Physical Therapy in Lynn Haven and Panama City Beach for Elbow

 

 

Welcome to First Choice Physical Therapy’s patient resource about Ulnar Collateral Ligament Injuries.

The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions.

Professional pitchers have been the athletes treated most often for this problem. Javelin, football, racquet sports, ice hockey, and water polo players have also been reported to injure the UCL. A fall on an outstretched arm can also lead to UCL rupture (often with elbow dislocation).

This guide will help you understand:

• how the problem develops
• what causes this condition
• how doctors diagnose the condition
• what treatment options are available

 

What parts of the elbow are affected?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

 

 

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens.

The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.

 

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

In the elbow, two of the most important ligaments are the ulnar collateral ligament (UCL) and the lateral collateral ligament. The UCL is also known as the medial collateral ligament. The ulnar collateral ligament is on the medial (the side of the elbow that\’s next to the body) side of the elbow, and the lateral collateral is on the outside. The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament.

 

 

 

Together these two ligaments, the ulnar (or medial) collateral and the lateral collateral, connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury or dislocation of the elbow. If they do not heal correctly the elbow can be too loose or unstable. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion.

 

What causes ulnar collateral ligament (UCL) injuries?

The ulnar collateral ligament can become stretched, frayed or torn through the stress of repetitive throwing motions. If the force on the soft tissues is greater than the tensile strength of the structure, then tiny tears of the ligament can develop. Months (and even years) of throwing hard causes a process of microtears, degeneration, and finally, rupture of the ligament. The dominant arm is affected most often. Eventually the weakened tendon my rupture completely causing a pop and immediate pain. The athlete may report the injury occurred during a single throw, but the reality is usually that the ligament simply finally became weakened to the point that it finally ruptured.

 

 

 

However, the general profile associated with this injury may be changing. Today, more and more children ages 10 to 18 are affected. Longer seasons with extended practice time and more tournaments increase the risk of UCL injury. Throwing volume, pitch type, and throwing mechanics can all contribute to the problem.

Children have their own unique risk factor in that they have an open growth plate in the elbow called the medial epicondylar physis. Force along the inside of the elbow during throwing is more likely to cause failure at the area of the growth plate than at the UCL. This injury is often termed Little League Elbow. Reconstruction of the UCL may not be needed in this age group unless the injury to the UCL occurs after the growth plate is closed. Sometimes the ligament avulses or pulls away, taking a piece of the growth plate with it. When the condition has been present for some time, the ligament is not all that may be damaged. The entire elbow joint is at risk due to the abnormal forces caused by the repetitive stress injury.

Pain along the inside of the elbow is the main symptom of this condition. Throwing athletes report it occurs most often during the acceleration phase of throwing. If there are loose fragments or uneven joint surfaces, you may also notice popping, catching, or grinding.

Sometimes swelling can be seen along the inside of the elbow. If the ligament was ruptured, there may be bruising in the same area. Some patients have a slight loss of elbow motion. Closing the hand and clenching the fist reproduces the painful symptoms.

Diagnosis is based on your history and symptoms. When you first visit First Choice Physical Therapy, we will complete an examination of the shoulder and elbow, performing specific tests to look for areas of tightness or laxity (looseness). Most patients will report tenderness along the inside of the elbow to palpation of the UCL ligament.

We will perform ligament stress tests at the elbow to test for joint stability. To do this our Physical Therapist generates force toward the inside of the elbow as the joint is moved from a position of slight flexion into full extension. Too much motion or opening of the joint at the medial joint line called gapping may be observed or felt by palpation. This test also allows us to see if there crepitation (popping, crunching) as the joint moves.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

What treatment options are available?

Non-surgical Treatment

Many athletes with elbow instability from UCL injury can be treated successfully with rehabilitation and without invasive procedures. When you begin your Physical Therapy at First Choice Physical Therapy, we may initially recommend rest and/or activity modification (fewer pitches per game, per practice, per day). The athlete’s posture, strength, and release of the ball must be analyzed and corrected. The use of curve balls should be avoided during the early phases of rehabilitation.

Anti-inflammatory drugs and analgesics may be recommended to reduce pain and inflammation. Icing may help, but must be used with caution. Too much cold can cause a worsening of the swelling as the body sends more blood to the area to warm things up. And cold can be an irritant to the already damaged (and irritated) nerve.

We may also use other modalities such as electrical stimulation and ultrasound with cortisone (called phonophoresis) when needed. Steroid injections are not usually recommended for this condition.

Your Physical Therapist will develop a daily program of stretching and strengthening; stretching exercises for the muscles of the forearm are usually included, as well as a strengthening program for the entire elbow/arm complex. We will employ high repetition, low weight exercise training to increase your endurance without placing additional stress across the joint.

We will also address any problems with flexibility, strength, and conditioning at your shoulder. Athletes will undergo plyometric strengthening of the entire arm, starting with the forearm muscles (flexors and pronators) and progressing to include the biceps, triceps, and rotator cuff of the upper arm. Plyometrics refers to training the nerves to fire quickly and the muscles to contract strong and fast. Plyometrics help develop explosive movements to improve muscular power and force. The goal is to increase the speed of the pitch (or throw for other throwing athletes).

Many athletes are able to return to play without further treatment. If conservative (nonoperative) care does not change the picture, then surgery may be needed.

Post-surgical Rehabilitation

When you begin your post-surgical rehabilitation program at First Choice Physical Therapy the type of program prescribed will depend on the types of surgery that you underwent.

Arthroscopic Debridement

After arthroscopic debridement, we will start you on gentle range of motion exercises right away. Full motion can be restored as the pain and swelling resolve. Elbow strengthening exercises are begun within the first few days to week after the procedure. As your rehabilitation program progresses, a gradual throwing program will be included. Although the time required for recovery varies, full sports participation can usually be anticipated within one to three months.

Repair or Reconstruction

The postoperative program is the same for repairs or reconstruction. However, your arm will initially be immobilized in a bulky dressing.

