵⁴

Management

Massage, passive stretching, and resistive exercise are contraindicated if the brachialis muscle is implicated after trauma. The elbow should be kept at rest in a splint, which should be removed only periodically during the day for active, pain-free ROM. Rest should continue until the boney mass matures and then resorbs. If the capsule also is involved, surgical excision of heterotopic bone from muscle or TEA is necessary only in rare instances.^54,57

Overuse Syndromes: Repetitive Trauma Syndromes

Overuse can occur in any musculotendinous structure in the elbow region, including the flexors and extensors of the elbow, but it most commonly occurs in the muscles attached to the lateral or medial epicondyles in response to repetitive stressful wrist motions. Problems anterior or posterior to the elbow frequently are caused by excessive extension or flexion strain in sporting activities.⁴ Discussion in the literature as to whether overuse syndromes have an inflammatory component or are primarily degenerative in response to repetitive trauma lead to questions on use of terminology.^27,46,85

Overuse of the medial and lateral musculotendinous structures causing microscopic tears and inflammation is commonly termed epicondylitis (medial and lateral epicondylitis), and overuse of the distal biceps and triceps tendons is called tendonitis.^23,85 Tendinosis or tendinopathy refers to degenerative changes in the collagen tissue without signs of inflammation. These changes include immature fibroblastic and vascular elements and weakening of the tendinous structure.^27,85

Related Pathologies

Lateral Elbow Tendinopathy (Tennis Elbow)

Tennis elbow is commonly called lateral epicondylitis, lateral epicondylalgia, or lateral epicondylosis depending on whether inflammation is present or not.^79,85 Symptoms include pain in the common wrist extensor tendons along the lateral epicondyle and HR joint with gripping activities. Activities requiring firm wrist stability, such as the backhand stroke in tennis, or repetitive work tasks that require repeated wrist extension, such as computer keyboarding or pulling weeds in a garden, can stress the musculotendinous unit and cause symptoms. The most frequent location of involvement is in the musculotendinous junction of the extensor carpi radialis brevis,^{23,26,27,39,69,85} although the extensor communis is also involved in many patients.²⁷ Symptoms also occur when the annular ligament is stressed.

Positive tests of provocation include palpation tenderness on or near the lateral epicondyle, pain with resisted wrist extension performed with the elbow extended, pain with resisted middle finger extension performed with the elbow extended, and pain with passive wrist flexion with the elbow extended and forearm pronated.^23,89

NOTE: Pulled elbow, pushed elbow, rotated elbow, radial head fracture, pinched synovial fringe,⁶⁸ meniscal lock, radial tunnel syndrome, tendinosis,⁴⁶ and periosteal bruise are also possible sources of pain at the elbow and are sometimes erroneously called tennis elbow.⁴⁹

Medial Elbow Tendinopathy (Golfer's Elbow)

Golfer's elbow, also known as medial epicondylitis, medial epicondylalgia, or medial epicondylosis, involves the common flexor/pronator tendon at the tenoperiosteal junction near the medial epicondyle. It is associated with repetitive movements into wrist flexion, such as swinging a golf club, pitching a ball, or work-related grasping, shuffling papers, and lifting heavy objects. Concomitant ulnar neuropathy is often an associated finding.^33,39

Positive tests of provocation include palpation tenderness on or near the medial epicondyle, pain with resisted wrist flexion performed with the elbow extended, and pain with passive wrist extension performed with the elbow extended.

Etiology of Symptoms

The most common cause of epicondylalgia is excessive repetitive use or eccentric strain of the wrist or forearm muscles. The result is microdamage and partial tears, usually near the musculotendinous junction when the strain exceeds the strength of the tissues and when the demand exceeds the repair process. Initially there may be signs of inflammation followed by the formation of granulation tissue and adhesions.⁶⁹ With repetitive trauma, fibroblastic activity and collagen weakening occurs. Recurring problems are seen because the resulting immobile or immature scar is re-damaged when returning to activities before there is sufficient healing or mobility in the surrounding tissue.

