REHABILITATION OF ELBOW

INJURIES
CHAPTER 18
ERICA M. FILEP, ATC
KATILYN MOFFETT, ATC
Fall 2013

Dynamic Stabilizers of the Elbow

Flexors
Biceps- does what else at the elbow?
Brachialis
Brachioradialis

Extensors
Triceps
Anconeus

ROM Norms

Flexion- 145
Extension- 0
Pronation- 90
Supination- 90

Injuries to the Elbow

Injuries to the Elbow

Fractures
Dislocations
Ligament sprains
UCL

Nerve Entrapments
Osteochonrdritis
Dissecans/ Panners
Disease

Medial/Lateral
Epicondylitis
Distal Biceps tendon
rupture
Compartment
Syndrome
Bursitis
Tendinitis
Muscle strains

General Rehab Progression

Timeline

Weeks 1-2: cold

compression,
ESTIM, PROM
and AROM

Weeks 3-6:
Isotonic
Exercises,
Passive
pronation/supin
ation

Weeks 7-12:
Plyometrics,
Closed kinetic
chain, functional
and sport
specific

Fractures
Surgical/Nonsurgical Management
Immobilization or Open Reduction and Internal
Fixation (ORIF)

Olecranon fx
Radial head fx
Makes up 1/3 of all elbow fractures
of all elbow trauma
More common in females than males, 2:1 ratio

Expected RTP: 12 weeks

Fractures

Week 1-2: Hinged ROM brace or cast

Goal = 15-105 degrees
AROM/PROM
Isometric pronation/supination/flexion/extension

Week 3: Isotonic Shoulder and Wrist Exercises

Joint mobs

Fractures
Week 7: Eccentric exercises
Closed kinetic chain
Some functional activities
Incorporating stresses and strains ..Which law?

Week 7-12: Beginning RTP

Week 12: full RTP

Full ROM, strength
Sport restrictions?
Throwing progression

Dislocations
Anterior/Posterior
Which is more common?

Can possibly have fractures involved

Manual or Surgical Reduction
Estimated RTP: 11 weeks

Dislocations
Day 1-3: Immobilized, gripping exercises, isometric
shoulder exercises

Day 4-5: gentle AROM flexion/extension elbow

exercises can be done out of splint
NO PASSIVE STRETCHING DURING THIS TIME.
Hinged ROM brace set to 30-90 degrees

Dislocations
Day 10: Splint can be discontinued if full ROM
Keep using isotonic shoulder exercises
Avoid EROT/IROT for first 6 weeks
Progressive isotonic elbow
flexion/extension/pronation/supination
PNF patters as tolerated (Rhythmic Initiation probably
best here)

Hinged ROM brace can be moved 5-10 degrees

depending on progress

Dislocations

Week 3-4: Hinged ROM brace can be

discontinued only if full ROM is achieved
Lightweight (1-2 lb)
flexion/extension/supination/pronation exercises
PROM flexion/extension may begin

Dislocations

Week 6-9: EROT/IROT Shoulder exercises,

functional activities
Eccentric exercises
PNF D1/D2 patterns
Closed kinetic chain activities

Week 10-11: Functional, Sport specific

activities, RTP

Ulnar Collateral Ligament (UCL)

Injuries
Sprains, grade I-III
Nonsurgical approaches

Depending on the grade and type of athlete

Analyze throwing mechanics

Surgical Repair- Tommy John

Repetitive valgus force in overhead throwing
Estimated RTP: 22-26 Weeks (approx. 9-12 months)

UCL Repair

Surgical repair- using Palmaris Longus/Extensor

Hallucis Longus OR Hamstring graft

Early goals:
Strengthening wrist flexors
Increasing static and dynamic flexibility while
AVOIDING valgus stressors

UCL Repair
Week 1 Post Op: Decrease pain and swelling
Hinged ROM brace set at 90 degrees
Isometric wrist/shoulder exercises (avoiding
shoulder EROT)

Week 2: Brace set to 30-100 degrees

ROM increased 5-10 degrees with each week
Same exercises as Week 1, adding isometric
elbow flexion/extension exercises

UCL Repair

Week 3-4: Weighted exercises can begin (1-2

lbs)
Isotonic flexion/extension/pronation/supination
Isotonic shoulder exercises, still avoiding EROT
PROM elbow flexion/extension out of brace

UCL Repair

Week 5-7: Full ROM achieved

Can begin EROT shoulder exercises at this point
Continuing exercises from earlier weeks,
strengthening
Hinged ROM brace can be discontinued