Gentle handgrip and shoulder and wrist mobilization exercises are usually allowed right away after surgery. We often discontinue postoperative immobilization in seven to 10 days at which time active range of motion for the elbow is started. Your surgeon may want you to wear a special hinged brace to protect the elbow.

Your Physical Therapist will instruct you in the active range of motion exercises to be done daily. Strengthening exercises for the entire upper quadrant (shoulder, arm, wrist, and hand) are included in the post-operative program. Specific strengthening exercises to help the athlete prepare for his or her particular sport begin around four months post-op. Up until this time, any stress to the medial elbow is avoided.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Standard X-rays are taken to look for bone spurs, loose fragments, or calcification in the ulnar collateral ligament. If the joint is gapping enough to sublux (partially dislocate), valgus stress radiographs may be taken.

Magnetic resonance imaging (MRI) with contrast dye is used to diagnose ligamentous rupture. The test doesn’t always show a problem when there is one. This is called a false-negative result. Ultrasound and CT scans may be helpful. Some surgeons prefer to use arthroscopy to make the final diagnosis. The presence and severity of valgus gapping can be confirmed. Studies using these more advanced test methods to diagnose UCL injuries are being done. More data is needed before they become routine in the diagnosis of UCL injuries.

When the condition fails to respond to conservative care described above, surgery may be indicated. If pain is the primary symptom and there is no evidence that the elbow joint is grossly unstable, the surgeon may use an arthroscope (a tiny fiber-optic TV camera) to look inside the elbow and see the condition of the joint and the soft tissues. It may be possible to debride any tissue fragments or frayed edges. During debridement, the surgeon carefully cleans the area by removing any dead or damaged tissue. Any bone spurs or areas of calcium build-up are also removed.

Arthroscope

 

 

If the ulnar collateral ligament has been injured acutely due to a fall on the outstretched arm, a direct repair of the ligament may be possible. If the ligament has pulled off the bone, it may be reattached with sutures through holes drilled in the bone. If the ligament is damaged by constant overuse and is not strong enough to restore stability to the elbow joint if it is simply re-attached or repaired, then the ligament must be replaced with a new ligament. This is termed a ligament reconstruction. During a reconstruction, the ulnar collateral ligament along the medial (inside) of the elbow is replaced with a tendon graft harvested from somewhere else in the body (autograft). One common technique used to replace the damaged ulnar collateral ligament is called the docking technique.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

 

Welcome to First Choice Physical Therapy’s  patient resource about adolescent osteochondritis dissecans of the elbow.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to an odd and troubling elbow condition. The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks and may actually break off. This condition is called osteochondritis dissecans (OCD).

In the past, this condition was called “Little Leaguer’s elbow”. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

This guide will help you understand:

• how this problem develops
• how doctors identify the problem
• what treatment options are available

 

What part of the elbow does this problem affect?

The elbow is the connection of the upper arm bone (the humerus) and the two bones of the forearm (the ulna and the radius). The radius runs from the outer edge of the elbow down the forearm to the thumb-side of the wrist.

 

The joint where the humerus meets the radius is called the humeroradial joint. This joint is formed by a knob and a shallow cup. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius. This cup is called the head of the radius.

Humeroradial Joint

When the head of the radius spins on the capitellum, the forearm rotates so that the palm faces up toward the ceiling (supination) or down toward the floor (pronation). The joint also hinges as the elbow bends and straightens.

Forearm Rotates

In the elbow joint, the ends of the bones are covered with articular cartilage. Articular cartilage is a slick, smooth material. It protects the bone ends from friction when they rub together as the elbow moves. Articular cartilage is soft enough to act as a shock absorber. It is also tough enough to last a lifetime, if it is not injured.

Articular Cartilage

Elbow OCD affects the articular cartilage in the capitellum. It also affects the layer of bone just below the cartilage, which is called the subchondral bone. In advanced stages of OCD, the upper end of the radius, particularly the head of the radius, is also involved.

 

How does this problem develop?

The cause of elbow OCD in adolescents is unknown. Scientists think that genetics is one possibility. This means that certain families are more likely to develop OCD. The condition often occurs among relatives, and it is sometimes seen in several generations of the same family.

Another possible cause is that the tiny blood supply to the humeroradial joint is somehow blocked. Only the ends of a few small blood vessels enter the back of the humeroradial joint. If this scarce blood supply is damaged, there is no back-up.

Although the exact cause of elbow OCD in adolescents is not known, most experts agree that overuse of the elbow plays a major role in its development.

Pitching can lead to overuse strain and, in turn, elbow OCD. Throwing puts a lot of force on the elbow joint. When the throwing action is repeated over and over again, it can damage the immature joint surface of an adolescent’s elbow. After winding up and cocking the arm back, the pitcher must quickly accelerate the arm to gain ball speed. Then, almost immediately, the pitcher has to slow the arm down and follow through. The pitcher may angle the elbow outward slightly during the acceleration phase to get more ball speed. This action jams the head of the radius against the capitellum. During the slowing and follow-through after a pitch, the forearm is fully pronated. This action puts extra pressure on the humeroradial joint.

Hitting a ball with a racket can strain the elbow just like pitching a baseball. The player may angle the racket and elbow out slightly to gain ball speed. Hitting the ball with the arm and racket in this position jams the radial head against the capitellum, similar to what can happen during pitching motions. Gymnasts are also at risk for high forces on the capitellum when they repeatedly do maneuvers on their hands with their elbows locked out straight.

These actions done over and over again can eventually cause an overuse injury to the humeroradial joint of adolescent athletes. Adolescents’ articular cartilage is newly formed and so can’t handle these types of forces. The subchondral bone (under the articular cartilage) in the capitellum takes the brunt of the stress. A portion of the bone may eventually weaken, and possibly even crack. When the bone is damaged, the tiny blood supply going to the area is somehow blocked. Without blood supply, the small area of bone dies. This type of cell death is called avascular necrosis. ( Avascular means without blood, and necrosis means death.)