Hypersensitivity over the radial and ulnar nerves has been reported to occur in women with lateral epicondylalgia, indicating a possible link between mechanical irritation and nerve sensitization.²⁹

Common Structural and Functional Impairments

• Gradually increasing pain in the elbow region after excessive activity of the wrist and hand

• Pain when the involved muscle is stretched or when it contracts against resistance

• Decreased muscle strength and endurance for the demand

• Decreased grip strength, limited by pain

• Tenderness with palpation at the site of inflammation, such as over the lateral or medial epicondyle, head of the radius, or in the muscle belly

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• Inability to participate in provoking activities, such as racket sports, throwing, or golf.

• Difficulty with repetitive forearm/wrist tasks, such as sorting or assembling small parts, typing on a keyboard or using a computer mouse, gripping activities, using a hammer, turning a screwdriver, shuffling papers, or playing a percussion instrument.

Nonoperative Management of Overuse Syndromes: Protection Phase

Utilize the following management guidelines and interventions when signs of acute or chronic inflammation are present.

Decrease Pain, Inflammation, Edema, or Spasm

• Immobilization. Rest the muscles by immobilizing the wrist in a splint such as a cock-up splint in which the elbow and fingers are free to move.

• Patient instruction. Instruct the patient to avoid all aggravating activities, such as strong or repetitive gripping actions.

• Cryotherapy. Use ice to help control edema and swelling.

Develop Soft Tissue and Joint Mobility

• Multiple-angle muscle setting (low-intensity isometrics). Have the patient remove the splint several times a day and perform gentle multiple-angle setting techniques to the involved muscle followed by ROM within the pain-free range.

  • Technique for wrist extensor muscles.

Patient position and procedure: Sitting with the elbow flexed, forearm pronated and resting on a table, and the wrist in extension. Begin with gentle isometric contractions with the wrist extensors in the shortened position. Resist wrist extension, hold the contraction to the count of 6, relax, and repeat several times; then move the wrist toward flexion and repeat the isometric resistance. Do not move into the painful range or provide resistance that causes a painful contraction.

When full wrist flexion is obtained without pain in the lateral epicondyle region, progress by placing the elbow in greater degrees of extension and repeat the isometric resistance sequence to the wrist extensors. Progress until gentle resistance can be applied to the wrist extensors in the position of elbow extension and wrist flexion. It may take several weeks to reach this position.

• Technique for wrist flexor muscles.

Patient position and procedure: Sitting with the elbow flexed, forearm resting on a table, and the wrist in flexion. Begin with gentle isometric contractions with the wrist flexors in the shortened position. Resist wrist flexion, hold the contraction to the count of 6, relax, and repeat several times; then move the wrist toward extension and repeat the isometric resistance. Do not move into the painful range or provide resistance that causes a painful contraction.

When full wrist extension is obtained without pain in the medial epicondyle region, progress by placing the elbow in greater degrees of extension and supination and repeat the isometric resistance sequence to the wrist flexors. As stated above, it may take several weeks to reach the full range of elbow extension, forearm supination, and wrist extension and to be able to tolerate gentle resistance.

• Cross-fiber massage. Apply gentle cross-fiber massage within tolerance at the site of the lesion. Teach the patient to self-administer the submaximal isometric and cross-fiber massage techniques in a home exercise program.

• Neuromobilization. If increased symptoms occur with nerve tension testing, use neuromobilization techniques as described in Chapter 13.

Maintain Upper Extremity Function

• Active ROM. Have the patient perform ROM to joints not immobilized to maintain the integrity of the rest of the upper extremity.

• Resistive exercises. Have the patient perform shoulder and scapular ROM and stabilization exercises with resistance applied proximal to the elbow.

Nonoperative Management: Controlled Motion and Return to Function Phases

Utilize the following management guidelines and interventions when there are no signs of inflammation.

Increase Muscle Flexibility and Scar Mobility

• Manual stretching techniques. Use agonist contraction, hold-relax, and passive stretching techniques to elongate the tight muscle to the end of its range (principles for application of these techniques are described in Chapter 4). Use an intensity of muscle contraction and stretch that causes a stretching sensation but not increased pain.

  • For both the wrist flexors and wrist extensors, the elbow must be extended.

  • To stretch the wrist extensors, pronate the forearm, flex and ulnarly deviate the wrist, and flex the fingers.

  • To stretch the wrist flexors, supinate the forearm, extend and radially deviate the wrist, and extend the fingers.

