elbow injuries in sports such as Tennis Elbow, Radial Tunnel Syndrome, Golfer’s Elbow, Medial Collateral Ligament Injury (Thrower’s Elbow), Valgus Extension Overload Syndrome, Little Leaguer’s Elbow, Ulnar Nerve Neuropathy (Cubital Tunnel Syndrome), Avulsion of Medial Epicondyle.

1. Dr. Usha (PT)
Assistant Professor
Elbow Pain/
Injuries

2. Contents
 Tennis Elbow
 Radial Tunnel Syndrome
 Golfer’s Elbow
 Medial Collateral Ligament Injury (Thrower’s Elbow)
 Valgus Extension Overload Syndrome
 Little Leaguer’s Elbow
 Ulnar Nerve Neuropathy (Cubital Tunnel Syndrome)
 Avulsion of Medial Epicondyle

3. Tennis Elbow

4. Tennis Elbow
The lesion affecting the tendinous origin of the wrist
extensors (ECRB) characterized by-
Local tenderness over the common extensor origin at
the lateral epicondyle
Exacerbated by continual use and resisted WRIST
extension.

5. The loosely used term, ill defined
Common in tennis players- associated with
overuse/overstress 45% of tennis player with
practice or game experience the problem.
This syndrome is also the occupational hazard in
individuals carrying out forceful pronation and
supination motion, heavy lifting, or repeated
hammering type activities.

6. Pathology
 The exact pathology of the tennis is still open to debate
 3 major site of pathological changes
1. Common extensor origin ,
2. Radio-capitular joint ,
3. Radioulnar joint with fibrillation and chondromalacic
changes

7. Pathology
Stage Characteristics
Stage I Acute inflammation,
No angioblastic invasion,
Pain during activity,
Minor aching usually after the activity
Stage II Chronic inflammation and scar ,
Some angioblastic invasion,
Pain during activity and also during rest
Stage III Extensive angioblastic invasion and scar,
May be micro rupture of tendon, sometimes partial rupture of the tendon,
Pain at rest, sometimes night pain,
Numerous activity of the daily living becomes painful

8. Etiology
 Little playing experience – novice players at risk
 More stress if consistently miss the sweet spot when hitting the ball.
 Poor stroke technique- use of arm instead of body
 Inadequate power, flexibility or endurance
 Heavier stiffer racquet increases stress
 Large handle size
 Too tight stringing
 Wet / heavy-duty balls
 Playing surface – cement floor gives more bounce and hence require more work
from the wrist extensors .

10.  The normal wrist extensor should be about 45-50% of the
flexors strength.
 Among the wrist muscles the strength of various muscle in
the descending order is
Flexors > Radial deviators > Ulnar deviators > Extensors.
 Supinators are stronger then pronators.
 The poor grip strength is factor implicating the genesis of the
tennis elbow

11. Clinical Features
 Local tenderness over the outside of the elbow at the common extensor
origin with aching and pain at the back of the forearm . aggravated by
continual use.
Special tests
1. Resisted wrist extension- precipitate pain at the common extensor
origin
2. Painful resisted extension of the middle and ring fingers implicates
extensor digitorum, whereas painful resistance to wrist extension and
radial deviation points to ECRL and ECRB.
3. Hold the elbow in extension and perform passive wrist flexion and
pronation. This stretches the tendinous insertion and produces pain .

12. Clinical Presentation: Two Type
Insidious onset
 24-72 hours after
unaccustomed activates
involving wrist extension
 Knitting, screwing, brick
lying, use of new racquet,
wet ball, ground
Acute onset
 Single exertion activity of
wrist extensor
 Lifting heavy objects , hard
back hand stroke

13. Treatment: Aim
Relief of inflammation,
Promotion of healing,
Reducing the overload forces (correction of
predisposing factors)
Increasing upper extremity strength, endurance and
flexibility
Gradual return to activity