 

The crack may begin to separate. Eventually, the small piece of dead bone may break loose. This produces a separation between the articular cartilage and the subchondral bone, which is the condition called OCD. If the dead piece of bone comes completely detached, it becomes a loose body. The loose body is free to float around inside the joint.

Another condition, called Panner’s disease, also affects the capitellum in children. It is not the same as elbow OCD in adolescents. Panner’s disease affects the bone growth center (the growth plate) of the capitellum. Panner’s disease generally occurs in kids (mainly boys) between five and 10. Panner’s disease is a childhood condition that involves the entire capitellum and usually heals completely when bone growth is complete.

Elbow OCD in adolescents is different. It occurs after growth in the capitellum has stopped, which is usually between the ages of 12 and 15. Elbow OCD in adolescents affects only a portion of the capitellum, generally along the inside and lower edges of the bony knob. Unless elbow OCD is diagnosed and treated early, the results are not as good as the results for Panner’s disease. The adolescent with elbow OCD sometimes ends up with elbow arthritis by early adulthood.

What does this problem feel like?

Only about 20 percent of kids with elbow OCD remember hurting their elbow. The remainder usually develop symptoms over time, which is typical with overuse problems.

In the absence of a specific injury, the athlete may at first feel bothersome elbow discomfort only while playing sports. The soreness generally goes away quickly when the elbow is rested. Over time, however, the elbow pain worsens, is hard to pinpoint, and may linger after using the arm. The elbow feel may feel stiff, and it may not completely straighten out.

In advanced cases of elbow OCD, the patient may notice that the joint grinds (called crepitus). The elbow may catch, or even lock up occasionally. These sensations may mean that a loose body is floating around inside the elbow joint. The joint may also feel warm and swollen, and the muscles around the elbow may appear to have shrunk (atrophied).

 

Bad cases of elbow OCD, and those that are not caught and treated early, tend to create bigger problems later in life. The joint may become arthritic early in adulthood. As a result, the patient may always have greater difficulty using the problem elbow.

How do doctors identify the problem?

The doctor begins by asking questions about the patient’s age and sports participation. In the physical exam, the sore elbow and healthy elbow will be compared. The doctor checks for tenderness by pressing on and around the elbow. The amount of movement in each elbow is measured. The doctor checks for pain and crepitus when the forearm is rotated and when the elbow is bent and straightened.

X-rays are needed to confirm the diagnosis. A front and a side view of the elbow are generally the most helpful. Early in the course of the problem, the X-rays may appear normal.

As the condition worsens, the X-ray image may show changes in the capitellum. The normal shape of the bony knob may appear irregular. In bad cases of elbow OCD, the capitellum might even look like it has flattened out, suggesting that the bone has collapsed. The X-ray could show a crack in the capitellum or even a loose body. In the late stages of elbow OCD, the radial head may appear enlarged, and the humeroradial joint not be aligned as it normally should. These findings suggest early arthritis.

A magnetic resonance imaging (MRI) scan may show more detail. The MRI can give an idea of the size of the affected area. It can show bone irregularities and also help detect swelling. Doctors may repeat the MRI test at various times to see if the area is healing.

The doctor might order a computed tomography (CT) scan. The CT scan helps confirm the diagnosis. A CT scan clearly shows bone tissue. The doctor can compare CT scans over a period of time to monitor changes in the bones of the elbow.

Once you’ve been diagnosed with elbow OCD, you may need to stop your usual sport activities. This gives the elbow a rest so that healing can begin. Your doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling.

At First Choice Physical Therapy, our goal is to calm pain and inflammation and to protect the elbow from further harm. We might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, we will work with you to improve flexibility, strength, and muscle balance in the elbow.

Your elbow may need to be rested. If your symptoms are especially bad, you may need to avoid activities that make the pain worse, including sports. Even after symptoms ease up, activity may need to be restricted for another six to eight weeks.

When your elbow starts to feel better, we will give you exercises to get it moving. At first, your therapist will move your arm through passive therapy exercises. Later, we will guide you through active motion exercises, in which your muscles help do the work of moving the arm. As elbow motion and strength improve, we will introduce more advanced strengthening exercises.

Our Physical Therapists will also work with you to help you improve your form in ways that reduce strain on your elbow during sports. Pitchers and racket-sport players might benefit from keeping the elbow aligned correctly, instead of angled outward, during the acceleration phase of the pitch or swing.

If your symptoms are especially bad, you may need to make changes that require less overhand activity. For example, pitchers could shift to playing first base. Gymnasts could focus on maneuvers that don’t stress the sore elbow. However, if the detached piece of bone is loose but still attached, all sports activities must be stopped. Sports can begin again when you have no pain and show full elbow movement.

If your case is severe, you may need to wear a sling or a long-arm splint for several weeks before starting elbow motion exercises. As symptoms ease and elbow movement improves, we will begin a guided program of strengthening and sport training.

When you are ready to resume sports activities, we will show you how to protect your injured elbow by applying ice. Ice treatments are simple to do: Place a wet towel on the elbow, then lay an ice pack or bag of ice over the elbow for 10 to 15 minutes. Ice treatments should be used after every sports activity.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What can you expect during rehabilitation?

If you require surgery, your doctor may have you wait a few weeks before starting Physical Therapy. During your first few Physical Therapy treatments, our goal will be to control the pain and swelling from the surgery.

After you’ve recovered from surgery, we will guide you through exercises that help improve elbow motion and to get your muscles toned and active again. At first, we will exercise your elbow in positions and movements that don’t strain the healing cartilage. As your program evolves, we will introduce more challenging exercises that safely advance the elbow’s strength and function.

Most patients with elbow OCD will need to modify their activities after surgery. Most pitchers are unable to throw hard and without pain afterward. In general, most athletes with elbow OCD need to stop playing high-level sports due to lingering elbow pain and reduced elbow motion.

If symptoms return, you will need to modify your activities until symptoms subside. You’ll need to avoid heavy sports activity until symptoms go away and you’re able to safely begin exercising your elbow again.