• Self-stretching techniques. The patient may use a wall (see Fig. 18.10) and slide the hand along the wall until a stretch force is experienced, or the patient may use the opposite hand to apply the stretch force. These techniques are described in the self-stretching section later in the chapter.

• Cross-fiber (friction) massage. Palpate to localize the scar, and then apply pressure and cross-fiber massage. Increase the intensity of massage as tolerated.

Restore Joint Tracking at the RU Joint

• Mobilization with movement (MWM). These techniques are used to restore normal tracking of the radius on the capitulum, so the forearm muscles can be strengthened without painful symptoms.⁶⁶ Several researchers have reported decreased pain and increased grip strength during or shortly after MWM at the elbow.^55,86,87 One researcher observed decreased shoulder rotation in patients with lateral epicondylalgia and demonstrated significant improvement in shoulder range after MWM at the elbow. He proposed that the mechanism was mediated neurophysiologically.¹ Refer to Chapter 5 for principles of application. The following techniques are used if the patient experiences pain when making a fist or with resisted wrist extension.

  • Patient position and procedure: Supine with the forearm pronated. Place a mobilization belt around the patient's proximal forearm and across your shoulders and stabilize the distal humerus with one hand. Apply a lateral glide to the forearm through the belt and then have the patient do repeated wrist extension against manual resistance applied by your other hand (Fig. 18.6 A).

  • Alternative method: Apply the lateral glide force against the proximal forearm with your distal hand and have the patient do repeated gripping by squeezing a ball or inflatable bulb (Fig. 18.6 B). Both the lateral glide force and the muscle contraction must be pain-free.

  • Self-MWM. The patient stands with the humerus of the involved elbow stabilized against a doorframe and the forearm in the opening and then applies lateral glide force against the proximal forearm with the contralateral hand. The patient then does repetitive gripping or squeezing against a resistive force, such as a pneumatic bulb or squeezable ball (Fig. 18.6 C).

Improve Muscle Performance and Function

• Counter force elbow sleeve or strap. Use an elbow orthosis to help reduce the load on the musculotendinous unit. This type of orthosis has been shown to have the immediate effect of improving pain-free grip strength in individuals with lateral epicondylosis.⁴²

• Isometrics. Progress the isometric exercises by applying resistance in various pain-free positions with emphasis on the lengthened position.

• Dynamic resistance exercise. Progress to dynamic exercises against manual or elastic resistance or free weights through pain-free ranges. Initially, use low-intensity resistance with multiple repetitions for muscular endurance, then progress to more intense resistance to strengthen the muscles in preparation for functional demands.

  • Eccentric training: Incorporate a progression of eccentric contractions of the involved musculotendinous unit, first within a comfortable wrist ROM against a low-intensity load, at a slow speed, and preferably with the elbow in a relatively extended position.⁷⁹ Use of an isokinetic dynamometer enables the patient to perform repetitive, eccentric-only contractions.¹⁹ If elastic resistance or a free weight is used, have the patient lift the weight or lengthen the elastic band with the sound hand when returning to the starting position of wrist extension.⁵²

  • Progressions: Progress to faster speeds before increasing the resistance. When resistance is increased, return to a slow speed and then again work up to a faster speed before increasing the resistance and so on. Gradually perform the eccentric contractions through a full, pain-free ROM.

• Functional patterns. As flexibility and strength improve and the pain is brought under control, incorporate functional training, utilizing functional patterns into the exercises. Emphasize control of the resistance through the pattern. If pain or deviation of the pattern with substitute motions occurs, have the patient rest before resuming additional repetitions. Exercises simulating the desired activity are progressed from slow, controlled motions to high speeds with low resistance to improve timing (see Fig. 18.22).

• General strengthening and conditioning. Incorporate any unused or underused part of the extremity or trunk into the training program prior to returning to the stressful activity.^27,90

• Plyometric exercises. Add plyometrics to the program if the patient's goals include returning to sports or occupational activities that require elbow and forearm power. Suggestions include the following and are described and shown in Chapter 23.^27,90

  • Dribbling a weighted ball against the wall or the floor

  • Flipping and catching a weighted ball

  • Bouncing a tennis ball on a short-handled racquet, progressing to a long-handled racquet

  • Rapid eccentric/concentric elbow and forearm motions against elastic resistance

  • Rapid chest passes or overhead passes using a weighted plyometric ball

• Activity modification. It may be necessary to modify the patient's activity or technique before he or she returns to the repetitive or stressful activity. For example, it may require taking tennis lessons to correct improper tennis techniques, adapting use of a hammer or other equipment, or making ergonomic modifications of a computer workstation.^{26,27,39,69,89}

NOTE: Information on ergonomic recommendations for computer workstations are described in Chapter 14.