14. Treatment: Method
 Inflammation and healing:
 Modalities: LASER, phonophoresis with 10%
hydrocortisone, IFT, HVGS, TENS, cold therapy.
 Manual therapy: soft tissue mobilization- transverse
friction, restoration of passive range of elbow and forearm
 Isometric pain free contraction of wrist extensor in non
stretched position
 Counterforce brace
 Taping

16. Post Acute: Exercise The Main Stay
Restoration of range & strength
Active stretching – wrist extensors, triceps
Concentric strengthening- all components of
extensor complex
Eccentric strengthening of– wrist extensor
Ensure pain free contraction
Buildup endurance (Local, General)

18. Specific Exercise Protocol: CURVIN &
STANNISH
Cryokinetic Eccentric strengthening
Warms up with local heat or general exercise
Passive stretching to the wrist extensors 3 times each for 30
seconds .
Three sets of ten eccentric contraction with the weight of 1-
5 lbs/Surgical tubing .
Stretches
Ice
20 minute sessions daily for about 3 weeks .

19. STenniselbowrehabilitation

20. Return To Play
Practice
The backhand, forehand, and serve and other
specific tasks using surgical tubing or pulley for
resistance
Correction of deficit of strength and range of motion
of shoulder and trunk
Overall fitness

21. Return To Play
Correction of predisposing factors
Grip size
Racquet weight and string tightness
Technique– use of foot work
Counterforce brace

22. Other Treatment Options
Nitric oxide donor therapy
Botulism toxin
Extracorporeal shock wave therapy
Steroid infiltration

23. Surgical Treatment
 Release of fascia and part of
common extensor origin
 Extensive post operative
physiotherapy
 Expected time of recovery 1-
3 months
Indication
 Documented adequate non-
operative treatment including
injections
 Adequate time which should be
up to a year
 Severe pain interfering with
activities of daily living,
employment or competition

24. Radial Tunnel Syndrome
Compression of radial nerve (posterior interosseous
nerve) in radial tunnel
A differential diagnosis of resistant tennis elbow
Common in activities requiring supination and
pronation

25. Presentation: Very Similar To Tennis
Elbow
 Pain and tenderness over lateral epicondyle.
 Stretching of wrist extensors elicit pain.
 Resisted finger extension elicits pain.
 Pain radiating up and down the elbow.
 Weakness of grip.
 Pain on resisted middle finger extension.
 Tenderness along radial nerve anterior to radial head, differentiates it
from tennis elbow.

26. Differential Features
Tenderness along course of radial nerve
Anterior to radial head
Resisted forearm supination with elbow in flexion is
painful

27. Management
Rest
Stretch supination and extensor carpi radialis brevis
within limits of pain.
NSAID’s and massage.
Surgical decompression if unresolved for several
weeks.

28. Medial Epicondylitis
 Other name are epitrochletitis, golfer’s elbow, medial tennis
elbow
 Acute tear or chronic tendonitis of common flexor origin at
medial epicondyle
 Common in golfers

29.  It is a tendinopathy of the common flexor origin including the pronator
teres.
It is an overuse syndrome seen commonly in-
 Throwing sports – related to repetitive valgus stress along with wrist
flexion and pronation .
 Golf – with excessive driving or by mis-hitting the ground who
continually take divots out of hard ground, resulting in overload to the
dominant arm’s wrist flexor at the point of impact.
 The other athlete who require a strong grip (gymnast, water skier) or
who grip excessively (tennis, squash) are also prone to this condition.

30.  Racquet sports due to repeated wrist action
 Acute tear or ruptures of the common flexor origin may
develop-
When an opponent or hard object unexpectedly block the
forceful flexion of the wrist or
Due to sudden excessive contraction of the flexors of the
wrist and fingers .
 The chronic involvement is often due to repetitive activity
that leads to damage to the collagen fibers.

31. Clinical Presentation
 Medial elbow pain.
 Tenderness around or just distal to common flexor origin.
 Painful resisted wrist and finger flexion.
 Passive elbow and wrist extension in supination also elicits pain
 Stretching of wrist and finger flexor together elicit pain.
 Acute tear may present with palpable defect, ecchymosis
 This condition is often coexist with MCL instability as excessive
valgus overload during forceful contraction places increased strain
on the medial elbow.

