Basic Functional Anatomy

The semilunar notch of the ulna is hinged with the hyperboloid trochlea of the humerus. The proximal head of the radius pivots with the spherical capitulum of the humerus and glides against both the proximal and distal ends of the ulna.

The distal end of the humerus consists of two columns: a larger one medially articulating with the semilunar notch of the ulna and a smaller one laterally articulating with the head of the radius. The pulley-like trochlea apparatus has

(1) a depression at the front that lodges the coronoid process of the ulna and
(2) a depression at the rear that holds the olecranon process of the ulna when the elbow is extended. The olecranon process restricts hyperextension of the elbow and protects the ulnohumeral articulation posteriorly.

The concave head of the radius glides against the spherical capitulum of the humerus. The capitulum and trochlea are separated by a bony crest that fits into the opening between the proximal ulna and the radius and serves as a fixed rudder to guide elbow motion. The elbow flexors originate from the medial epicondyle, and the extensors originate from the lateral epicondyle. This structural arrangement should be visualized during examination to discriminate normal from abnormal motion.


Elbow Motion

The basic range of elbow joint motion involves elbow flexion and extension, and forearm supination and pronation. The patient may be examined in either the standing or sitting position. If a blockage is obtained in active motion, passive motion should be checked and the type of block and degree of restriction noted.


Biomechanics

The elbow functions as a first-class lever during extension. The mechanical advantage is poor because of the short lever arm between the insertion of the triceps and the center of the joint. During flexion, the elbow functions as a third-class lever. Force from the biceps and brachialis act between the fulcrum and weight of the forearm.


Screening Kinetics

Flexion and Extension.   The excursion of the head of the radius over the capitulum in full flexion is about 140°. Active flexion is judged by having the patient touch an ipsilateral shoulder with the supinated hand, and extension is checked by the patient straightening the elbow as far as possible. Many females normally reach 5° hyperextension. The easiest testing maneuver is to have the patient flex and extend both elbows at the same time in one continuous movement. Flexion is limited normally by the biceps muscle mass, and extension is limited when the olecranon touches the olecranon fossa.

Pronation and Supination.   During forearm pronation, the ulna remains fixed and the radius crosses over it. In supination, the bones merely uncross. Active pronation and supination are checked with the patient's elbow 90° in flexion and firmed against the waist. The patient is then instructed to turn the closed fist first downwards to that the palmar surface is parallel with the floor (pronation) and then upward so that the dorsal surface is parallel with the floor (supination). Restriction in pronation suggests pathology at the elbow, radioulnar articulation at the wrist, or within the forearm. Restriction in supination is associated with an elbow disorder or with a blocked radioulnar articulation at the wrist.

Elbow Kinesiology

Flexion.   Elbow flexion is controlled by the brachialis (C5–C6) and biceps brachii (C5–C6) with assistance by the brachioradialis (C5–C6) and supinator (C6). Strength is tested with the examiner in front of the patient placing his stabilizing hand cupped under the patient's 90 degree flexed elbow and his active hand gripping the patient's wrist. Increasing resistance is added as the patient attempts to flex the elbow. See Table 4.


Table 4.   Elbow and Forearm Motion

Extension.   Extension of the elbow is provided by the triceps (C7–C8) with help from the anconeus (C7–C8). The examiner's stabilizing and active hands are in the same position described above, and increasing resistance is offered as the patient attempts elbow extension.

Supination.   Forearm supination is conducted by the biceps (C5–C6) and supinator (C6), aided by the brachioradialis (C5–C6). The examiner's stabilizing hand remains cupped under the elbow, and the active hand grips the patient's pronated wrist. Increasing resistance is applied as the patient attempts to turn the forearm from pronation to supination.

Pronation.   Pronation of the forearm is provided by the pronator teres (C6–C7) and pronator quadratus (C8–T1), with assistance from the flexor carpi radialis (C7–C8). The examiner's stabilizing hand remains in place as described above, and the active hand grips the patient's supinated wrist. Increasing resistance is applied as the patient attempts to turn the forearm from supination to pronation.

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy (never apply ice or severe cold directly on the olecranon)
Cool packs
Ice massage
Vapocoolant spray and stretch of related trigger points
Compression
Pressure bandage
Aircast
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Mild pulsed ultrasound
Pulsed alternating current
Auriculotherapy
Meridian therapy
Spondylotherapy (upper thoracic)
Rest
Bed or chair rest
Foam/padded appliance
Sling
Immobilization
Brace
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.


2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Indirect therapy (reflex therapy)
Spray-and-stretch related trigger points
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cool cryokinetic passive exercise
Meridian therapy
Spondylotherapy (upper thoracic)
Rest
Chair rest
Foam/padded appliance
Sling
Immobilization
Brace
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.


3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch related trigger points
Cool cryokinetic active exercise
Moderate active range-of-motion exercises
Meridian therapy
Alternating stretching
Sinusoidal current
Ultrasound, continuous
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy (upper thoracic)
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
Foam/padded appliance
Sling
Immobilization
Semirigid appliance
Foam support
Indicated diet modification and nutritional supplementation.


4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics
Spondylotherapy (upper thoracic)
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch of related trigger points
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound, continuous
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Sling and light elastic cuff
Indicated diet modification and nutritional supplementation.


5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.

Rotator Cuff Injuries

Five deep muscles are around the glenohumeral joint. They comprise the rotator cuff. The infraspinatus and teres minor work as external rotators of the humerus. The subscapularis and teres major rotate the humerus medially. The supraspinatus pulls the humerus into the glenoid fossa and abducts the humerus initially (10 ° –15 °) before the deltoid becomes effective. In further abduction, the supraspinatus and deltoid stabilize the humerus during full abduction. The mechanism of rotator cuff injury may be a fall with outstretched hand, a blow on the shoulder, throwing, or heavy lifting.

Stages.   Three stages are commonly recognized and related to age:

(1) Edema and hemorrhage resulting from overuse (eg, swimming, tennis, baseball, arm work) characteristically seen before age 25 but may be seen at any age.
(2) With repeated episodes, the subacromial bursa becomes fibrotic and thickened. The patient is usually 25–40 years old. (3) This stage is characterized by wearing of the bone and rupture of the tendon in individuals over 40 years, associated with anterior acromial erosion and spurs. However, these stages fail to recognize the effect of a reflex-produced ischemia so often seen in practice.

Classes.   Rotator cuff strain can be classified as follows:

Grade I injury:   Minor pain and weakness; tenderness over upper end of humerus, weakness and loss of normal shoulder rhythm on flexion and abduction.

Grade II injury:   Pain with moderate disability; exaggerated signs of Grade I. Unpalpable tear site.

Grade III injury:   Pain at tear site (partial or complete) with severe disability; weakness with inability to actively abduct shoulder. A tear is possibly palpable. Later signs of atrophy appear. A supraspinatus tear is characterized by a dull ache on rest which is aggravated by abduction. It is usually sited in the rotator cuff or common tendinous insertion, rather than within the tendon itself. Complete ruptures are rare in comparison to partial tears.

The degree of cuff injury is determined by the degree of pain or weakness on passive motion or active motion against resistance. Differentiation must be made from bicipital tenosynovitis by a positive Yergason's sign and severe pain on palpation. Roentgenograms are usually negative; but in chronic cases, the anterior edge of the acromion may show spur formation or a displaced fracture of the tuberosity.

Clinical Features.   On examination, the patient's arm is held to the side and cannot be abducted actively without pain, but nearly a full range of passive movement can be obtained with care. The arc of pain is generally located between 45° –90 ° as the tuberosity of the humerus passes under the acromion process. Pain may also arise during adduction from 120°–170 ° with subacromial crepitus, varying amounts of weakness, and recurrent "bursitis" episodes. When the patient is asked to raise his arm, the shoulder hunches in support, a short motion may be made, but the arm quickly collapses to the side in pain.

While passive motions of the shoulder are unrestricted, pain may be felt when the humeral head presses under the acromial arch. When the shoulder is extended, the front and back of the humerus will be tender but not as acute as at the greater tubercle. Extreme tenderness is found where the cuff inserts into the tuberosities. A superior subluxation of the humerus is often associated. Associated supraspinatus tears (full or partial rupture) are characterized by a total loss of initial abduction. The tendon of the supraspinatus may be the site of peritendinitis or ectopic calcification.