Welcome to First Choice Physical Therapy’s guide to fractures of the forearm.

 

Forearm fractures are those that occur in the middle section (shaft) of the forearm bones. The forearm has a complex anatomy to serve its functions of supporting and positioning the hand in space and providing anchorage for muscles that serve hand function. To fully restore these functions after a forearm fracture the bones must heal in the normal anatomical position.

This guide will help you understand:

• what parts of the forearm are involved
• what the symptoms are
• what can cause these fractures
• how health care professionals diagnose these fractures
• what the treatment options are
• what First Choice Physical Therapy’s approach to rehabilitation is

 

What structures are most commonly injured?

 

There are two bones in the forearm.  The ulna is a straight thin bone that goes from the elbow to the wrist and forms the axis of rotation of the forearm. The radius is thin at one end becoming thicker and stronger towards the wrist. It is slightly bowed to allow it to rotate around the ulna when the forearm is rotated. To demonstrate this, place your forearm flat on a table in front of you with the palm up and the back of the little finger touching the table. Now roll the hand over until it is positioned palm down on the table. Note that the little finger and the elbow are still in nearly the same position while the thumb has moved from outside to inside. When the forearm rotates, the little finger side where the ulna is forms the axis (spindle) around which the rest of the forearm rotates. We can see that the radius is on the outside of the forearm when it is rolled outwards but crosses over the ulna when the forearm is rotated in. The radius is bowed to allow this movement to occur. If the bowing is not accurately restored after a fracture the forearm will not rotate correctly and this would limit some important functions of the hand.

 

 

 

How do fractures of the forearm commonly happen?

All fractures occur when the limb is subjected to stress outside the normal range. Forearm fractures most commonly occur in three situations- a blow to the forearm, a bending force such as falling on the outstretched hand, or a twisting force where the forearm is over-rotated. Most often these forces cause both bones to break, but a fracture of the ulna alone can occur if you put your arm up to ward off an attack. This isolated fracture of the ulna used to be called the nightstick fracture! Nowadays, the pattern is more common in sports collisions, motor vehicle accidents (MVAs), and falls but it does still occur with violent assault.

Twisting and bending fractures occur with falls, sports accidents, and MVAs. As with all fractures, the damage done to the muscles and tendons is a significant feature of the injury. Open fractures, where the bone comes out through the skin are quite common in the forearm.

What symptoms do forearm fractures cause?

Pain and tenderness immediately following an accident are the most common symptoms of a fractured forearm. The pain is made worse if the forearm is moved or rotated and may be partly relieved by splinting the limb. Deformity of the forearm is common following this type of fracture and there is immediate loss of hand function. You can no longer lift things or grip them with any strength. The forearm is often bruised and swollen. In some severe injuries there may be a wound where the broken bone end has come through the skin. Numbness of the hand is an indication that a nerve to the hand may have been injured at the time of the fracture.

How will my fracture be evaluated?

First aid evaluation consists of inspecting the limb. A fracture would be assumed if the limb is severely painful, if the hand cannot be moved, or the forearm rotated or if the limb is deformed. A sling is usually a sufficient splint for transport to hospital.

In the Emergency Room assessment will include establishing the history and mechanism of injury, looking at the arm (inspection), and palpation (gently feeling it) for tender points. X-ray examination will be undertaken if there is suspicion of fracture of the forearm. In most situations an orthopedic surgeon will be consulted if a forearm fracture is confirmed by x-ray. The orthopedic evaluation will focus on the anatomy of the fracture, the patient’s expectations, and a plan for treatment. There are no special tests usually employed in this situation, other than x-ray.

What treatments should I consider?

Nonsurgical Treatment

An isolated fracture of the ulna (nightstick fracture,) may be treated in a cast. It is not as important to make the bone absolutely straight so the result of non-operative treatment is often acceptable. The arm is placed in a cast extending from the palm of the hand to above the elbow. This is called a long arm cast. The wrist is held in the neutral position and the elbow at 90 degrees of flexion. It may be painful to put on this cast so an anesthetic may be required for cast application.

For reasons described earlier, a fracture of both forearm bones needs to heal with great accuracy. Closed reduction, in which the bone ends are re-aligned without surgery is often not accurate enough. However, in some circumstances a closed reduction is tried. If this is successful the arm will be immobilized in a long arm cast. There is a risk that the fracture will displace in the cast, so frequent follow-up X-rays will be needed.

If the ulna shaft fracture is badly displaced the forearm may need surgery to realign the bone fragments and to fixate them in place. This has the additional advantage of allowing early movement of the limb.

In the majority of cases, the surgeon will recommend surgery to ensure that the fracture is reduced accurately and fixed with internal fixation. Fixation with plates and screws is a common method although some surgeons recommend the less invasive method of placing a rod into the hollow medullary cavity of the bone, called intramedullary fixation.

 

Because fixation allows early recovery of movement of the forearm and hand, the long-term risk of stiffness and loss of function are reduced. After surgery (internal fixation) a cast is not usually necessary although weight should not be put through the limb until the bone is healed. A sling for protection and pain relief is the usual practice but unloaded hand, wrist, and elbow movements can be started right away.

Removal of the implants is controversial. The hardware is often uncomfortable and in those cases the patient and surgeon usually agree to removal. However, about 1/10th of these cases have a re-fracture within six weeks of the removal operation. This risk deters some surgeons from removal of the hardware where there are no symptoms. Others believe that the life time risk of a problem from a retained plate is great enough to warrant removal of plates as a precaution.

Bone Healing

New bone formation (hard callus) is commonly seen on x-ray bridging across the fracture by six weeks. At this stage the fracture will not easily move out of position. If a cast was used it may be taken off at this stage. The decision to proceed is based on interpretation of the x-rays and assessment of the stage of healing reached.

If your fracture has been immobilized by a cast, then treatment with a Physical Therapist at First Choice Physical Therapy can begin once the cast is removed. While you are in the cast simple finger movements as well as exercises to maintain your shoulder range of motion, such as lifting your arm overhead, will be your only exercises.