32. Management
 Main aim is prevention and restoration of lost range of motion.
1. In acute stage- ice, pulsed ultrasound, and other modalities may
be used in conjunction with NSAIDs.
 The exercises later on constitute the main stay of the treatment.
The stretching and strengthening routine of tennis elbow should
be used but the direction of movement is reversed.
2. In recalcitrant cases, the injection of steroid may be given into the
area and
3. If failed release of the common origin may be considered.

33. Golfer’selbowrehabilitation

34. Medial Collateral Ligament Injury
(Thrower’s Elbow)
Acute inflammation of medial collateral ligament may
be caused by repetitive valgus stress in pitchers and
javeline throwers or by one single episode of trauma
can also cause partial or complete tear of the ligament.

35. Causes
Micro trauma due to tensile valgus stress placed on
medial aspect of elbow during acceleration phase of
throwing
Macro trauma: single vigorous valgus stress

36. Features
 Point tenderness over medial joint
line and effusion.
 Tenderness distal to medial
epicondyle.
 Valgus stress test- demonstrates
pain and instability, stress need to
be applied with elbow flexed to
15-30 degree
 Differential diagnosis
 Medial epicondylitis
 Medial epicondyle fracture
avulsion
 Ulnar nerve entrapment
 Medial olecranon fossa
impingement

37. Differential Diagnosis
Medial epicondylitis- painful wrist flexor contraction
Medial epicondyle fracture/avulsion- acute injury
history of trauma, limitation of elbow range of motion
Ulnar nerve entrapment- motor sensory deficit
Medial olecranon fossa impingement syndrome-
dull aching pain, negative valgus stress test

38. Line of Management
Acute phase- reducing inflammation- PRICE &
NSAIDs
Promote healing and repair- use of modalities
Within 1-2 weeks- all active and passive movement
should be within pain free limit only in order to
prevent stretch on the ligament, as the all the three
bands of the ligaments gets taut in different part of
the elbow range.

39. Return to activity
Taping during return to play
In disruption of ligament (Grade 3), orthopaedic
referral as untreated instability of the MCL can be a
source of ulnar nerve injury and can lead to the
cessation of throwing career.

40. Valgus Extension Overload Syndrome
Throwing generated extreme valgus stress on elbow
Repeated throwing with inadequate rest can give rise
to a spectrum of pathological changes within joint
leading to chronic pain and disability
In growing athlete, the term little leaguers elbow is
used to describe these varying presentations

41. Impact of Throwing
Distractive force of medial structure
Compressive force at lateral and posterior structure
In growing athlete affect the growth plate and
ossification centers
If unrecognized may lead to non reversible changes in
the joint forcing premature retirement

42. Long Term Consequences of Throwing
Overuse
 Medial compartment:
 Strain flexor origin, MCL stress, spur on ulnar coronoid,
ulnar nerve traction, avulsion of medial ossification center
 Lateral compartment:
 Lateral epicondylitis, radial head compression, Capitular
osteochondral injury, deformity of radial head, loose body
formation
 Posterior compartment:
 triceps strain, synovial impingement, olecranon fracture,
degenerative changes

43. Little Leaguer’s Elbow
The term encompass all the stress changes involved in
baseball pitching (throwing) that occurs in immature
athlete
Original pathology- stress on medial epicondylar
epiphysis

44. Presentation
Vague symptoms
Pain– insidious onset.
Swelling following game, later on for long periods.
Stiffness after prolonged period of throwing
Progressive reduction of rom due to fibrosis of soft
tissue
Tenderness over involved area.
Test– radiograph

45. Line of Management
Early recognition
 Adequate rest from repeated
stress
 Symptomatic conservative
treatment of lesions in early
stages
 Correction of technique
 Fitness
 Education of coach, players
Established cases
 Surgical exploration and
repair
 Prolonged physiotherapy
 Return to sports doubtful