Subacute Cases.   An important sign arises in 1–2 weeks after injury. It is an area of thinning or depression at the fossae of the supraspinatus and infraspinatus (especially) muscles. If this is the site of rupture, a "catch" and clicking sound may be felt and heard at the site during passive movements if swelling is minimal.

Arm Drop Test.   The patient's arm is held at 90° abduction and the patient is asked to hold that position without assistance. If this cannot be done actively for a few moments without pain, it indicates a torn rotator cuff. In lesser tears, the patient may be able to hold the abduction (a slight tap on the forearm will make it drop) and slowly lower it to his side, but the motion will not be smooth.

Patient Counsel.   Both the amateur and professional must avoid stressful activity (eg, golf, tennis, throwing, swimming, weight lifting, etc) for several weeks (5–7). Return to full activity is a conditioning process that takes time and patience. Explain to the patient that sensations of joint noise (eg, snapping, grinding) are normal in this syndrome and that they will slowly disappear with treatment. During restoration, emphasis will be on prescribed low-weight high repetition exercise. A maintenance program may be necessary for 1–2 years to discourage recurring symptoms.

Management.   The main early treatment for small tears is rest and support, assisted by cryotherapy. Any taping technique should be designed to assist the action of the rotator cuff tendons and the joint capsule. This requires strapping from just above the elbow to the neck. Horizontal strips should be laid "in line" at the base of the neck to cover the entire shoulder to stabilize the clavicle and scapula. Early rehabilitation exercises should emphasize flexion, extension, and abduction, and adduction in the late stage. Significant tears usually require surgery.

Deltoid Contusion and Strain

Because it is such a powerful abductor and used to some degree in almost all shoulder motions, acute and chronic disabilities of the deltoid are common. Strong contractions are known to produce tearing of its attachments to the humerus or clavicle solely from the intrinsic forces produced.

As with most strains, pain arises with active motion but not passive motion. Point tenderness, swelling, and disability arise after injury. Grade III strains are not uncommon and require surgical repair if a distinct rupture can be palpated.

Anterior deltoid strain is often seen in football following an attempted one-arm tackle. Symptoms arise slowly, often peaking 6-8 hours after injury. Pain and weakness increase on forward abduction. Evidence of swelling and tenderness appears in the anterior third of the muscle.

Middle deltoid strain follows forceful abduction against resistance in the lateral plane. Symptoms arise slowly. Pain and weakness increase on lateral abduction. Evidence of swelling and tenderness appears in the mid-third of the muscle.

Posterior deltoid strain is the result of a posteriorly directed strain such as seen in swimmers using the butterfly stroke. Symptoms arise slowly. Pain and weakness increase on posterior abduction, and evidence of swelling and tenderness appears in the posterior third of the muscle.

Management.   Cold packs, shoulder-cap strapping, and an arm sling are necessary during the first 2 days, followed by moist heat and passive manipulation. Active exercises should be conducted during a warm shower. Full activity can usually be allowed (with support) in 3–5 days.

A contributing spinal major will likely be found at C5. Mobilize fixations found in the shoulder girdle or involved upper extremity. After relaxing the tissues and adjusting the subluxated/fixated segments, deep high-velocity percussion spondylotherapy can be applied over segments C7–T4 for 3–4 minutes to stimulate pertinent vasomotor activity. Also treat discovered trigger points, especially those found in the deltoid, supraspinatus, scaleni, pectorals, upper and mid trapezius muscles, coracobrachialis, infraspinatus, and biceps. Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended by nutritional authorities.

Other helpful forms of treatment include cryotherapy and massage with eucalyptus oil in the early stage, followed by spray and stretch, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat or shortwave diathermy, ultrasound for deep heat and cellular massage, hot needle-spray showers, interferential therapy, iontophoresis or phonophoresis with proteolytic enzymes, local vibration-percussion, alternating current, or high-voltage therapy.

Shoulder cap taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, the attending physician should demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.

The Bicipital Syndrome

In shoulder injury, after possible dislocation and fracture have been eliminated, special attention should be given to the bicipital muscle because it is the most powerful flexor of the elbow and a strong supinator. Within the shoulder area, proximal strains and tears along the long head's course within the bicipital groove to the glenoid rim are frequent.

Acute rupture of the biceps tendon results from forceful contraction of the biceps muscle or forceful movement of the arm with the biceps contracted. The injury may be avulsion of the tendon from the muscle belly anywhere along its course or be pulled free from its glenoid attachment. It is often a crippling problem in sports and certain occupations, often accompanied by tenosynovitis. The condition is often called "golfer's shoulder" but may occur in almost any sport.

Clinical Features.   An acute tendon tear may be felt by the patient as a "snap," followed by swelling, tenderness, and ecchymosis over the bicipital groove and bulging of the biceps near the antecubital fossa at the lower half of the humerus. Pain is usually felt in the anterior shoulder about 2 inches below the humeral head at the site of the thecal tunnel. If the long head is torn, the contracted muscle belly moves distally and bulges even if the short head is intact. This is an important sign in differentiating a proximal biceps problem from other shoulder problems. A hollow in the upper humeral area can be both seen and felt. Flexion and supination, especially against resistance, increase the bulging at the lower half of the upper arm. Strength of forearm supination decreases.

Yergason's Stability Test.   The seated patient flexes the elbow, pronates his forearm, and attempts elbow flexion, forearm supination, and humeral external rotation against the resistance of the examiner. The doctor stabilizes the patient's elbow with one hand while offering resistance to the patient's distal forearm with his other hand during the maneuver. Severe pain in the shoulder is a positive sign of a bicipital tendon lesion, a tear of the transverse humeral ligament, or bicipital tendinitis.

Management.   Bicipital injury with or without tenosynovitis requires careful strain therapy. Rest in an arm sling is necessary until all symptoms subside. Graduated exercises can be initiated once the tissues appear stable to clinical testing. Impatient pitchers must be advised against "testing" throws because progress may be completely destroyed. Steroid injections are rarely helpful in the athlete, although frequently employed by habit by some medical physicians. Complete tear or rupture requires surgical approximation.

Loose-Tendon Syndrome.   In some chronic bicipital disorders, the tendon may appear slack and actually glide from side to side on palpation during repeated adduction and external rotation. To further test this condition, the examiner places the patient's affected forearm on his knee. Palpate the bicipital groove with one hand while the other hand moves the patient's elbow laterally and anteriorly while the patient resists the movement. If the tendon is slack, it will be felt to "jump" during the motion. Injury to the transverse humeral ligament is also often involved.

Bicipital Tendon Dislocation

A stable biceps tendon may be displaced or at least partially disrupted from its groove and express symptoms of a bicipital syndrome. This is due to rupture or loosening of the transverse ligament which holds it within the bicipital groove.

Clinical Features.   The disorder is often a consequence of painful strains, sprains, capsule tears, and contractures. The subluxated tendon can be felt and/or heard to snap as the patient forward flexes and abducts his arm, then returns it to its natural position. The patient is unable to place the ipsilateral hand on his sacrum. As time passes, motion restrictions indicate cuff degeneration. Yergason's test is positive on resisted external rotation.

Abbott-Saunders Test.   This is a modification of Yergason's test that forces the biceps tendon against the lesser tuberosity, which will stress an unstable tendon. The arm of the seated patient is brought into full abduction, externally rotated, and then lowered to the patient's side. A "click" felt or heard, frequently accompanied by pain and a reproduction of symptoms, is a sign of subluxation or dislocation of the biceps tendon.