If you have had surgery to fixate your forearm fracture, then rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon recommends it. Each surgeon will set his or her own specific restrictions based on the type of fracture, surgical procedure used, personal experience, and whether the fracture is healing as expected. Generally, however, early non-weight bearing hand, wrist, and elbow movements will be allowed. Your Physical Therapist at First Choice Physical Therapy will prescribe these exercises for you and liaise with your surgeon regarding the optimal time to begin more advanced exercises such as putting weight through the healed forearm bone via the hand.

Even if extensive Physical Therapy for your forearm is not yet appropriate, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  Maintaining general cardiovascular fitness is easy with lower extremity fitness activities such as walking or using a stationary bike or stepper machine. Avid runners may even be able to continue running with clearance from the surgeon.  Weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing forearm are strictly abided by. Generally, lifting any weight with your injured limb will not be allowed or will be difficult as your forearm heals so you may require a friend to assist you with your workout setup if you are keen to continue while your bone heals.  Your Physical Therapist can discuss the most appropriate way for you to maintain your fitness while abiding by your surgeon’s restrictions and can provide a general fitness program specific to your needs.

When the initial cast is removed or immediately after surgery, you may experience some pain when you start to move your wrist, elbow and forearm. If you were immobilized this pain is from not using the joints regularly. If you have had surgery, the pain is likely from the surgical process itself. Your pain may also be from concurrent soft tissue injury that occurred when you fractured your forearm. Your Physical Therapist will focus initially on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the fracture site or anywhere along the arm or into the hand. In addition, we may massage the forearm, wrist, or elbow to improve circulation and assist with the pain.

The next part of your treatment will focus on regaining the range of motion, strength, and dexterity in your wrist, hand, elbow, and shoulder. If you have been immobilized, your arm will look and feel quite weak and atrophied after the period of immobilization. Your Physical Therapist will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as pliable balls or Theraband that provide added resistance for your hand and wrist. We may even give you exercises for your shoulder.  The shoulder is the forearm’s link to the rest of the body so it needs to be strong and well controlled for the rest of the upper limb, including the hand, to work well. If necessary, your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your wrist and elbow to move gradually into their normal range of motion. Fortunately, gaining range of motion and strength after a forearm fracture occurs quickly. You will notice improvements in the functioning of your limb even after just a few treatments with your Physical Therapist. As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility will add to this decline. Although your forearm and hand are not traditionally thought of as weight-bearing joints, even an activity such assisting yourself with your arms to get out of a chair or pulling a glass from a cupboard requires weight to be put through or lifted by your forearm and for your body to be proprioceptively aware of your limb. If you are an athlete, then proprioception of your upper extremity is paramount in returning you to sport after a forearm fracture.  Your Physical Therapist will prescribe exercises for you to regain this proprioception. These might include exercises such rolling a ball on a surface with your hand, holding a weight up overhead while moving your shoulder, or pushups on an unstable surface. Advanced exercises will include exercises such ball throwing or catching.  For athletes we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in.

Generally, the strength and stiffness one experiences after a forearm fracture responds very well to the Physical Therapy we provide at First Choice Physical Therapy. With our initial one-on-one Physical Therapy treatment along with the exercises of your home program, the strength, range of motion, and proprioception gradually improve towards near full recovery/function over a period of 3-6 months even though the actual final stages of bone healing won’t occur for another 6-12 months after that. If your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the fracture site is tolerating the rehabilitation well and ensure that there are no hardware issues that may be impeding your recovery.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What are the potential complications of this fracture?

Nonunion and malunion are common complications of this fracture but compartment syndrome does occur and has severe consequences.

Compartment Syndrome

The muscles of the forearm move the hand and fingers. When a fracture occurs the bone and muscle bleeds into the closed muscle compartments of the forearm. In some cases this is enough to raise the intra-compartment pressure high enough to stop blood flow to the muscle. As a result the muscle fibers may swell up and die (called necrosis). The swelling increases the pressure to cause a vicious cycle that may end in extensive damage to the muscles of the forearm. This condition is called a compartment syndrome. Untreated, this results in shortening and scarring of the muscles and loss of finger movement. The result is sometimes referred to as a claw hand, because the hand assumes the shape of a claw.

The cardinal sign of compartment syndrome is pain and tenderness of the forearm increased by pressure and by movement of the fingers. Since it is normal for the forearm to hurt after a fracture or after surgery it is often quite difficult to diagnose compartment syndrome.
Doctors and nurses pay a lot of attention to this problem and maintain a high index of suspicion. The treatment for compartment syndrome is immediate surgery to open up the muscle compartments and relieve the pressure. If this is done before any die off of the muscle fibers the outcome is satisfactory although the skin wound may be quite dramatic. Otherwise the outcome depends on the amount of muscle necrosis that has occurred.

Malunion

If the bones of the forearm heal with angulation, shortening, or rotation the fracture is said to be malunited. This is referred to as a malunion. The deformity may be significant enough to prevent full rotation of the forearm or it may be unsightly. Loss of rotation causes a problem with normal hand function so this problem usually requires treatment. The healed fracture is cut and the bone restored to normal length, rotation, and bowing.

Sometimes the extra bone laid down as part of the healing process causes a bony block which interferes with movement of the forearm and it has to be removed. In rare cases the radius actually heals to the ulna (this is called a cross union) and this completely prevents rotation of the forearm. Once the normal shape of the bone has been restored by surgery the fragments are fixed with internal fixation. Early movement to maintain the motion achieved by surgery is recommended.

Closed reduction may not result in anatomical alignment of the bones. Malunion is less common after operative treatment for two reasons. The first is that one aim of surgery is to restore normal alignment of the bones and this aim is usually achieved. The second is that the patient is encouraged to move the forearm once it has been fixed and this reduces the chances of cross-union or the development of a bony block.