UCL Repair

Week 9-13: Continuing increases in strength,

some functional activities

Eccentric elbow flexion/exension

PNF Patterns
Plyometrics
Closed kinetic chain

UCL Repair

Week 14-26: Interval Throwing Progression

Program may begin for overhead athletes

Table 18-1

Throwing Progression Program

http://www.theulitmatepitcher.com/stephen-strasburgs-pitching-mechanics/

Interval Throwing Program

45, 60, 90, 120, 150, 180 feet individual phases

Example, 45 ft. Phase:
Step 1

Warm up throwing
45 feet (25 throws)
Warm up throwing
45 feet (25 throws)

Interval Throwing Program

Step 2

Warm up throwing
45 feet (25 throws)
Rest 10 mins
Warm up throwing
Rest 10 mins
45 feet (25 throws)

Follow the same pattern for each different phase

UCL Repair

Criteria for RTP:

Full ROM
Strength closely resembles uninvolved elbow
No complaints of pain while throwing, loading,
etc.
Throwing program completed

Nerve Entrapments

Can be due stress on the medial side, compression

Ulnar, Radial, Median nerves
Check for brachial plexus, c-spine and wrist
neuropathies
Estimated RTP: 12 weeks

Nerve Entrapments

Management:

Avoid activities that cause pain

NSAIDs
Protective padding
Night splints
Exercises focused on ROM

Nerve Entrapments
Surgical options: Decompression and
transportation

Rehab program should be focused on

strengthening involved muscles
Stretching of surrounding muscles
Massage area can help prevent adhesions

Nerve Entrapments

Following Surgical interventions

Week 1: Brace at 90 degrees, gripping
exercises
Week 2-3: Brace adjusted to 30-90 degrees,
then moved to 15-120 degrees
Can be removed for exercises

Nerve Entrapments
Week 3-6: Brace discontinued at 3 weeks postop
PROM with an emphasis on regaining extension
Same isotonic activities in this stage

Week 7: More functional activities can begin

PNF Patterns
Plyometrics
Interval Throwing Program for overhead athletes

Nerve Entrapments

Criteria for RTP:

Throwing athlete- 12 weeks
ROM, Neuromuscular control, strength, etc. all
equal to uninjured side
Proper mechanics dont want to end back up
where you started

Osteochondritis
Dissecans/Panners Disease

Lateral aspect of the elbow

Capitellum or radial head involvement
Compressive forces
Commonly found in Gymnasts and Basketball
players, 12-15 y.o.

Estimated RTP: 7-8 Weeks

**Panners Disease: Children 10 or younger

Osteochondritis
Dissecans/Panners Disease
Surgical removal of loose bodies
Arthroscopic

Week 1-2 Goal = Full ROM

Day 1-2: Isometric elbow flexion/extension,
pronation/supination exercises
Day 3-7: Light weight (1-2 lb)
flexion/extension/supination pronation exercises

Osteochondritis
Dissecans/Panners Disease
Dont forget about shoulder and wrist!
Week 3: Eccentric Exercises
Joint Mobs to normalize arthrokinematics

Week 5: Gradual return to Functional Activities

Sport Specific!

Osteochondritis
Dissecans/Panners Disease
Criteria for Return:
Full ROM
Strength closely resembles uninvolved elbow
No complaints of pain while throwing, loading,
etc.

Medial/Lateral Epicondylitis

Medial: Golfers elbow (or Little League elbow)

Lateral: Tennis elbow
Chronic in nature, difficult to treat
Two approaches
Conservative or Surgery

Medial/Lateral Epicondylitis

Most likely will use conservative approach

Rest or restricted activity, NSAIDS, cryotherapy,
injections
Inflammatory process can get stuck with
these conditions
Massage, avoiding NSAIDS, ice, stretching

Medial/Lateral Epicondylitis

Goal is to aid the inflammatory response,

wean them off NSAIDS, injections

If not resolved after 1 year, surgery can be

considered
Use everything at your disposal first!

Medial/Lateral Epicondylitis

Criteria for RTP:

???
Depends on the athlete
Avoid rushing them back to full activity
Strength and functionality are KEY!

Open Kinetic Chain

Exercises

Isotonic Strengthening

Putty
Gripping exercises
Resisted elbow
flexion/extension/pronation/supination

Isotonic Strengthening

Bicep curls
Can use weights or Theraband/tubing
TRX?

Pronation/Supination with a weighted bar

Make it sport specific so they dont get bored

Closed Kinetic Chain Exercises

Standing push-ups progressing to floor

Push-ups on a ball, BOSU
Slide board- good for neuromuscular control

What else?

Plyometrics

Sit-ups
Rebounder
What if you dont have one?

Aquatic Exercises!

Pool Exercises

Bicep curls
Elbow extension using dumbbells (buoyant of
course)
Dips
Elbow extension with a Kickboard
PNF patterns??

Activities!