Adjustment Technic.   To re-set a displaced bicipital tendon, stand behind the sitting patient toward the side of involvement. If the right shoulder is involved, place your left hand over the shoulder cap and grasp the patient's right wrist with your right hand. The patient's arm is allowed to hang loose, the elbow should be flexed about 45 °, and the arm should be abducted about 45°. Press the thumb of your left hand against the back of the tendon, and wrap your fingers under the short head of the biceps and coracobrachialis to compress the tendon of the biceps. Advise the patient that the adjustment is not painful and to relax the shoulder. With firm contact on the shoulder muscles, quickly bring the patient's flexed arm anterior and medial to internally rotate the humerus. This usually brings immediate relief. If not, a steady lateral (rarely medial) pressure is applied to the slipped tendon while the elbow is drawn posterior and held close to the chest until the limit of motion is reached. Then with continued pressure on the tendon, abduct the elbow, bring it forward, and return it to its original position. Follow adjustment with traction strapping, sling, and the usual treatment of sprain depending on the history. Efforts to elongate the tendon with weight exercises following the acute stage are very helpful. If the ligament is severely torn, it will not remain in place; surgery is required for permanent correction.

Rupture of the Transverse Humeral Ligament

An important function of this ligament is to hold the long head of the biceps within its humeral groove. The mechanism of injury is usually heavy lifting, "Indian" arm wrestling, or a slip while carrying a heavy object. Injury occurs, especially in young adults, when the contracted biceps meets an overload.

Clinical Features.   Extreme tenderness will be found at the superior aspect of the bicipital groove, with some tenderness along the groove distally. A slack tendon will be found on palpation of the upper groove as the humerus is abducted and internally rotated. A "jumping" sensation from the tendon is felt if the transverse ligament is partially torn. A gliding sensation is felt if the ligament is completely torn.

Management.   Mild partial tears respond to strapping and sling, and the usual physiotherapeutic measures for sprain. Supplementation with 140 mg of manganese glycerophosphate six times daily speeds healing. Severe ruptures require surgical attention.

Brachialis Contusion and Strain

Brachialis strain is common in contact sports and industrial accidents. The muscle is continually subjected to bruises in football as it is exposed to contusion just below the epaulettes of the shoulder pad.

Clinical Features.   In sprain of the proximal radioulnar joint, there is often a related injury to the brachialis anticus muscle with contracture, or, especially in children, a strip of periosteum may be torn from the anterior aspect of the humerus followed by callus formation and blocked joint motion. The athlete or well-developed laborer will present a large muscle belly on the anterolateral aspect of the upper arm that is easily found between the deltoid and the lateral head of the triceps.

Management.   Treat for acute sprain with cryotherapy and pressure, and follow with typical physiotherapeutic procedures such as heat and progressive exercises. See strain/sprain template.

Bicipital Tendinitis

The synovia of the bicipital groove is a common site of chronic peritendinous inflammation. It is frequently a complication of bicipital rupture (long head) or displacement of the tendon from the groove.

Clinical Features.   Pain is aggravated on abduction and extension, and tenderness is localized over the inflamed tendon. Symptoms mimic supraspinatus tendinitis, but the pain is referred distally in the area of the biceps insertion to the radius. Tenderness is found along the anterior shoulder in the bicipital groove. Pain is increased if the patient abducts, flexes, and internally rotates the shoulder. When the patient flexes the arm and supinates the wrist against resistance, a positive sign is pain within the anterior medial upper humerus area.

Lippman's Test.   Ask the sitting patient to flex the elbow on the involved side and rest the forearm in the lap. Palpate the tendon of the long head of the biceps, which is located about 3 inches distal from the glenohumeral joint. Attempt to displace the tendon laterally or medially from its groove. Pain, reduplication of other symptoms, and a palpable displacement of the tendon from its groove signifies tenosynovitis with instability.

Gilcrest's Sign.   Ask the patient to lift a 5-lb weight (eg, dumbbell) overhead and then to externally rotate the arm and slowly lower it to the lateral horizontal position. Pain and/or reduplication of symptoms during this maneuver (with or without tendon displacement from the groove) suggests instability of the long head of the biceps and probable tenosynovitis.

Management.   Check for lower cervical, 1st rib, and upper thoracic subluxations. Mobilize any fixations found in the glenohumeral, acromioclavicular, and sternoclavicular joints, and the scapulothoracic "articulation." A trigger point is frequently found just above or over the ipsilateral scapula. Supraspinatus and infraspinatus muscle spasms are often associated. In the acute stage, cold is indicated. Interferential therapy or ultrasound combined with pulsating high-voltage galvanism is reported to be especially beneficial in degenerative tendinitis. Apply strapping for 3–5 days. An arm sling should be used for relieving the tendon of weight for 7–10 days from injury. Progressive exercises such as circumduction, pendulum exercises, two-hand rod swinging, and lateral and front finger wall-walking may begin at home as soon as symptoms subside. Treat essentially as a severe sprain. Magnesium and vitamin C supplementation may assist healing. The beneficial use of acupuncture and DMSO has been supported.

Contributing spinal majors will likely be found at C5–C6, and any fixations found should be mobilized -especially those in the shoulder girdle, involved upper extremity, upper thoracics, ribs, and scapula. After relaxing the tissues and adjusting the subluxated/fixated segments, it's helpful to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes.

Other helpful forms of treatment include massage with eucalyptus oil, in the early stage, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat or shortwave diathermy, ultrasound for heat and massage at the cellular level, hot needle-spray showers, iontophoresis or phonophoresis with proteolytic enzymes, local vibration-percussion, alternating current, or high-voltage therapy. Taping or at least an arm sling may be necessary in the early stage to rest the joint and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures. Supplemental processed brain extract and nutrients B1, C, RNA, calcium, and magnesium are recommended by several authorities. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Supraspinatus Tendinitis

Supraspinatus tendinitis is often a part of rotator cuff injury and/or a complication of supraspinatus strain. The typical history is a complaint of shoulder ache occurring on rest and aggravated by abduction. It is painful to sleep on the affected side. The pain may be referred distally as far as the deltoid insertion. A differentiating feature is the pain is restricted to movement only within a certain point of the arc (painful arc syndrome) because the acromion process affects the tendon area only during part of its excursion. Point tenderness will be found over the site of inflammation. The stages of supraspinatus tendinitis are shown in Table 5.


Table 5.   The Stages of Supraspinatus Tendinitis

Stage	Pathophysiologic Picture	Symptoms
1	Hyaline degeneration of the tendon's collagen, with calcific deposits beginning to form.	Ache, muscle soreness.
2	Hyperemia develops and calcium deposits begin to enlarge.	Pain on motion.
3	Tendon engorgement and swelling.	Pain on abduction near 70 degrees Painful arc syndrome.
4	Inflammation of surrounding bursa.	Same as 3 but greater pain with less motion.
5	Rupture of tendon and bursal sac.	Same as above.
6	Adhesive capsulitis, with severely limited range of motion.	Frozen shoulder.

Inflamed peritendinous supraspinatus tissues are frequently a part of subdeltoid or subacromial bursitis. Also note that the area of the supraspinatus tendon is a common site of referred pain from the gallbladder, right diaphragm (eg, hiatal hernia), and heart.

Supraspinatus Press Test.   With the patient in the relaxed seated position, apply strong thumb pressure directed toward the midline in the soft tissues superior to the midpoint of the scapular spine. The production of pain signifies an inflamed supraspinatus muscle (eg, strain, rupture, tendinitis).

Shoulder Abduction Stress Test.   Ask the patient to abduct the arm laterally to the horizontal position with the elbow extended while you apply resistance. If this causes pain in the area of the insertion of the supraspinatus tendon, acute or degenerative shoulder tendinitis is suggested.

Codman's Sign.   This is a variation of the shoulder abduction stress test and the arm drop test. If the patient's arm can be passively abducted laterally about 100° without pain, remove support so that the position is held actively by the patient. This produces sudden deltoid contraction. If a rupture of the supraspinatus tendon or strain of the rotator cuff exists, the pain elicited will cause the patient to hunch the shoulder and lower the arm.

Impingement Syndrome Test.   Place the patient supine with the arms resting loosely at the sides. The elbow on the involved side is then flexed to a right angle and the arm is rotated internally so that it rests comfortably on the patient's upper abdomen. Place one hand on the patient's shoulder and your other hand on the patient's elbow. Apply a compressive force to push the humerus against the inferior aspect of the acromion process and the glenohumeral fossa. Pain and/or a reduplication of symptoms indicates an impingement syndrome of the supraspinatus and/or bicipital tendon. This is sometimes called the locking position test.

