The Elbow Complex: Part III

Common Injuries and Pathologies.


Introduction.

Up to this point, we have covered the basic anatomy and kinesiology of the elbow complex.  In the following section, the common pathologies of the elbow complex will be discussed.

Because of elbow’s place in the upper extremity, it is usually the unfortunate link in the chain which is injured due to repetitive stress.  There are several muscular and ligamentous attachments, which account for the increased strain and stress placed on this joint.  Not only that, but having dysfunction or hypomobility at the wrist or shoulder can also have huge implications at the elbow.  This is due to the elbow’s ability to adapt (albeit poorly) to a hypomobile thoracic spine, poor scapular positioning, or decreased shoulder girdle extensibility.


The Elbow’s Role in the Upper Extremity Complex

We have already discussed that the elbow’s primary role in the upper extremity complex is to support the function of the hand and wrist by allowing greater degrees of freedom and range of motion.  The elbow lets us bring our hands to our mouth, turn our hands over, and extend our hands to grab things away from our center of mass.  But, the elbow is an innately stable joint, and with too much mobility, problems begin to arise.  This is due to the complexities of the anatomical structures discussed in Part One.  When the elbow is asked to go above and beyond in terms of its normal mobility, herein lies the problem.  The tendons and ligaments of the elbow have a certain “life cycle,” meaning they can only adapt so much before pain and dysfunction begins to arise.  We call these problems “overuse injuries,” because of the chronic repetitive movements it takes to cause these injuries over the span of weeks, years, or even decades.  The body is amazing at adapting to poor movement patterns, but once the critical threshold is reached, pain and dysfunction will surely follow.


Common Impairments of the Elbow

One can look at this in one of two ways, what impairments are most common (i.e. what type of movement dysfunctions are present), or what is the pathoanatomical reason why someone is experiencing pain and discomfort.  The most common will be discussed in this section.

COMMON MOVEMENT IMPAIRMENTS:

  • Decreased range of motion, secondary to pain, post-trauma or post-surgical, poor joint mobility, and true muscular contracture.
  • Decreased muscular strength, secondary to pain inhibition, overuse tendinitis/osis, and poor motor control in the UE complex.  This can also be seen as decreased grip strength and poor fine motor control in the hand/wrist complex.
  • Decreased soft tissue mobility, including poor fascial gliding, nerve entrapment, and scar tissue formation.

 

COMMON PATHOANATOMICAL IMPAIRMENTS

  • Lateral Epicondylalgia
       Formerly known as Lateral Epicondylitis, is more well known as “Tennis Elbow.”  This is the most common overuse injury in adults, with roughly 3% of the adult population experiencing pain and dysfunction.  The root cause is “micro-tearing” at the common extensor tendon of the wrist extensors, as they insert into the lateral epicondyle of the humerus.

 

  • Medial Epicondylalgia
    Formerly known as Medial Epicondylitis, and more well known as “Golfer’s Elbow.” This condition is much like lateral epicondylalgia, with dysfunction of the common flexor-pronator tendon of the wrist flexors.  About 1% of the population suffers from this condition at any given time.  This is very common in weight lifters, CrossFit competitors, and occupations that require increased fine motor control of the hand/wrist complex (carpenters, electricians, etc).  Pain is typically felt just past the medial epicondyle in proximal portion of the common flexor-pronator tendon of the forearm.

 

  • Distal Bicipital Tendonitis
    Typically due to overuse of the biceps brachii, this condition presents as achey pain on the front of the elbow, near the insertion of the biceps brachii onto the radius.  This injury is most seen in weight lifters, body builders, or throwers, due to the high activity and strain they place on the biceps brachii.  To date the incidence of distal biceps tendinosis has not been well reported, with available literature discussing either partial or complete tendon ruptures(2).  Males in the 4th decade of life are more likely to undergo distal biceps tendon injuries, with injuries typically occurring between the ages of 30 and 60 years of age(3). Incidence has been reported as being even higher in smokers, who run a 7.5x increased risk of injury(3).

 

  • Ulnar Collateral Ligament (UCL) Sprain
    The UCL is the primary stabilizer to the valgus stress encountered at the elbow during the throwing motion(1). High tensile stresses into a valgus position, may exceed the failure strength of the ligament, producing ligament attenuation or acute rupture(1). Anyone who follows professional baseball can attest to the staggering increase in UCL injuries and subsequent Tommy John procedures (UCL Reconstruction or Repair) over the last ten years.  UCL sprains in baseball players has reached an epidemic proportion.  Treatment options for ulnar collateral ligament injury include nonoperative rehabilitation, direct ligament repair, or free-tendon graft reconstruction (1).

 

  • Little League Elbow
    This is much like UCL sprains, but in the youth population.  Repetitive throwing imparts a tensile stress and on the medial elbow and a compressive force at the lateral elbow(4). Twenty-eight percent of all youth pitchers report a history of elbow pain(4).  Most seen in youth throwing athletes from ages 8-11, this is due to chronic stress to the medial aspect of the elbow during throwing.  The root cause is inflammation of the growth plate at the medial epicondyle of the humerus.  When growth plates are put under chronic strain, it causes localized inflammatory response terms apophysitis.  Much like UCL injuries, poor motor control, throwing mechanics, and decreased mobility of the shoulder girdle and thoracic spine contribute to risk factors associated with this condition.

 


SUMMARY

In this section, the most common overuse injuries of the elbow were discussed.  Part Four will give you simple, yet effective ways, of managing pain and improving function.


 

REFERENCES

  1.  Cain, Dugas, Wolf, Andrews. Elbow Injuries in Throwing Athletes: A Current Concepts Review. Am J Sports Med. 2003; 31; 621.
  2. Jayaseelan DJ, Magrum EM. Eccentric Training for the Rehabilitation of a High Level Wrestler with Distal Biceps Tendinosis: A Case Report. Int J Sports Phys Ther. 2012 Aug; 7(4): 413–424.
  3. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002 Nov; (404):275-83.
  4. Shanely, Thigpen. Throwing Injuries in the Adolescent Athlete. IJSPT. 2013; 8(5):630.

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