Nonunion

A nonunion occurs when the healing process does not go on to completion. The first stage of healing results in scar tissue developing in the gap between the bone fragments and this normally turns to bone. If the gap is too big or there is significant movement at the site bone development may not occur and it stays as scar tissue (called soft callus). This failure of healing is also affected by the blood supply of the area and such general medical factors as smoking, diabetes, and alcoholism.
Diagnosis of nonunion is a judgment call by the orthopaedic surgeon. In his/her judgment the fracture will not heal without intervention. The treatment depends on the circumstances but the principle is to do surgery to freshen the bone ends, immobilize them and improve the biological environment by using bone graft to stimulate healing.

Nonunion is more common after nonoperative treatment. It is painful to put stress on an nonunited fracture so treatment is usually continued until healing has been accomplished. The long term consequence of multiple procedures to achieve healing may be scarring and loss of function of the forearm muscles with stiffness.

Painful Hardware

The plates and screws used to immobilize the fracture fragments may be tender. Sometimes they can be felt under the muscle layers and are sore when you rest your arm on a table. Very commonly there is a persistent ache that may be increased by weather changes. The reasons for this symptom are not known but removal of the hardware eliminates the problem.
Surgery to remove the plates and screws is often done once the bones have healed. However, there is a well recognized risk of refracture in the first few weeks after plate removal and patients are advised to be protective of their arm during this period.

Infection

After an open fracture or less commonly after surgery the wound may develop a bacterial infection. This results in increased pain, redness and swelling of the wound area with drainage of pus developing later. Early recognition and treatment of a wound infection may prevent it from becoming established and infecting the bone. Bone infection hinders healing and may be difficult to eliminate.
Treatment requires long-term use of antibiotics and surgery to remove all dead and contaminated tissue. The fixation is often left in so that the bone heals more quickly but hardware removal after healing is often required to finally eliminate the infection. With early aggressive treatment of infections the outcome is quite favorable.

A fracture of the forearm is a serious injury that results from moderate to severe accidents. The goal of treatment is to avoid the complications of malunion and nonunion and restore the best possible function of the limb. Surgery to straighten the bones and fix them in the correct position while they heal is a common way to treat this fracture and the eventual outcome from this treatment is good.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow Fractures

 

Welcome to First Choice Physical Therapy’s patient guide on elbow fractures.

The elbow is a very important region of the arm. It serves as a hinge joint between the upper and lower parts of the arm and allows movements for activities like feeding and lifting. It also allows rotation of the hand and forearm. Together these functions allow us to position the hand in space to perform all its unique and skillful actions. Fractures of the bones that make up the elbow prevent normal movement at the joint and therefore limit the function of the hand, wrist, and forearm. As a result, these injuries must be treated with care to achieve the best possible long-term outcome.

This guide will help you understand:

• what parts of the elbow are involved
• what the symptoms are
• what can cause these fractures
• how health care professionals diagnose these fractures
• what the treatment options are
• what First Choice Physical Therapy’s approach to rehabilitation is

 

What structures are most commonly injured?

The bones that join to form the elbow joint include the humerus (upper arm bone) and the radius and ulna (the two bones of the forearm). There are actually two different joints at the elbow; the first is a hinge joint between the humerus on the one side and the combination of the radius and ulna on the other. The second joint is between the upper ends of the radius and ulna. The radius can spin in this joint allowing the forearm to rotate. This allows us to position the hand into supination (the hand palm up) or into pronation (palm down).

The lower end of the humerus has a complex shape. The tube-shaped shaft divides into two columns just above the joint. These columns support the condyles of the joint. You can feel these two condyles as the two bumps of bone on either side of the elbow joint, the medial epicondyle and the lateral epicondyle. This joint has cavities, grooves and ridges in it to accommodate the ends of the other bones coming from the forearm. The joint surface of the humerus is covered by articular cartilage. Articular cartilage is a smooth slippery material that is hard wearing and well adapted to protecting the bone surfaces that move on each other inside the joint.

There are three features of articular cartilage that are important when considering fractures that involve a joint. First, articular cartilage is nourished by joint fluid and does not have a blood supply of its own. Secondly, articular cartilage does not re-grow. Any damage to articular cartilage is permanent. Any gaps or ridges in a joint will be filled in with scar tissue rather than articular cartilage. Thirdly, blood vessels do not penetrate through the joint surface. All the blood supply of the bone that supports articular cartilage comes from inside the bone rather than from the side covered with articular cartilage. If a fracture breaks off a piece of bone that is covered by articular cartilage, the bone loses its blood supply and will die. The articular cartilage remains viable because it is still bathed in joint fluid. Some elbow fractures do result in multiple fragments of the joint surface. On a positive note, if the fragments remain in good position the joint surface will survive and the bone may grow underneath the surface to support it.

The upper end of the ulna (the bone on the inside of your arm) is shaped like a hook. When the elbow is straight the olecranon process (the tip of the hook) fits into a cavity in the back of the humerus (the olecranon fossa). When the elbow is fully bent the prominence on the front of the ulna (the coronoid process) fits into a cavity in the front of the humerus (the coronoid fossa). The joint surface of the ulna is shaped like the roof of a house and fits into a corresponding groove in the surface of the humerus (the troclear groove). This gives some side-to-side stability to the joint.

The upper end of the radius (the bone of your forearm on the same side as your thumb) is called the radial head. It is shaped like a drum to allow rotation of the bone. The part that touches the humerus is slightly concave to fit against a rounded area of the humerus called the capitellum. These bones stay in contact throughout the range of flexion and extension of the elbow.

The joint between the radius and ulna is continuous with the joint between the humerus and the ulna/radius, meaning they are all encircled within the same joint capsule. There is a divot on the side of the ulna where the radial head rests and in which it rotates. The entire head of the radius is covered with articular cartilage. There is a ligament, the annular ligament that circles the radial head and keeps it snug against the ulna as it rotates. If the radial head or neck is fractured, due to the anatomy in this region the blood supply to the fractured fragments is at risk.