Management Considerations.   Treatment is similar to that for bicipital tendinitis. Initial cold followed by ultrasound, spray-stretch trigger point therapy, interferential therapy, transverse muscle massage, meridian therapy, and neurolymphatic reflexes have all been reported to relieve the associated pain. During rehabilitation, graded active and passive shoulder exercises, vitamin C, and proteolytic enzymes are helpful.

General Rotator Cuff Tendinitis

When tendinitis is diffuse throughout the rotator cuff, the pain is poorly defined in the area of deltoid insertion and often more prominent at night. As in a typical rotator cuff lesion, a painful arc appears on abduction between 60° and 120°. The tendons and muscles of the rotator cuff are tender throughout.


Pitching and Related Injuries

Shoulder girdle muscle forces must act through four relatively unique joints (glenohumeral, scapulothoracic, acromioclavicular, sternoclavicular) to achieve the normally graceful coordination required of shoulder motion. Because of this, alterations of the throwing mechanism about the shoulder produce a clinical picture that can be difficult to diagnosis and effectively treat.

It has been estimated that two of every three professional baseball pitchers have an elbow abnormality. Arm and forearm hypertrophy is typical. Hypertrophy of the humerus is invariably demonstrated in roentgenography, and traction spurs and loose bodies of bone within the elbow joint are frequent. Most loose bodies are found in the olecranon fossa, near the epicondyle, and near the tip of the coronoid process -where ulnar nerve irritation is likely. In 50% of professional pitchers, flexion contracture of the elbow is present. In addition to pitching, outfield throwing and batting mishaps account for similar sports injuries.

Avulsion and displacement of the medial epicondyle may complicate supracondylar fracture, or they may occur in association with soft-tissue trauma alone. Biceps spasm after 5 minutes of pitching strongly suggests an avulsion. Finger numbness following pitching suggests a scalenus anticus syndrome from a cervical or 1st rib condition. Avulsion and displacement of the epicondyle are common between 7 and 17 years of age and vary from slight epicondylar separation to complete avulsion and displacement into the elbow joint.

Predisposing Mechanics of the Arm During Elevation.   The position of the clavicle and the suspension of the upper extremity are determined by the integrity of the capsule of the sternoclavicular joint and its associated ligaments, while the vertical stability of the upper extremity at the glenohumeral joint is determined by the strength of the capsule's superior aspect and the coracohumeral ligament. During the first half of arm abduction in a pitch, all components of the rotator cuff are active and, along with the deltoid, produce compressive and shear forces at the surface of the glenoid cavity. These forces peak at 90 ° elevation. At 150° elevation, they are usually absent. During the last phase of elevation, EMG studies show the infraspinatus and teres minor tendons maintain their high level of activity to provide necessary external rotation for complete elevation of the arm.

Initiating Mechanisms in Throwing.   The act of throwing includes an initially smooth sequence of elevation, abduction, and external rotation of the upper arm that quickly leads to a sudden, forceful forward flexion, anterior abduction, and internal rotation of the shoulder associated with elbow, wrist, and finger extension. Crucial to the initial motion is the integrity of the rotator cuff. The cuff muscles are well beneath overlying muscles, thus difficult to palpate and differentiate. Because the path of the ulnar nerve is quite close to the medial epicondyle, strenuous pitching can easily result in traumatic ulnar neuropathy. Cases often present with paresthesias associated with fragmentation and partial avulsion of the medial epicondyle.

The biceps tendon whips against the outer edge of its groove when "round house" curves are thrown, initiating an inflammation and degenerative process ("glass arm" syndrome). The injury is essentially a localized tendinitis from intrinsic overload particularly at the subscapularis insertion on the lesser tuberosity. This produces disability on elevation and external rotation of the arm in the early stages of throwing. A cause is found in overstretch of the subscapularis at the end of "draw back," which is instantly interrupted by a sudden force on the tendon as the throw is made. Examination reveals limited motion and pain on abduction and external rotation of the shoulder. Pain is increased when active internal rotation is resisted, and tenderness will be found over the lesser tuberosity.

For purposes of analysis, Tullos/King divide the throwing mechanism into three separate and independent stages, each of which is associated with specific shoulder injuries:

1. The cocking phase.   During wind-up, the shoulder is brought into extreme external rotation, abduction, and extension. The biceps, triceps, and internal and external rotators are highly tensed. Thus, a professional baseball pitcher invariably exhibits abnormal external humeral rotation and subnormal internal rotation. Overstress makes the proximal arm vulnerable to biceps tendinitis, triceps tendinitis, and humeral subluxation.
   
   

2. The acceleration phase.   The actual throwing phase is a two-stage process: (a) With the forearm and hand stationary, the shoulder is brought forward, the elbow is put in extreme valgus strain as the muscular forces multiply on the shaft of the humerus, and the elbow is stabilized by the flexors of the forearm. (b) In the second stage, the forearm is rapidly whipped forward by internal shoulder rotation produced by severe contraction of the pectoralis major and latissimus dorsi. This stage ends when the hand is near ear level and the ball is released. Overstress makes the shoulder complex vulnerable to pectoralis and latissimus tendinitis, along with the effects of the mechanical forces on the humerus.
   
   

3. The follow-through phase.   The last phase begins as the ball is released near head level and ends when the pitch is completed. Its major function is involved with deceleration of the arm and forearm and, usually, some type of ball rotation. Great stress is applied at that time to the glenohumeral joint and its adjacent tissues. See Table 6.

Table 6.   Features of Typical Throwing Injuries

Throwing Phase	Especially Vulnerable Structure	Picture
Cocking	Biceps, long head	Tendinitis; localized pain in the anterior shoulder and bicipital groove, aggravated by resisted forearm supination.
	Triceps, long head	Tendinitis; pain in the posterior aspect of the shoulder, which radiates to axilla or deltoid area.
	Rotator cuff	Impingement syndrome during abduction and external rotation involving entrapment against either the acromion or coracoacromial ligament.
	Humerus	Abduction subluxation during internal or external rotation.
	Axillary artery	Occlusion by the pectoralis minor when the arm is brought into hyperabduction, extension, and extreme external humeral rotation, leading to intimal damage and subsequent thrombosis.
	Subdeltoid bursa	Bursitis and the development of fibrous adhesions.
Acceleration	Pectoralis major	Strain, tendinitis, rupture.
	Latissimus dorsi	Strain, tendinitis, rupture.
	Humerus	Fatigue fractures, coracoid process avulsion, epiphysitis in the young
Follow-through	Glenohumeral joint	Posterior capsulitis or tear; traction spurs.
	Quadrilateral area	Strain, myositis ossificans; occlusion of the posterior humeral circumflex vessel.

Triceps Brachii Calcification

Repetitive stretching of the posterior elements of the shoulder in baseball pitchers frequently causes an inflammation of the posterior capsule tissues of the shoulder. This can result in an osteotendinous calcification at the infraglenoid area where the long head of the triceps originates. Once calcification forms, the pitching follow-through is very painful. Management is similar to that of supraspinatus calcification.

Roentgenography.   Throwing injuries can be complex -acute trauma inserted within a framework of old scars. Anterior abnormalities may be found with the long head of the biceps tendon within the intertuberous groove or the supraspinatus. In rupture of the biceps brachii, a mass of soft tissue may appear at the anterior or anterolateral aspect of the mid or lower humerus. The long head of the triceps originating from the scapula at the infraglenoid tubercle may present an avulsion throwing injury detectable on roentgenography.

Less common throwing injuries include avascular necrosis of the head of the radius; thrombosis of the axillary artery; stress fracture of the olecranon process, the first rib (usually the contralateral midrib), and the front tips of the lower three ribs; and humeral fracture. Fracture of the humerus, a spiral fracture of the mid or lower third of the shaft (sometimes comminuted), appears to be associated with the sudden stopping of the throwing movement by the deltoid. While it is most common in the unconditioned baseball player, it is sometimes seen in softball, javelin, shot put, and handball.