46. Early Management
Rest along with icing, NSAIDs, TENS.
Avulsion fracture (medial epicondyle)- Splinting and
rest

47. Ulnar Nerve Neuropathy (Cubital Tunnel
Syndrome)
Compression of ulnar nerve during its course around
elbow

48. Cause
Direct
 Dislocation of elbow
 Fracture humeral condyle
 Mal-union, secondary valgus
deformity due to epiphyseal
injury
 Irregularity in ulnar groove
Indirect
 Inflammation and adhesion
following repeated throwing
stress
 Overdevelopment of FCU
 Recurrent subluxation of nerve
due to attenuation of UCL

49. Presentation
Postero-medial elbow Pain.
Sensory symptoms: pins and needle or numbness
along ulnar nerve distribution, Clumsiness and
heaviness of hand. (ulnar aspect of forearm and
hand).
Positive tinnel sign
Weakness of introssie and 3rd and 4th lumbricals

50. Special Tests
Palpation of ulnar nerve at medial elbow elicits
tenderness.
Position of fully flexed elbow and wrist extension for 3
minutes elicits pain and paranesthesia along ulnar
aspect of forearm.

51. Differential Diagnosis
 Nerve entrapment at Guyton canal
 Thoracic outlet syndrome
 Carcinoma of apex of lung
 Systemic conditions (DM, Alcoholism)
 Referred from neck
 Glioma/ lipoma at medial elbow

52. Line of Management
 Initial: treatment of neuritis
 Rest, NSAID, soft tissue mobilization, electrotherapy,
stretching ,
 Later: removal of compressing factor
 Surgical exploration and decompression

53. Fractures
Medial epicondyle avulsion fracture

54. Avulsion of Medial Epicondyle
Cause
 Massive contraction of forearm flexors, posterior elbow
dislocation, fall on hand, repeated valgus stress at elbow.
Presentation
 Pain, swelling and tenderness at medial aspect of elbow.
 Limited elbow and wrist flexion and extension.
 Valgus instability.
X-ray
 Gravity stress test – opens the medial aspect of elbow
joint.

55. Treatment
Displace fracture requires internal fixation.
Post operative physiotherapy
Active mobilization of wrist and elbow in pain free
range.
Wrist extension accompanied with finger flexion to
avoid stress on medial epicondyle.
Gradually resisted exercise within pain free range at
4 weeks.

56. General Physiotherapy Protocol For
Medial Elbow Injuries
Phased process
1. Phase1- 0 to 2 weeks
2. Phase2- 2 to 4 weeks
3. Phase3- 4 to 6 weeks
4. Phase4- 6 to 10 weeks

57. Phase 1- Week 0 To 2
Ice and compression.
Brace, tape to restrict movement if required
Passive and active assisted non painful ROM for wrist
and elbow.
Strengthening- all within pain free range
Isometrics- wrist and elbow muscles
Isotonic strengthening of shoulder muscle except
external rotators

58. Phase 2- Week 2 To 4
Increase motion to 0 to 135 degrees. (10 degrees/
week)
Initiate isotonic strengthening
Wrist – flexors and extensors
Elbow – flexors and extensors
Pronation and supination
Shoulder muscles with external rotators.

59. Phase 3- Week 4 To 6
Eccentric exercises for wrist and elbow muscle.
Continue concentric strengthening.
Continue shoulder muscle strengthening.

60. Phase 4- Week 6 To 10.
Plyometrics
Practice throwing.

61. Progression of Throwing
 High lob, light toss, 15 to 20 m throwing, 50% of maximum
velocity, one set of 10 reps, gradually progress to five sets.
 Gradually increase by 10 m until competitive distance is
reached.
 Throw straight and flat instead of high lob.
 First 15 to 20 m at 75% of maximum velocity.
 Gradually progress as above,
 Then throw 15 to 20 m at maximum velocity.
 Gradually progress to competitive distance.

62. Thank You