You can easily feel the bony structure of the elbow. With the elbow bent place your thumb on the bone on the inside of the elbow and your long (middle) finger on the outside. The index finger will naturally feel the tip of the elbow. Your thumb is touching the medial epicondyle, your index finger is touching the olecranon process and your long finger is on the lateral epicondyle. With the elbow bent these three bony landmarks form a triangle. As you straighten the elbow the olecranon process (index finger) moves up until all three points are in a straight line. You can also feel the radial head. With the elbow bent it is halfway between the lateral epicondyle and the olecranon. You can feel it rotate as you rotate the forearm back and forth from pronation to supination.

The elbow is normally a very stable joint with movement between the upper and lower parts of the arm in virtually one plane only. There is very little side-to-side motion or front-to-back movement. There are strong ligaments that go from the humerus to the ulna and radius that provide the side-to-side stability. Front-to-back stability is more a function of the shape of the bones. In some elbow injuries, especially dislocations, some of the ligaments or their attachments are torn. This can result in instability of the elbow joint if these ligaments fail to heal properly.

 

The muscles that cross the elbow joint also contribute to stability. These muscles either bend (flex) or straighten (extend) the elbow. Two powerful elbow flexor muscles attach at the elbow. The brachialis muscle attaches to the coronoid process of the ulna and the biceps attaches to tuberosity of the radius.  The most powerful muscle of the arm is the triceps, which straightens the elbow. This muscle attaches to the olecranon process, which is the point at the back of the elbow. The pull of any of these muscles is strong enough occasionally to pull off a piece of their bony attachment. This type of injury is called an avulsion fracture.

 

 

How do fractures of the elbow commonly occur?

The complicated anatomy of the elbow joint is reflected in a wide variety of fractures that can occur in this region. Each of these injuries has its own “personality” and will be presented separately.

Fractures of the lower end of the humerus include:

 

 

Types

Fractures of the lower end of the humerus include:

Fractures not involving the joint surface: These injuries have a good prognosis because the joint surface is still intact. There is less likelihood of long-term wear and tear of the joint.

Supracondylar fractures. These injuries affect the area shaped like an inverted Y just above the joint. Severe bending forces, hyper-extension (over straightening) forces, or impact can break the bone in this area. Accurate reduction of the fracture is important otherwise the mechanics of the elbow will be affected. It is difficult to keep these fractures in a good position in a cast. For this reason it is common for this injury to be treated surgically to put the pieces back into a good position (open reduction) and hold them with pins or plates (internal fixation) until they are healed. This operation is often referred to as open reduction, internal fixation surgery (ORIF.) Fractures in the supracondylar region are much more common in children. Major trauma such as a motor vehicle accidents are probably the most common cause of this type of fracture in an adult.  This fracture is of special concern because the radial artery courses very close to the bone in the supracondylar region and can be torn when the bone breaks.

Avulsion of the medial epicondyle: The medial epicondyle is the origin site of the strong medial collateral ligament of the elbow and the flexor muscles of the forearm. A force that bends the elbow outwards may dislocate it and disrupt the ligaments on the inner side of the elbow. This may result in an avulsion (pull-off) fracture of the medial epicondyle. The medial collateral ligament pulls off a fragment of the bone.

As the elbow may be opened up widely in such an injury, the piece of bone broken off may end up trapped inside the joint. In this case it is necessary to do an operation to extract the bone fragment from the joint and fix it back into place.  More commonly the avulsed piece of bone is still close to its correct position and the injury can be treated non-operatively. Avulsion of the medial epicondyle as a result of a muscle pull is rare. This injury can usually be treated without surgery.

Avulsion of the lateral epicondyle: This region of bone is the site of origin of the lateral ligament of the elbow and the extensor muscles of the forearm. A force that bends the elbow inwards may tear the ligaments or pull off the epicondyle. This is a rare injury that occurs most often in combination with other more severe injuries to the elbow. Avulsion fracture of the epicondyle in which the muscles pull off a piece of bone is also very uncommon.

Fractures affecting the joint surface

Breaks of the humerus extending into the region of the bone covered by articular cartilage are called intra-articular fractures. They carry with them a more serious prognosis because an irregular joint surface will promote post-traumatic arthritis in the long term. The aim of management with this injury is to restore smoothness to the joint surface whenever possible.

Fracture of the Capitellum: This is the rounded end of the humerus on the outer side of the elbow. It forms a joint with the radial head and is important for the stability of the joint. A piece of the capitellum can be broken off when the elbow is dislocated or when force is transmitted up the radius as a result of a fall on the outstretched hand. The floating piece may jam in the joint, limiting movement. The irregular joint surface may cause long-term wear. It is often necessary to operate on the elbow to retrieve any loose pieces following this fracture and it is sometimes possible to fix them back in position.

T or Y Fractures. The lower part of the humerus divides into two columns that support the joint. If you sustain a blow on the elbow, a common fracture pattern is for the columns to be broken and the fracture to extend into the trochlear region of the joint forming a T or Y pattern.

This type of injury is unstable as the columns themselves are small. Once disrupted the fracture fragments are likely to separate and leave a big gap in the joint. If possible, it is best to treat these fractures surgically (ORIF.)

Smash Fracture. More severe forces on the elbow may cause multiple fractures to the end of the humerus. The joint surface may be in many pieces and some of the bone fragments may lose their blood supply. This is a difficult situation to manage but the best results come from an ORIF surgery, restoring the joint surface, and fixing it rigidly to allow early movement of the joint.

 

Fractures of the Proximal Ulna

Olecranon and coronoid process fractures are two common isolated fractures of the proximal ulna; both may be considered avulsion fractures. The Monteggia fracture is a combination injury with dislocation of the elbow (radial head) and a fracture of the ulna. The ulna is often involved in combination fracture-dislocation injuries that involve than one bone at the elbow. This fracture is discussed further below.

Olecranon Process Fracture.

The triceps muscle straightens the elbow by pulling on the olecranon. If you fall the muscle may be contracting to straighten the elbow but the force of the fall is great enough to make the elbow bend anyway and in this situation, something must give way. Often it is the bone of the olecranon process. A transverse fracture into the joint is the common pattern. An impact on the point of the elbow may result in a complex fracture where the bone breaks into multiple pieces.