Fracture of the proximal humeral epiphyseal cartilage is sometimes seen in adolescent baseball pitchers. Radiographs may show irregular ossification of the capitellum, abnormalities of the medial epicondyle, accelerated closure of the epiphyseal cartilage, or fragmentation of the medial epicondylar epiphysis from avulsion injury.

In heavy throwing sports such as shot put, hammer throw, and javelin, tears of the interscapular, scapulocostal, and rotator cuff muscles are often seen. In javelin activity, overstress may lead to elbow abnormalities such as bony- surface irregularities, soft-tissue calcification, para-articular ossification, capitellar erosion, rupture of the collateral ligaments, and intra-articular loose bodies at the lateral epicondyle and olecranon area. Bursal or tendon ossification are best shown in coned-down views taken during external and internal rotation.

Most subluxations in the elbow area will offer dramatic relief on correction. Generally, the adjustment is made with a quick short thrust to minimize the pain (and time) of relocation. It is essential that the patient's muscles be relaxed or correction will be inhibited and extremely painful. Naturally, quick thrusts are contraindicated in arthritic and sclerotic conditions or if adhesions are advanced.

Techniques to Release Humeroulnar Hypomobility

Internal and external rotation of the head of the radius on the head of the ulna and capitulum of the humerus and internal and external rotation of the olecranon of the ulna on the trochlea of the humerus are spinning actions that are readily reflected in standard procedures for evaluating passive ranges of motion.

Freeing Restricted Distraction.   The humeroulnar joint can be jammed by a fall on the outstretched hand or simply by severe para-articular muscle spasm. It is sometimes seen in patients whose occupations require repeated violent pushes with the heel of the extended hand (eg, football linemen, carpenters). Almost any type of axial traction will help to relieve this condition. A common procedure is to first place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90°, flex the elbow to 90°, and pronate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the humerus, grasp the under surface of the proximal forearm with both hands, slightly abduct the forearm so that more pressure will be applied to the ulnar than the radius, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times.

Freeing Restricted Medial-Lateral Tilt.   Place the patient supine, and sit or stand at the side of the table on the involved side (obliquely facing the patient). The patient's involved limb should be resting loosely at the side, near the body, with the elbow extended and the wrist supinated. This is a two-phase procedure:

The first maneuver is to stabilize the patient's distal forearm with your medial hand and grasp the lateral surface of the patient's proximal ulnar with your active (lateral) hand. This position allows you to apply a horizontal shearing force across the humeroulnar joint, from the lateral to the medial. Slowly apply force to patient tolerance, hold, and gradually release. Repeat several times.

The second maneuver is just the reverse. Stabilize the patient's distal forearm with your lateral hand and grasp the medial surface of the patient's proximal ulnar with your active (medial) hand. This position allows you to apply a horizontal shearing force across the humeroulnar joint, from the medial to the lateral. Slowly apply force to patient tolerance, hold, and gradually release. Repeat several times.

Techniques to Release Proximal Radioulnar Hypomobility

Freeing Restricted Distraction.   This method is a variation on that for a jammed humeroulnar joint. Place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90°, flex the elbow to 90°, and supinate the forearm. Place the medial side of your knee in the patient's antecubital fossa to stabilize the humerus, grasp the upper surface of the proximal forearm with both hands, slightly adduct the forearm so that more pressure will be applied to the radius than the ulna, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times.

Freeing Restricted A-P Glide.   Place the patient supine, sit at the side of the table on the involved side, and face the head of the table. Abduct the patient's shoulder to 90°, flex the elbow to 90°, supinate the forearm, and lift the arm so that the patient's hand points toward the ceiling. Place your thumb (lateral side) on the head of the radius (which serves as a fulcrum) and cup the patient's elbow with the palm of your stabilizing hand. With your active hand (medial), move the patient's distal forearm toward the shoulder (elbow flexion). Once resistance is felt, slowly apply force to patient tolerance and release. This is essentially a rocking-type motion. Repeat several times. The patient must completely relax the arm as any contraction of the patient's biceps against your thumb produces pain.

Freeing Restricted Pronation (Internal Rotation).   Place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90°, flex the elbow to 90°, and supinate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the humerus, grasp under the patient's distal forearm with both hands, pronate the patient's forearm to tolerance by rotating your hands, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times, progressively increasing the degree of pronation possible.

Posterior-Medial Radial Head Subluxation-Fixation Release

This "pulled elbow" injury results from the radial head being jerked from under the annular (orbicular) ligament, manifesting pain and tenderness in the area of the radial head. A "snap" is usually heard and felt at the time of trauma. The injury was once called "nursemaid's elbow" because it was frequently found after young children were quickly lifted up by the wrist or hand when the child's elbow was extended and the forearm was pronated. This classic form rarely occurs after the age of 6 years.

Significant Features.   Motion is severely limited in pronation and supination, but flexion and extension are normal. The arm is held motionless at the side in slight flexion and pronation, and pain is fairly localized at the elbow. X-ray films are usually negative. This type of subluxation is commonly associated with tennis elbow, lateral elbow pain, restricted anterolateral radial-head motion, and wrist trauma.

Adjustment Technic.   When adjustment is indicated, hold the patient's affected elbow with one hand so that your thumb rests on the back of the head of the involved radius. With your other hand, grasp the patient's hand and move the forearm into a position of slight flexion at the elbow, full forearm pronation, and full flexion at the wrist. The adjustment (Mills' movement) consists of fully extending the patient's elbow while maintaining pronation and flexion of the wrist. The maneuver is made gently but quite sharply; thus, it is essential that the patient's elbow muscles are relaxed. The maneuver does not usually cause pain in a normal elbow, but there is sharp pain quickly followed by relief when a "tennis elbow" is freed. After correcting malposition, treat the condition as a severe sprain and offer rest in a flexion sling for several days.

Alternative Technic.   An alternative procedure to re-establish a slipped radial head is to grasp the hand of the sitting patient and extend the patient's wrist. Support the elbow firmly with your contact hand. Flex the patient's elbow to a right angle. Maintain axial compression along the radius, and firmly alternate forearm supination and pronation in a "screwing" manner until the head of the radius slips back into its normal seat. The thumb of your hand holding the patient's elbow can be used to apply manual pressure against the head of the radius. A click can usually be felt and heard on replacement, which is followed by immediate relief.

Anterior Olecranon Subluxation-Fixation Release

Subluxation of the olecranon anteriorly is often found associated with hyperextension sprains and restricted posterior olecranon motion.

Adjustment Technic.   Stand on the involved side and face the sitting patient. Slightly abduct the patient's arm, and flex the elbow. Grasp your medial (active) hand around the patient's distal forearm. Cup the medial aspect of your lateral (stabilizing) hand deep within the antecubital fossa, and wrap your fingers around the proximal aspect of the patient's forearm so that your thumb points upward. Make a short brisk thrust with your contact hand toward the patient's shoulder, using your stabilizing hand as a fulcrum to bring the olecranon out of its depressed position.

Posterior Olecranon Subluxation-Fixation Release.   This type of subluxation is associated with elbow or wrist trauma, epicondyle and bursa tenderness, triceps weakness, and restricted anterior olecranon movement.

Adjustment Technic.   Stand on the affected side of the supine patient so that you face cephalad. Extend the patient's elbow, and slightly externally rotate the patient's forearm. Cup the patient's elbow with your medial hand, and place your thumb against the epicondyles for leverage. With your lateral hand, grasp the patient's lower forearm. A short, brisk, thrust (downward) is made toward the tabletop on the distal forearm as your medial hand applies mild counterpressure upward.

Superior Olecranon Subluxation-Fixation Release

Subluxation of the ulna superiorly is related to elbow or wrist trauma. It is often a consequence of a falling person protecting the head by an outstretched hand, resulting in the proximal aspect of the ulna being jammed against the distal aspect of the humerus.