Patient Education

• Education includes advice and techniques on prevention, recognition of provoking factors, and identification of warning symptoms.

• Teach the patient how to reduce the overload forces that caused the problem and retrain the patient in proper techniques.^26,27,39

• In addition to exercises, include home instructions on the application of friction massage and stretching the involved muscle prior to using it.

Exercise Techniques to Increase Flexibility and Range of Motion

Prior to initiating a muscle stretching program, be sure the joint capsule is not restricting motion. Techniques to increase joint play in the elbow and forearm articulations are discussed earlier in the chapter. Principles and techniques for applying joint mobilization techniques are presented in Chapter 5.

In addition to the description of principles and techniques of stretching presented in Chapter 4, manual, mechanical, and self-stretching techniques directed to the elbow are described in this section. When teaching the patient self-stretching, emphasize the importance of maintaining a low-intensity, prolonged stretch and not applying a ballistic stretch force (bouncing at the end of the range).

Manual, Mechanical, and Self-Stretching Techniques

To Increase Elbow Extension

Mechanical Stretch: Mild Flexion Contracture

Patient position and procedure: Supine with the arm supported on the treatment table and a folded towel under the distal humerus as a fulcrum. Place a cuff weight around the distal forearm. Position the forearm in pronation, mid-position, and then supination to affect each of the three flexor muscles. Have the patient stabilize the proximal humerus with the other hand or place a sandbag or belt across the proximal humerus to stabilize it. Instruct the patient to maintain the stretch for an extended period of time.⁹⁰

Self-Stretch: Mild Flexion Contracture

Patient position and procedure: Sitting with arm supported on the treatment table and a folded towel under the distal humerus as a fulcrum. Using the opposite hand, have the patient apply the stretch force against the distal forearm positioned in pronation, mid-position, and then supination to affect each of the flexor muscles.

Mechanical Stretch: Dynamic Splinting

Apply a low-intensity, long-duration mechanical stretch force with a dynamic splint to reduce a long-standing elbow flexion contracture by affecting the soft tissue properties of creep and stress-relaxation.^13,38

Manual Stretch: Biceps Brachii

Patient position and procedure: Prone with the elbow in end-range but comfortable extension and forearm in pronation. Stabilize the scapula and passively extend the shoulder.

Mechanical Stretch: Biceps Brachii

Patient position and procedure: Supine with a cuff weight around the distal forearm and the elbow in extension and forearm in pronation. Have the patient stabilize the proximal humerus with the opposite hand and then place the arm over the side of the table. Allow the elbow and shoulder to extend as far as possible and sustain the stretch position for an extended period of time (Fig. 18.7 A).

Self-Stretch: Biceps Brachii

Patient position and procedure: Standing at the side of a table. Have the patient grasp the edge of the table and walk forward, causing shoulder extension with elbow extension (Fig. 18.7 B). It is important to note that this stretching position does not include forearm pronation.

To Increase Elbow Flexion

Self-Stretch: Mild Extension Contracture

• Patient position and procedure: Prone-lying and propped up on elbows with forearms resting on the exercise mat. Have the patient lower the chest as far as elbow flexion allows and maintain the position as long as tolerated.

• Patient position and procedure: Sitting with elbow flexed as far as possible. Have the patient press against the distal forearm with the opposite hand to provide the stretch force into flexion. Alternatively, with the forearm supported on a table or arm rest of a chair, have the patient lean forward flexing the humerus against the stabilized forearm and maintaining the position as long as tolerated.

Self-Stretch: Long Head of Triceps

Patient position and procedure: Sitting or standing. Have the patient flex the elbow and shoulder as far as possible. The other hand can either push on the forearm to flex the elbow, or push the shoulder into more flexion (Fig. 18.8). Hold the stretch position as long as tolerated.

