elbow injury mechanism and types.

1. Elbow injuries
-Dr. Krupal Modi(MPT)
10/9/2018

2. Elbow pain is considered
under the following headings:
• lateral elbow pain, with a particular focus on extensor
tendinopathy
• medial elbow pain
• posterior elbow pain

3. lateral elbow pain

4. 1) Extensor tendinopathy
• Lateral elbow pain is an extremely common presentation
among sportspeople and manual workers.
• The most common cause is an overuse syndrome related to
excessive “wrist extension”.
• This condition has traditionally been known as ‘tennis elbow’.
This is an unsatisfactory term as it gives little indication of the
pathological processes involved. In fact, the condition is more
common in non-tennis players than in tennis players.

5. • It has also been referred to as
‘lateral epicondylitis’. This is
also inappropriate as the site
of the abnormality is usually
just below the lateral
epicondyle and the primary
pathology is due to collagen
disarray rather than
inflammation.
• The primary pathological
process involved in this
condition is tendinosis of
the extensor carpi radialis
brevis (ECRB) tendon, usually
within 1–2 cm of its
attachment to the common
extensor origin at the lateral
epicondyle.

6. Clinical features
• Diffuse pain of extensor tendinopathy typically radiates from
the lateral epicondyle into the proximal forearm extensor
muscle mass.
• The pain may be more localized.
• The onset of pain may be either acute or insidious.
• It is important to note whether the pain is aggravated by
relatively minor everyday activities, such as picking up a cup,
or whether it requires repeated activity, such as playing
tennis or bricklaying, to become painful.

7. • Pain may radiate into the lateral aspect of the forearm. This
may be consistent with posterior interosseous nerve
entrapment or irritation of other neural structures.
• Associated sensory symptoms, such as pins and needles, may
indicate a neural component. Presence of neck, upper thoracic
or shoulder pain should also be noted.
• An activity history should also be taken, noting any recent
change in the level of activity. In tennis players, note any
change in racquet size, grip size or string tension and whether
or not any comment has been made regarding his or her
technique.

8. Pathophysiology
• Light microscopy reveals an excess of both fibroblasts and
blood vessels.
• This abnormal tissue has a large number of nociceptive fibers,
which may explain why the lesion is so painful.
• With continued use, tendinosis may extend into microscopic
partial tears.
• Conversely, a tear may be the primary abnormality with
degenerative change being secondary.

10. • With wrist extension, a considerable shearing stress is placed
on the ECRB tendon.
• The ECRB muscle crosses both the elbow and the wrist and,
therefore, contracts eccentrically at both ends during certain
maneuvers.
• Additional stress is applied by the head of the radius, which
rotates anteriorly, compressing the ECRB tendon during
pronation of the forearm.
• Neural structures may contribute to the patient’s lateral elbow
pain. Lateral elbow pain is often associated with cervical and
upper thoracic abnormalities, particularly of the C5–6 region.

11. • On examination, the maximal area of tenderness is usually
approximately 1–2 cm (0.5–1 in.) distal to the lateral
epicondyle in the ECRB tendon.

12. • The pain is reproduced by
resisted wrist extension,
especially with the wrist
pronated and radially
deviated (Mills’ test).
• Resisted extension of the
middle finger is also
painful. The ECRB tendon is
preferentially stressed in
this position as it must
contract synergistically to
anchor the third
metacarpal to allow
extension to take place at
the digits.

14. Medial elbow pain
• Patients who present with medial elbow pain can be
considered in two main groups.
• One group has pain associated with excessive activity of the
wrist flexors. This is the medial equivalent of extensor
tendinopathy with a similar pathological process occurring in
the tendons of pronator teres and the flexor group. This
condition will be referred to as ‘flexor/pronator tendinopathy’.

15. • The second group of patients have medial elbow pain related
to excessive throwing activities.
• Throwing produces a “valgus stress” on the elbow that is
resisted primarily by the anterior oblique portion of the
medial collateral ligament (MCL) of the elbow and
secondarily by the stability of the radiocapitellar joint.
Repetitive throwing, especially if throwing technique is poor,
leads to stretching of the MCL and a degree of valgus
instability.
• A fixed flexion deformity of the elbow may develop as a
result of scarring of the MCL.