Adjustment Technic.   The patient sits next to a narrow table and is instructed to lean forward to slightly forward-abduct the arm and extend the forearm horizontal to the table's surface. The elbow should never be fully extended as this subjects the tip of the olecranon process to injury. Stand on the opposite side of the table and face the patient. With your contact hand, grasp the patient's lower forearm and slightly rotate it externally. Place the web of your other hand around the patient's lower anterior humerus and extend your elbow to stabilize the patient's arm. Apply traction with your contact hand, and then make a short quick pull to bring the ulna inferiorly (toward your body).

Alternative Technic.   Stand on the affected side of the supine patient. Abduct the patient's arm, and flex the elbow. Grasp the patient's lower forearm with both hands, with emphasis on the ulnar aspect, and place your knee in the patient's antecubital fossa for stabilization. Traction is applied, followed by a strong upward pull.

Lateral Olecranon Subluxation-Fixation

This type of subluxation is often related to elbow or wrist trauma that is followed by lateral elbow pain, triceps weakness, a decreased distance between the olecranon and the lateral epicondyle, and/or restricted olecranon motion.

Adjustment Technic.   Face cephalad on the affected side of the prone patient. Abduct the patient's involved arm, extend the elbow, and internally rotate the extremity. Apply a soft pisiform contact with your medial hand on the lateral aspect of the patient's olecranon, and stabilize the patient's lower forearm with your other hand. A short brisk thrust is made caudally to shift the olecranon medially as your stabilizing hand pronates the lower forearm.

Medial Olecranon Subluxation-Fixation Release

Subluxation of the olecranon medially is often seen in association with wrist or elbow trauma that is followed by ulna nerve paresthesias, medial elbow pain, triceps weakness, a decreased distance between the olecranon and the medial epicondyle, and/or restricted lateral olecranon joint motion.

Adjustment Technic.   Face cephalad on the affected side of the supine patient. The patient's arm is slightly abducted with the elbow extended. The heel of your medial contact hand should be placed over the medial aspect of the patient's olecranon, while your stabilizing hand grasps the patient's forearm. The patient's involved elbow is then gently brought into full extension. A short thrust is then made from the medial to the lateral with your contact hand while your stabilizing hand applies lateral to medial pressure.

Alternative Technic.   The positions for both doctor and patient are similar to those described above, but the doctor stands more parallel to the patient's arm when applying this technic. Abduct the patient's arm so that the arm is in front of you, pronate the patient's wrist, and extend the elbow. Firmly grasp the patient's olecranon with the 1st and 2nd finger of your contact hand, and stabilize the patient's distal forearm with your other hand. A short brisk pronating medial to lateral pull and full elbow extension is then made with your contact hand as your stabilizing hand tends to supinate the patient's forearm.

Reducing and Managing Simple Dislocations

Reduction of uncomplicated posterior elbow dislocations can usually be performed without anesthesia if they are presented soon after they occur and spasm has not become severe.

Classic Reduction Technic.   All that might be necessary is gentle steady longitudinal traction on the wrist of the supine patient, with countertraction on the shoulder. This countertraction is easily accomplished by a long towel looped around and under the patient's arm pit, with the loose ends of the towel held cephalad by an assistant while the doctor performs the reduction. Slight manual extension pressure may be necessary to unlock the olecranon during wrist traction.

Parvin's Method.   An alternative procedure is conducted with the patient prone. The involved limb is allowed to hang so that the fingers point toward the floor. A 5-lb weight can be applied to the patient's padded wrist by tape or manual downward traction can be used. After several minutes, when any spasm has subsided, gently place your medial hand in the involved antecubital fossa and grasp the patient's wrist with your lateral hand. Gently lift the patient's wrist upward to produce elbow flexion. This simple maneuver will often reduce the dislocation.

General Management Direction.   After reduction, the elbow should be immobilized for 3 weeks in a molded posterior plastic splint at 90° flexion. This time should be sufficient for adequate ligamentous and capsular healing to take place before mild unsupported activity is resumed. Gentle passive stretching and active range-of-motion exercises should be initiated after the splint is removed. Motion should never be forced because it will only lead to greater swelling and joint stiffness. Moist heat can be applied by the patient at home at least once daily for 20–30 minutes and continued until residual stiffness resolves. It may take several months for full recovery to occur, and a minor nondisability stiffness may remain.

Common Elbow Contusions and Strains

There may be an injury to the upper radioulnar articulation by sudden overpronation or oversupination that is followed by pain over the articulation with limitation of rotation. Normally, the olecranon bursa is not palpable; in bursitis, it will feel boggy and thick. Trigger points are usually found just below the horizontal midline of the antecubital fossa over the proximal radius and ulna. When the joint proper is involved, motion is limited chiefly in extension and may persist indefinitely. An associated injury of the brachialis anticus muscle with later contracture is common. In children, it has been previously described that a strip of periosteum may be torn from the anterior humerus, followed by bone formation and blocked joint motion. Local myositis ossificans may also develop in the tendon of the brachialis anticus. Some cases will be complicated by ulnar neurapraxia.

Management.   During the early stage, rest in a sling for 3–4 days is required for the acute symptoms to subside. Thereafter, physical therapies with passive and progressive active exercises are recommended. Diathermy is especially helpful in absorption of joint effusion. Rarely is joint aspiration necessary.

Distal Bicipital Strain

Strains of the bicipital attachment to the ulna are not common. They occur in elbow hyperextension injuries and in overenthusiastic weight-lifting efforts. The course of the tendon is tender on palpation. Management consists of rest in a sling for a few days along with standard sprain therapy.


Olecranon Bursitis

Smooth mobility of the elbow is provided by the olecranon bursa. Besides a direct blow, this fluid-filled pouch is exposed to injury when the elbow is repeatedly pressed against a firm surface. Excessive intrinsic forces also may cause inflammation, synovial thickening, and the formation of excessive fluid. Repetitive friction of extensor tendons may initiate the inflammatory process. Thus, olecranon bursitis is often a part of the clinical picture of epicondylitis (medial or lateral), forearm strains, and traumatic inflammation of the elbow.

Posterior elbow swelling, pain, and tenderness exhibit. Active flexion and extension are restricted. Most cases of olecranon bursitis will heal spontaneously in a few days once the irritating factor is removed, but proper clinical management speeds the process and prevents secondary infection from converting the inflammation into an abscess.

Diagnosis.   A typical protocol is to motion palpate the elbow and the spine and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests. Check pertinent tendon and superficial reflexes, and grade the reaction. Check involved joint motion and muscle strength against resistance, and grade resistance strength. Interpret resisted motion signs.

Management.   Treat with cold. Check for elbow motion restrictions and gently mobilize fixations if such maneuvers are not too painful. Follow with compression and elevation for 1 or 2 days. Contributing spinal majors will likely be found at C5–T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, it helps to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes.

The adjunctive therapy commonly recommended includes interferential therapy, transverse friction massage at the periphery of the elbow area, acupuncture, and surge stimulation to reduce the swelling. Refer for aspiration if necessary, but crisscross taping in elbow extension usually brings quick relief after primary therapy has been applied. In mild moderate cases, an elastic ankle support can be worn with the heel opening placed on the antecubital fossa.

Recurrent swelling is common, and protective elbow padding is necessary long after symptoms subside. Rehabilitative procedures should be designed to improve the strength of wrist extensors, flexors, abductors, and adductors. Stressful elbow flexion and extension should be avoided. Monitor carefully for possible signs of secondary cellulitis.

Discovered treat trigger points should be treated, especially those found in the triceps, extensors, and serratus posterior muscles. Supplemental nutrients B1, B6, C, niacin, P, manganese, and zinc are recommended by several authorities. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Other helpful forms of treatment include contrast baths during the acute stage, iontophoresis with proteolytic enzymes or hyaluronidase, alternating current for passive exercise and pain control, or high-voltage therapy. When swelling and tenderness have disappeared, the attending doctor should demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Traumatic Arthritis

Injury to the proximal radioulnar articulation occurs by sudden overpronation or excessive supination. The injury is followed by joint pain and restricted rotation. The clinical picture resembles a combination of tennis elbow and forearm strain, but take care not to overlook the possibility of a spontaneously reduced dislocation of the head of the radius.

Forced movement beyond the normal range of joint motion in any position may produce a rupture in the capsule and its supporting ligaments. If this occurs, the capsule will be tender and likely distended with blood. Movement in the direction of injury will aggravate the pain, and motion will be voluntarily restricted.