To Increase Forearm Pronation and Supination

Patient position: Sitting with the elbow flexed to 90° and the elbow resting on a padded table or stabilized against the side of the trunk.

Self-Stretch to Increase Pronation

Have the patient grasp the dorsal surface of the involved forearm so the heel of the uninvolved hand is against the dorsal aspect of the radius just proximal to the wrist and so the fingers wrap around the ulna. Then have the patient pronate the forearm and sustain the stretch as long as tolerated. The force is applied against the radius, so there is no trauma to the wrist.

Self-Stretch to Increase Supination

Have the patient place the heel of the uninvolved hand against the volar aspect of the involved radius just proximal to the wrist, supinate the forearm, and sustain the stretch as long as tolerated (Fig. 18.9).

Self-Stretching Techniques: Muscles of the Medial and Lateral Epicondyles

To Stretch the Wrist Extensor Muscles (From the Lateral Epicondyle)

• Patient position and procedure: Sitting or standing with the elbow extended and forearm pronated. While holding this position have the patient ulnarly deviate the wrist and flex the wrist and fingers; then apply a gentle stretch force against the dorsum of the hand. The patient should feel a stretching sensation along the lateral epicondyle or proximal forearm.

• Patient position and procedure: Standing with elbow extended, forearm pronated, and back of the hand against a wall (fingers pointing down). Have the patient then slide the back of the hand up the wall (Fig. 18.10). For additional stretch, have the patient actively flex the fingers.

To Stretch the Wrist Flexor Muscles (from the Medial Epicondyle)

• Patient position and procedure: Sitting or standing with the elbow extended and forearm supinated. While holding this position, have the patient radially deviate and extend the wrist and apply a gentle stretch force with the other hand against the palm of the hand. A stretch sensation should be felt along the medial epicondyle or proximal forearm.

• Patient position and procedure: Standing with the elbow extended and forearm supinated. Have the patient place the palm of the hand against a wall, fingers pointing down, and then move the hand up the wall until a stretch sensation is felt in the wrist flexor muscles.

Exercises to Develop and Improve Muscle Performance and Functional Control

In addition to the conditions already described in this chapter, imbalances in length and strength of muscles crossing the elbow and forearm can be the result of a variety of causes, such as nerve injury or after surgery, trauma, disuse, or immobilization. Appropriate exercises to develop neuromuscular control, increase strength, and improve muscular endurance for return to functional activities can be selected from the following exercises as well as the techniques described in Chapters 6 and 23.

For patients with elbow impairments, exercises for the regions above (shoulder girdle) and below (wrist and hand) also should be incorporated into the therapeutic exercise program to prevent complications and restore proper function of the entire upper quarter. The general principles of managing acute soft tissue lesions are discussed in Chapter 10. The exercises described in this section are for use during the controlled motion and return to function phases of intervention when tissues are in the subacute and chronic stages of healing and require only moderate to minimum protection.

Isometric Exercises

Multiple-Angle Isometric Exercises

Use manual or mechanical resistance at various positions throughout the available ROM of elbow flexion and extension and forearm rotation. Isolate the key musculature. Apply resistance at the distal forearm, not at the hand, to avoid forces across the wrist joints.

Angle-Specific Training

During isometric exercises, emphasize joint positions that simulate use of the elbow for anticipated functional activities. For example, to simulate carrying large boxes close to the chest, strengthen the elbow flexors in a 70° to 90° position with the forearm in mid-position and supination. Emphasize holding objects for extended periods of time to increase muscular endurance for sustained control.

Alternating Isometrics and Rhythmic Stabilization

Open-Chain Exercises

Apply manual resistance to alternating isometric contractions of antagonists at multiple angles of elbow flexion/extension and forearm pronation/supination. Stabilize the humerus and apply the resistance against the forearm.

When the patient is able to respond to the alternating resistance at various elbow and forearm positions and at varying speeds, progress to alternating isometrics using total upper extremity patterns. To further develop stability superimposed on movement (dynamic stability), have the patient hold a vibrating BodyBlade^® in various positions of the elbow, forearm, and the entire upper extremity and then during a variety of movements.