17. • In children, repetitive valgus
stress may result in damage
to the medial epicondylar
epiphysis with pain and
tenderness in this region.
• This usually responds to a
period of rest but may
progress to avulsion with
continued activity. This
condition, commonly
known as ‘little leaguer’s
elbow’.

18. 2) Flexor/pronator tendinopathy
• This condition is not as common as its lateral equivalent but is
seen especially in golfers (‘golfer’s elbow’) and in tennis
players who impart a lot of top spin on their forehand shot.
• The primary pathology exists in the tendinous origin of the
forearm flexor muscles, particularly in the pronator teres
tendon.

19. • On examination, there is
usually localized
tenderness just at or below
the medial epicondyle with
pain on resisted wrist
flexion and resisted
forearm pronation,
especially when passive
stretch is placed on the
tendon (reverse Mills’ test).

20. 3) Medial collateral ligament sprain
• Sprain of the MCL of the elbow may occur as an acute injury,
or as the result of chronic excessive valgus stress due to
throwing.
• This occurs particularly in baseball pitchers and javelin
throwers. The repeated valgus stress, especially in throwers
who ‘open up too soon’ (i.e. become front-on too early in the
throwing motion), leads initially to inflammation of the
ligament, then scarring and calcification and occasionally
ligament rupture.

21. • On examination, there will be localized tenderness over the
ligament and mild instability on valgus stress .
• There will often be associated abnormalities such as a flexion
contracture of the forearm muscles, synovitis and loose body
formation around the tip of the olecranon, as well as damage
to the radiocapitellar joint.

22. Posterior elbow pain
• The main causes of posterior elbow pain are
• Olecranon bursitis
• Triceps tendinitis and
• Posterior impingement.
• Gout should always be considered.

23. 4) Olecranon bursitis
• Olecranon bursitis may
present after a single
episode of trauma or, more
commonly, after repeated
trauma, such as falls onto a
hard surface affecting the
posterior aspect of the
elbow.
• It is also seen in individuals
who rest their elbow on a
hard surface for long periods
of time and is known as
‘student’s elbow’.

24. • Occasionally, olecranon bursitis can become infected.
• This is a serious complication that requires immediate
drainage, strict immobilization and antibiotic therapy.
• Osteomyelitis and septic arthritis can follow. Excision of the
bursa is occasionally required.

25. 5) Triceps tendinopathy
• Tendinopathy at the insertion of the triceps onto the
olecranon is occasionally seen.
• The patient has pain and tenderness in the triceps tendon
insertion into the olecranon, this pain exacerbate by a forced
extension of the elbow. It is also possible that there's swelling
around the elbow.
• Standard conservative measures for treatment of
tendinopathy should be used. Soft tissue therapy and dry
needling to reduce excessive tightness of the triceps are often
helpful.

26. 6) Posterior impingement
• Posterior impingement is probably the most common cause of
posterior elbow pain.
• It occurs in two situations.
1) In the younger athlete there is the ‘hyperextension valgus
overload syndrome’. Repetitive hyperextension valgus
stress to the elbow results in impingement of the posterior
medial corner of the olecranon tip on the olecranon fossa.
• Over time this causes osteophyte formation, exacerbating the
impingement and leading to a fixed flexion deformity.

27. 2) In the older patient the most common cause is early
osteoarthritis, which often predominantly affects the
radiocapitellar joint.
• Generalized osteophytes forms through the elbow.
Impingement of these osteophytes posteriorly results in
posterior pain.
• The main clinical feature in athletes with posterior
impingement is a fixed flexion deformity of some degree and
posterior pain with forced extension.
• The elbow is forced into end-range extension. If posterior pain
is produced, then posterior impingement is present

28. 7) Forearm compartment
pressure syndrome
• Forearm compartment pressure syndromes have been
described in kayakers, motor cyclists and weight-training
athletes.
• The flexor compartment is most usually affected.
• Symptoms include activity related pain that is relieved by rest.
Diagnosis requires compartment pressure testing.