Management.   Associated spinal majors will likely be found at C6–C7. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, it's beneficial to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes. Because of its poor vascularity, never apply ice massage to the elbow. Treat trigger points discovered, especially those in the anconeus, triceps, brachialis, brachioradialis, and extensor and pronator muscles. Supplemental nutrients B1, B6, C, niacin, P, copper, manganese, zinc, and rutin are recommended by authorities. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Other helpful forms of treatment include rest, temporary support, contrast baths, comfrey ointment, and spray-and-stretch therapy during the acute stage, followed by moist heat or shortwave diathermy, ultrasound, interferential therapy, iontophoresis with hydrocortisone, alternating current for passive exercise and pain control, high-voltage therapy, or tendon friction massage of involved muscles. When pain and tenderness subside, the attending physician should demonstrate and prescribe therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Common Elbow Sprains

Forced motion beyond full extension, abduction, or adduction ruptures the capsular apparatus and its reinforcing ligaments from their attachment to the humerus, radius, and ulna. The capsule is tender and frequently distended with blood. Movement in the direction of injury aggravates the pain, and there is some restriction at extreme ranges.

Articular or extra-articular injuries to the elbow without fracture are not uncommon and are peculiarly resistant to treatment. There may be a primary or secondary injury to the upper radioulnar articulation by sudden overpronation or oversupination, followed by pain over the articulation and limited rotation. Overlooking radial-head dislocation is a common orthopedic error.

Biomechanics Involved.   The proximal forearm, elbow joint, and distal humerus are frequently injured when the mechanism of trauma is a fall on the outstretched hand. When the elbow is extended, the upper extremity acts as a mechanical brace that transmits force from the point of hand contact to the neck and trunk. An axial compression combined with a bending motion to sharply dorsiflex the wrist produces a force couple that compresses the wrist dorsally and stretches the ventral soft tissues. If a portion of this strut is weakened by age, for instance, where bone is weaker than the involved ligaments and tendons, this weakness determines the type of injury. Thus, falls on the outstretched hand usually involve the wrist of the elderly and the distal humerus of the young.

When a fall is made on the outstretched hand, several mechanisms are effected:

(1) axial compression forces throughout the limb;
(2) bending moments at the wrist, elbow, and shoulder joints;
(3) torsion about the long axis of the limb; and
(4) violent lateral flexion of the cervical spine. The moment of axial loading (impact force X lever arm) must be resisted by the elbow tissues to prevent failure. If the elbow holds, the force not absorbed is transmitted to the shoulder.

Common Types of Elbow Sprain

Hyperextension Sprain.   Severe hyperextension sprain strongly resembles posterior dislocation of the elbow. Swelling and tenderness will be found at the joint capsule (posteriorly), bicipital tendon, olecranon fossa, lateral and medial collateral ligaments, and attachments of the flexors at the medial condyle. Pain is relieved by flexion and increased on attempted extension. If the joint proper is involved, extension is chiefly limited, and it may persist for weeks or years.

Hyperabduction Sprain.   Tenderness is found below the medial epicondyle, suggesting sprain of the ulnar collateral ligament. Pain is increased by forcing the elbow into valgus stress.

Hyperadduction Sprain.   Tenderness is located below the lateral epicondyle, indicating sprain of the radial collateral ligament. Pain is increased by forcing the elbow into varus stress.

Ligament Stability Tests

Elbow Abduction-Adduction Stress Test.   To roughly judge the stability of the medial and lateral collateral ligaments of the elbow, hold the patient's wrist with one hand and cup your stabilizing hand under the patient's distal humerus. After the patient has slightly flexed the elbow,

(1) push medially with your active hand and laterally with your stabilizing hand, then
(2) push laterally with your active hand and medially with your stabilizing hand. With the fingers of your stabilizing hand, note any joint gapping felt during either the valgus or varus maneuver. Painful instability indicates torn ligaments.

Elbow Extension-Flexion Stress Test.   Passively extend and flex the patient's elbow. Painful instability suggests sprain or destructive joint disease, while discomfort with limited motion suggests contractures or degenerative arthritis.

Forearm Pronation-Supination Stress Test.   Passively pronate and supinate the patient's forearm. Painful instability suggests sprain or destructive joint pathology, while discomfort with limited motion points to contractures or degenerative arthritis.

Tennis Elbow (Lateral Epicondylitis)

"Tennis elbow" is a vague term. It generally refers to any painful elbow condition of traumatic origins (not limited to tennis) occurring about the external epicondyle of the humerus, especially the tendinous origins of the forearm extensors. The syndrome incorporates a group of associated conditions, especially epicondylitis or radiohumeral bursitis. It is usually caused by repeated violent elbow extension combined with sharp twisting supination or pronation of the wrist against resistance thus its association with tennis. The result is severe contraction stress of the extensor-supinator muscle insertions of the forearm. The supinator has its tendinous origin just behind the common extensor tendon.

The overt clinical picture is synovitis, subperiosteal hematoma, fibrositis, and/or partial rupture of the fibrous origin of muscles and ligaments at the affected epicondyle, with some associated periostitis. Radial nerve entrapment may be involved. If the medial epicondyle is sore, the flexor-pronator muscles and medial ligaments are involved (golfer's elbow). However, the lateral epicondyle area is affected seven times more often than the medial epicondyle.

Clinical Features.   Hasemeir describes the typical symptomatic picture as pain over the outer or inner side of the elbow, distal to the affected epicondyle. The pain may be severe and radiate when the patient extends his arm. The pain is usually sharp and lancinating on exertion, but it may be dull, aching, and constant. Squeezing an object with the fingertips is painful (writer's cramp). Tenderness, abnormal warmth, and swelling are found over the affected epicondyle, and limited passive movement on extension can often be found. Grip strength as well as supination and pronation strength are affected.

In medial epicondylitis (golfer's elbow) and lateral epicondylitis (tennis elbow), Palo points out that simple palpation over the involved epicondyle will elicit a painful response from the patient. The definitive tests involve stretching or stressing the involved joint.

Palo reinforces Southmayd's reason tennis elbow is slow to heal. It has to do with the myology of the joint.

"The forearm muscles are attached to what most physicians call a tendon. But in reality they are attached to a muscle origin. A true tendon slides. It has a sheath and is bathed in synovial fluid, which both nourishes and lubricates. The muscle origin of the forearm muscles has none of these. In a few instances, I have operated on the muscle origin. It is like cutting into gritty tissue. It has the worst blood supply of any structure in the body. The incision gives forth only a drop or two of blood. It is this infinitesimal blood supply which slows the healing process when the muscle origin is ripped or torn."

Kaplan's Test.   This is a two-phase test:

(1) The sitting patient is given a hand dynamometer and instructed to extend the involved upper limb straight forward and squeeze the instrument as hard as possible. Induced pain and grip strength are noted.
(2) The test is then repeated except that this time you firmly encircle the patient's forearm with both hands (placed about 1–2 inches below the antecubital crease). Induced pain and grip strength are noted. If the second phase of the test shows reduced pain and increased grip strength when the muscles of the proximal forearm are compressed, lateral and/or medial epicondylitis is indicated.

Mills' Test.   The patient makes a fist; flexes the forearm, wrist, and fingers; pronates the forearm, and then attempts to extend the elbow against your resistance. This stretches the extensors and supinators attached to the lateral epicondyle. Pain at the elbow during this maneuver is a general indication of radiohumeral epicondylitis (tennis elbow).

Cozen's Test.   With the patient's forearm stabilized, the patient is instructed to make a fist and extend the wrist. Cup the patient's elbow with your stabilizing hand and the top of the patient's fist with your active hand, and attempt to force the wrist into flexion against patient resistance. A sign of tennis elbow is a severe sudden pain at the lateral epicondyle area.

Management.   For appropriate adjustment procedure, refer to posteromedial subluxation of the radial head that has been described previously. Check for elbow, shoulder, wrist, lower cervical, 1st rib, and upper thoracic subluxations/fixations. In chronic cases, the correction of local elbow lesions will often be designed to relieve fixation produced by probable scar tissue in the vicinity of the lateral epicondyle.