Closed-Chain Exercises

Patient positions include standing with hands against a wall or table, in the quadruped position, or in the prone push-up position (with knees or toes as a fulcrum). Have the patient hold the desired elbow position and apply alternating isometrics and rhythmic stabilization by means of manual resistance against the shoulders and trunk.

Dynamic Strengthening and Endurance Exercises

Many muscles that cross the elbow joint are multijoint muscles, such as the biceps, long head of the triceps, and wrist flexors and extensors. It is particularly important to consider the position of the shoulder and forearm during resistance training at the elbow. Dynamic strengthening and endurance activities for the prime movers of the elbow, forearm, and wrist using manual or mechanical resistance are noted in this section. Combined patterns of motion during open- and closed-chain activities are described in the final section describing a functional progression for the elbow and forearm.

Elbow Flexion

Muscles include the biceps brachii, brachialis, and brachioradialis.

• Patient position and procedure: Sitting or standing, with the humerus at the side of the chest (arm perpendicular to the floor). Have the patient hold a weight or grasp a piece of elastic band or tubing (secured under the foot or to the floor), and flex and extend the elbow. This strengthens the elbow flexors concentrically and eccentrically throughout the available ROM to simulate functional lifting and lowering. Perform this motion with the forearm supinated, pronated, and in mid-position.

• Patient position and procedure: Supine or prone, with the humerus supported on a treatment table. When the patient is supine, the resistive force from a free weight or gravity has a greater effect on the muscles near end-range extension and has little to no effect as the elbow reaches 90°. With the patient prone and the forearm over the side of the bed, use a pulley system or elastic resistance to provide resistance to the elbow flexors.

• Patient position and procedure: Standing or sitting while holding a weight with the forearm supinated. Have the patient extend the shoulder as the elbow flexes (Fig. 18.11). This combined motion elongates the biceps brachii over the shoulder as the muscle is shortening to move the elbow and thus most efficiently maintains optimal length for development of maximum tension in the biceps. This combined motion develops control for carrying objects at the side.

Elbow Extension

Muscles include the triceps and anconeus.

• Patient position and procedure: Prone, humerus abducted to 90° and supported on a rolled towel on a treatment table. Have the patient extend the elbow while holding a weight. This position strengthens the elbow extensors from only 90° of flexion to terminal extension.

• Patient position and procedure: Supine with the shoulder flexed 90°, holding a weight in the hand. Have the patient begin with the elbow flexed and the weight either at the ipsilateral or contralateral shoulder (external or internal rotation of the shoulder); then extend and flex the elbow (lift and lower the weight) to strengthen the elbow extensors concentrically and eccentrically. To help maintain the shoulder in a stable position, have the patient stabilize the humerus in the 90° position with the opposite hand.

Long Head of Triceps with Elbow Extension

Patient position and procedure: Sitting or standing with the arm held overhead (shoulder flexed) and elbow flexed so the weight is near the shoulder (Fig. 18.12). Have the patient lift the weight overhead and then lower the weight for concentric and eccentric strengthening. The patient may support the humerus with the opposite hand. Perform this exercise only if the patient has sufficient control of the shoulder.

Pronation and Supination

Muscles of pronation are the pronator teres and quadratus; muscles of supination are the supinator and biceps brachii. Patient position: Sitting or standing with the elbow flexed to 90°. When sitting, the forearm may be on a table for support.

• Free weights. When using a free weight to strengthen the pronators and supinators, the weight must be placed to one side or the other of the hand (Fig. 18.13). If a dumbbell is held, weight is equal on each side of the hand; therefore, one side of the weight is assistive and the other is resistive, in essence canceling out the resistive force. Note also the position of the thumb for each exercise, so it is not lifting the bar. The weight also can be turned through a downward arc by placing the resistance on the ulnar side of the hand.

• Elastic resistance. Have the patient grasp one end of the elastic resistance with the sound hand, or secure one end by standing on it. Have the patient grasp the other end with the involved extremity and turn the forearm against the resistance. For greater resistance, secure the elastic resistance around the end of a short rod, and have the patient pull against the resistance force.

• Functional activity. Have the patient stand, facing a doorknob with the arm kept at the side and the elbow flexed to 90° to avoid substituting with shoulder rotation. Have the patient turn the knob.

Wrist Flexion and Extension

Wrist flexion involves muscles of the medial epicondyle; extension involves muscles of the lateral epicondyle.

NOTE: In the following exercises, when the forearm is pronated, resistance is applied to the wrist extensors; when supinated, resistance is applied to the wrist flexors.

• Elastic resistance.

Patient position and procedure: Tie the ends of an elastic band or tubing together. While sitting, have the patient place one end of the loop under one foot. Stabilize the forearm on the thigh and place the other end of the loop across the dorsum (Fig 18.14) or palm of the hand to resist the wrist extensors or flexors respectively. Placing the elastic band in this manner is useful for the patient with epicondylalgia if simultaneous gripping during resisted wrist motions is painful.

Progression: Perform the same resisted wrist motions while grasping one end of the elastic material as simultaneous gripping during resisted wrist motions becomes comfortable.

• Free weights.

Patient position and procedure: Sitting, with forearm resting on a table and hand over the edge of the table holding a small weight (Fig. 18.15). Extend and flex the wrist against the resistance.

• Wrist roller.

Patient position and procedure: Sitting or standing, with the elbows flexed or extended and the forearms pronated or supinated. Tie a 2- to 4-ft cord to the middle of a short rod and a weight to the other end of the cord. Have the patient hold each end of the rod and with an alternating wrist action, turn the rod causing the cord to wind around the rod and elevate the weight. The weight is then lowered with a reverse motion (Fig. 18.16).

Functional Progression for the Elbow and Forearm

A comprehensive rehabilitation program for the elbow and forearm designed to achieve an individual's functional goals involves a sequence of carefully progressed exercise interventions designed to develop or restore sufficient mobility, strength, stability, muscular endurance, and power. The final section of this chapter identifies integral components and examples of exercise interventions and simulated functional activities that often are included in a functional progression for the elbow and forearm. Refer to Chapters 17 and 23 for additional exercises and activities.

NOTE: Because the elbow primarily functions during activities that also involve the shoulder and hand, combined patterns of exercise that develop mobility and control the entire upper extremity should be implemented. Be careful that substitute motions do not occur to compensate for a weak link in the chain.

Diagonal Patterns

PNF patterns against manual or mechanical resistance. Use unilateral or bilateral diagonal patterns as described in Chapter 6. Use manual resistance, free weights, elastic resistance, a weight-pulley system, or an isokinetic dynamometer to provide the resistance as the patient moves through the diagonal patterns. Gradually increase resistance, speed (if appropriate with the choice of equipment), and repetitions.

Combined Pulling Motions

Elbow flexors are used in pulling, lifting, and carrying activities in open- and closed-chain activities. These upper extremity actions also require strength of the scapular retractors, shoulder extensors, and wrist and hand musculature. Many of the exercises that are described for the shoulder in Chapter 17 also involve resisted elbow flexion and therefore can be used to strengthen muscle groups during pulling motions. Suggestions include:

• Bilateral pull-ups against elastic resistance (Fig. 18.17).

• Closed-chain chin-ups or modified pull-ups on an overhead bar (Fig. 18.18).

• Unilateral combined pulling pattern simulating starting a lawn mower (Fig. 18.19) or bilateral or unilateral rowing motions, such as using a rowing machine.

• Pulling a variety of weighted objects with one or both arms, emphasizing elbow flexion and proper body mechanics.

Combined Pushing Motions

The triceps muscle is involved in pushing motions. Pushing also involves variations of shoulder flexion and scapular protraction or depression so that muscles controlling these motions are functioning with the triceps. Many of the exercises described in Chapter 17 for the shoulder and Chapter 23 also involve resisted elbow extension and may be used to strengthen muscles groups involved in pushing patterns. Suggestions include:

• Military press-up (see Fig. 17.55).

• Bench press.

• Upper extremity ergometry (see Fig. 6.54).

• Wall push-ups, semi-prone or prone push-ups (Fig. 18.20 A).

• Push-ups from a chair or on parallel bars (Fig. 18.20 B).

• Stepping/stair-climbing machine with hands on the "steps." Emphasize elbow extension.

• Pushing a variety of weighted objects with one or both arms using dynamic elbow extension (Fig. 18.21).

Plyometric Training (Stretch-Shortening Drills)

The following are suggestions for increasing power of the elbow musculature using plyometric exercises.^27,90 These advanced training activities are described in Chapter 23.