Contributing spinal majors will likely be found at C5–T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, it's helpful to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes. Treat trigger points discovered, especially those found in the triceps, supraspinatus, anconeus, brachioradialis, extensors, and supinator muscles.

Physiologic Therapeutics.   Apply cold (eg, packs, ice massage), spray-and-stretch isolated trigger points as described below, secure forearm muscles with a short strap placed about 1-1/2 inches below the antecubital crease (splint in severe cases), and rest the joint with a sling. A firm but not tight strap applied around the circumference of the forearm just below the antecubital crease will afford protection to the injured tissues and relief during healing. An elastic bandage offers little therapeutic value.

After the acute stage, transverse friction massage, interferential therapy, auriculotherapy, positive galvanism, diathermy, or ultrasound, along with progressive exercises are the common adjunctive procedures used. Underwater ultrasound is recommended by several authorities. Caution the patient that return to activity immediately on fading of symptoms invites recurrence. Other helpful modalities include iontophoresis with salicylate, alternating current for passive exercise and pain control, and high-voltage therapy.

Several nutritionists recommend protein, vitamin C with bioflavinoids, manganese, and zinc to speed the healing process. Supplemental nutrients B6, niacin, P, copper, and rutin are also suggested. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

When swelling and tenderness have disappeared, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures. Squeezing a rubber ball helps recuperation. Graduated restoration to painless function under stress conditions is necessary before full activity is resumed. Strengthening wrist extensors is important.

Golfer's Elbow (Medial Epicondylitis)

A severe strain opposite to that of tennis elbow may be found at the origin of the flexor pronator muscles at the medial epicondyle with associated sprain of the medial ligament. This injury is often called "golfer's elbow." Subperiosteal hematoma and periostitis are often involved. Poor warm-up is usually the predisposing cause in golf or bowling, but taking a divot too deep during chipping is sometimes the precipitating factor.

Medial Epicondyle Test.   The patient flexes the wrist with the forearm in supination. The doctor then attempts to force the patient's wrist into extension against patient resistance. Pain originating at the medial epicondyle is a sign of medial epicondylitis. This test is sometimes called the reverse Cozen's test.

Management.   The classic adjustment is to extend the wrist and fingers and supinate the forearm while the elbow is fully extended. Contributing spinal majors will likely be found at C5–T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, it helps to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes. Treat trigger points discovered, especially those found in the triceps, pronators, and pectoral muscles. Supplemental nutrients C, B6, niacin, P, copper, manganese, zinc, and rutin are recommended in the literature. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Other helpful forms of treatment include contrast baths and spray-and-stretch therapy during the acute stage, followed by moist heat or shortwave diathermy, ultrasound, interferential therapy, iontophoresis with salicylate, alternating current for passive exercise and pain control, high-voltage therapy, or tendon friction massage of involved muscles.

Exercises for Elbow Epicondylitis.   An excellent exercise for lateral epicondylitis, medial epicondylitis, related strains, or weak wrist dorsiflexors is to have the patient sit, loop the middle of a length of surgical tape or a Theraband under the ipsilateral foot and grasp the taut ends of the tubing in the hand, palm down. The wrist is then dorsiflexed against the resistance of the tubing to the point of fatigue where rapid rhythm fails. A mild burning sensation in the posterior forearm muscles is often perceived. After a period of rest, the exercise is repeated. Three successive bouts several times a day is recommended. The subject will advance to heavier resistance (eg, hand dumbbell).

This exercise is also effective in wrist flexor/pronator tendinitis. The only difference is the tubing is grasped first with the palm up and later with the palm facing medially.

Pitcher's Elbow

Background for this disorder has been described earlier. Its chronic form is similar to golfer's elbow but associated with baseball pitchers. It is caused by elbow extension and snapping pronation or supination as the pitcher throws a "slider" or "breaking curve." Degenerative changes are essentially on the medial epicondyle, thus indicating pronator strain. It can be considered an elbow "whiplash" injury where the olecranon impinges the fossa at the distal humerus. Loose bodies from cartilage flaking, trochlea osteophytes, medial ligament ossicles, and olecranon chips are frequently related.


Little League Elbow

Displacement and fragmentation of the medial condyle in youthful baseball pitchers (Little Leaguer's elbow) have a high incidence. "Little league elbow" is a general term for "pitcher's elbow" in youth. The term basically refers to elbow sprain complicated by an avulsion of the ossification center of the medial condyle, a nonunion fatigue fracture through the olecranon growth plate, osteochondritis, or loose bodies, or a combination of such factors. The syndrome may at first resemble either diffuse lateral or medial epicondyle inflammation. Avulsions, osteochondritis dissecans of the capitulum, and proximal forearm muscle strain may also be involved. The primary lesion will determine whether the onset is abrupt or gradual.


Javelin Elbow

When the javelin is thrown or a similar action is made the olecranon pivots medially in the trochlea and its tip is forced against the edge of the fossa during the extreme forearm pronation and elbow extension necessary. This may result in repeated sprain from amateur "round house" throws complicated by fracture fragments, calcification, and spur development along the course of the medial collateral ligament of the elbow. Transient ulnar nerve paralysis and "pitcher's" symptoms are early indications. In some cases, a "golfer's elbow" syndrome is seen from flexor-origin strain.


Direct Peripheral Nerve Trauma

Musculospiral Contusion.   The path of the radial nerve in the musculospiral groove, which courses along the lateral distal-third of the humerus, is relatively superficial and not infrequently the site of contusion. The clinical picture ("dead arm") is sudden radiating pain throughout the distal radial distribution and extensor paralysis. Damage is rarely permanent, and symptoms usually ease within a few minutes. Local ice massage and standard nerve-contusion management are usually adequate. If symptoms persist, neurologic consultation should be considered.

Radial Nerve Compression at the Elbow.   This nerve compression syndrome features pain and disturbed sensation in the area of distribution of the nerve's superficial branch and is thus frequently confused with de Quervain's disease. If the deep branch is involved, pain is at or below the lateral epicondyle. On palpation, the nerve trunk is tender near the origin of the extensors, and active extension of the fingers initiates or aggravates pain. If the elbow is extended and the middle finger is actively extended against resistance, pain is acutely increased because the extensor carpi radialis inserts at the base of the third metacarpal. If conservative therapy fails to afford relief, referral for exploratory surgery should be considered.

Ulnar Nerve Compression at the Elbow.   The ulnar nerve is injured just slightly less in incidence than radial nerve trauma. The damage is usually at the inner side of the elbow where it is quite vulnerable in its superficial position along the elbow's posteromedial aspect. After severe damage, a characteristic "claw hand" can result with sensory loss at the medial side of the hand.

Cubital Tunnel Syndrome.   Ulnar nerve compression at the elbow is called cubital tunnel syndrome or tardy ulnar nerve palsy. It is often the result of trauma or compression of the ulnar nerve at the elbow when the medial ligament ruptures during elbow dislocation. It may also be involved if the medial epicondyle becomes fractured. Disability and pain occur along the ulnar aspect of the forearm and hand. Early signs are inability to separate the fingers and disturbed sensation of the 4th and 5th digits. Interosseous atrophy is usually evident. Light pressure on the cubital tunnel initiates or aggravates the pain. Nerve conduction studies help to confirm the diagnosis. The cause can be repetitive trauma, and response to conservative therapy is often poor unless the source of irritation can be removed. Surgery may stop the progressive neuropathy, but it does not guarantee return of normal neurologic function.

Management.   Associated spinal majors will likely be found at C5–T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, it helps to apply deep high-velocity percussion spondylotherapy over segments C7–T4 for 3–4 minutes. Treat trigger points discovered, especially those found in the anconeus, triceps, brachialis, brachioradialis, and extensor and pronator muscles. Supplemental nutrients B1, B6, C, niacin, P, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Helpful modalities include contrast baths, interferential therapy, iontophoresis with magnesium, alternating current for passive exercise and pain control, or high-voltage therapy. When the acute stage has passed, the attending physician should demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.