• Perform elbow flexion and extension exercises against elastic resistance, emphasizing rapid reversal between eccentric and concentric motions.

• Using a weighted ball, have the patient catch the ball and then quickly throw it back. Emphasize elbow motions with overhead passes, chest passes, and lateral passes.

• Bounce a ball against a wall or a tennis ball on a racquet with the forearm pronated and supinated.

Simulated Functional Tasks and Activities

Determine the component motions of the patient's desired functional activities as well as occupational or recreational tasks. Have the patient simulate these motions and practice the entire task. Activities could involve lifting, lowering, carrying, pushing, pulling, twisting, turning, catching, throwing, or swinging. For example, if the patient is recovering from repetitive trauma to the muscles of the lateral epicondyle when playing tennis, have the patient practice the various racquet strokes using a wall-pulley system (Fig. 18.22). Impose controlled forces to challenge the patient by increasing the time or repetitions, speed, or resistance.^27,90

Critical Thinking and Discussion

1. Differentiate between the etiology, signs and symptoms, and management of lateral and medial epicondylalgia. Note the similarities and differences.

2. Develop, compare, and contrast the postoperative management (including an exercise progression and precautions) after two types of total elbow arthroplasty: (1) a semicon-strained implant/triceps-reflecting approach and (2) a resurfacing implant/triceps-splitting approach.

3. The goal is to increase muscle performance and function of the elbow flexors that are currently functioning at a 3/5 strength level and endurance of four repetitions. Identify exercises that could be used at each increment of strength, including exercises for strength, endurance, power, control, stability, and function. Identify parameters for progression of each exercise and any precautions.

4. Do the same sequence of analysis and identification to increase muscle performance and function of the elbow extensors.

5. Analyze the following household, occupational, or sports-related activities. Identify the components and sequence of motions related to each of these motor tasks; pay particular attention to elbow and forearm motions during these tasks. Design a sequence of upper extremity exercises and simulated activities that could be incorporated into a late-stage rehabilitation program to prepare a patient to return to the desired task after an elbow injury.

   • Housecleaning

   • Gardening

   • Grocery store stocking

   • Carpentry

   • Volleyball

   • Tennis

   • Throwing sports

Laboratory Practice

1. Apply mobilization techniques to a laboratory partner to increase the following elbow and forearm motions: mid- and end-range elbow flexion; mid- and end-range elbow extension; forearm pronation and supination (proximal and distal articulations).

2. Demonstrate passive stretching and hold–relax techniques to elongate the following muscles that cross the elbow: brachialis, brachioradialis, biceps, long head of the triceps, extensor communis digitorum, flexor carpi ulnaris, flexor carpi radialis.

3. Using the following pieces of resistance equipment demonstrate at least two methods (setups) to strengthen the elbow flexors/extensors and forearm rotators: free weights, weight-pulley system, and elastic resistance. Then demonstrate a progressive sequence of resistance exercise to strengthen the same muscle groups using self-resistance (body weight or manual resistance).

Case Studies

1. Describe the mechanical problem causing impairments in the elbow and forearm in the following scenario and what techniques could be used for intervention. A patient is referred to you 4 weeks after sustaining a fracture of the distal radius with immobilization in a cast following a fall on an outstretched arm and hand. She has limited elbow, forearm, and wrist motions. On palpation, you note a decreased space between the lateral aspect of the head of the radius and capitulum as well as decreased joint play at all articulations of the elbow, forearm, and wrist.

2. A 15-year-old patient with a 5-year history of polyarticular JRA just underwent open synovectomy and excision of the head of the radius with implant for late-stage joint disease of the elbow. Prior to surgery, the patient had severe pain in the elbow region, lacked full elbow flexion/extension and forearm rotation, and had limited use of the arm for functional activities. Continuous passive motion (CPM) was implemented during the patient's hospitalization (3 days). A day prior to discharge, the patient was referred to physical therapy for a home program. Design an exercise program for this teenager. Prioritize and describe each exercise you want the patient to do for the first week at home. Outline a program of exercises for later use in the rehabilitation process. The patient plans to return to school within a week of discharge from the hospital. Indicate whether you recommend outpatient therapy; if so, indicate the frequency and duration; justify the need for this recommendation.