This injury is significant because the joint surface is involved. The usual treatment is surgery (ORIF) to line up the fragments exactly, make the joint smooth again, and fix the fracture fragments until they heal. Olecranon fractures are quite often seen in combination with other elbow injuries.

Coronoid Process Fracture.

The brachialis muscle acts to bend the elbow and attaches to the coronoid process at the front of the ulna. When the flexed elbow is suddenly loaded this muscle may pull so hard that it pulls off the coronoid process. If this is an isolated injury and the fragment is not displaced it may be treated non-operatively even though the fracture goes into the joint. When this injury is combined with elbow dislocation and a radial head fracture it has a poor prognosis.

Monteggia Fracture. This fracture pattern involves dislocation of the radial head combined with a fracture of the shaft of the ulna. The mechanism of injury can be a fall with the elbow straight or a bending force on the upper part of the forearm. The shaft of the ulna breaks near the joint. There is a spectrum of damage to the radial head ranging from ligament damage only, through to joint surface damage right up to a fracture of the neck of the radius. Restoring the ulna to its correct length and orientation is the critical element in treating this injury and making the elbow stable again. For this reason an ORIF surgery on the ulna is usually undertaken in adults. The treatment of the radius depends on the extent of the injury.

 

Fractures of the Proximal Radius

Fractures of the shaft of the radius are not discussed here. Fractures that directly affect the elbow joint are discussed below.

Radial Neck Fractures: Longitudinal compression forces such as those resulting from a fall may cause a transverse fracture of the radial neck just below the head of the radius. A variable amount of compression and skewing of the bones can occur. A direct impact on the elbow may also cause this fracture. Due to the importance of the radial head in the functioning of the forearm, skewing of the bones as a result of this injury may limit forearm rotation. Also, due to the radial head being covered by articular cartilage a fracture through the neck region may deprive the radial head of its blood supply.

Radial Head Fractures. Axial forces compressing the radial head against the capitellum cause these injuries. This may happen with a fall, especially with the elbow slightly bent. The result is a fracture with a depressed segment of the radial head. The broken segment is most likely deprived of its blood supply. Treatment depends on the extent of the injury and the degree of displacement and angulation. The more severely displaced fractures may be treated by surgery.

Combination Fractures

Many of the more severe elbow fractures involve more than one of the parts of the bones of the elbow. Combinations of capitellum fractures with radial head or neck fractures are common as are combinations of intra-articular fractures of the distal humerus with fractures of the ulna. In general these combination injuries make the prognosis worse and increase the likelihood that the best treatment for the fracture will be surgery.

Open Fractures

The bones of the elbow are near the skin. High energy injuries to the elbow joint quite often result in the broken bone ends tearing through the skin. This means that the bone and often the joint become contaminated resulting in a high risk of infection. Regardless of the fracture pattern, these injuries are treated by  a debridement surgery to wash the dirty tissue and remove any tissue that is contaminated or dead. This type of surgery may be followed by reduction and fixation of the fracture fragments (ORIF) but avoiding infection is the first consideration and some surgeons prefer not to disturb the blood supply of the area by further surgery. Others feel that there is less likelihood of infection if the fracture fragments are immobilized.

Fractures with Bone Loss

Some open fractures are so severe that part of the bone is lost. This is typical of gunshot wounds or blast injuries. There is a real risk of losing the arm in these types of injuries as they may be accompanied by damage to nerves and blood vessels and may be heavily contaminated. Saving the arm by restoring the blood supply and careful removal of all dead tissue including bone and joint fragments is the first priority. Reconstructing the elbow after the risk of infection has passed is a difficult problem, which is approached on a case-by-case basis. The options are to accept the damaged joint, to fuse the joint so it is painless, or to plan for an artificial joint.

What symptoms do elbow fractures cause?

Severe pain in the elbow following an accident is the typical symptom of an elbow fracture. Rapid swelling of the elbow joint will often follow the injury as the joint fills with blood from the broken bone ends. The elbow will be tender and movement is likely to be very painful. The patient will often hold the arm close to the body to prevent movement. Any wounds in the region of the elbow joint should raise suspicion of an open fracture.

Numbness of the forearm or hand may indicate an injury to one of the nerves at the elbow.

After treatment there will continue to be symptoms of pain, tenderness, reluctance to move as well as pain on motion, swelling, and bruising. These symptoms are caused by tearing of the muscles and by bleeding into the joint and tissues. They resolve slowly in the weeks following the injury. Immobilization in a cast reduces some of these symptoms, such as pain on moving the elbow, but may increase others such as stiffness of the joint.

How will my fracture be evaluated?

First aid for elbow fractures would consist of dressing any wounds, making sure that the nerves and blood vessels to the hand are intact, and splinting the arm. If the patient is holding the elbow flexed then a standard sling may be applied. Otherwise it may be a good idea to splint the elbow in its current position. The patient should be treated for shock and transferred rapidly to hospital.

In the Emergency Room (ER) the focus will be on diagnosing the nature of the elbow injury, making sure there are no other injuries, treating pain and shock and obtaining an orthopaedic consultation. The ER staff will remove clothing from the arm so it can be completely examined and this may mean cutting off your clothing. The position of the fracture may be identified by gentle palpation of the elbow and the nerve and blood supply will be examined. Any wounds will be dressed. The x-ray evaluation will normally consist of two or three views of the elbow.

The orthopaedic consultation will usually take place after it has been established that you have a fracture. The orthopaedic surgeon will evaluate your general medical status, examine the arm and evaluate the x-rays. The treatment options will then be discussed with you with consideration being given to your overall medical status, your expectations, work and sports activities, and your preferences. If the fracture is complex the surgeon may order investigations of the elbow such as a Computerized Tomography (CT) scan or Magnetic Resonance Image (MRI) to get more detail of the anatomy of the fracture.

What treatments should I consider?

Nonsurgical Treatment

For the reasons outlined above, surgery is often the treatment of choice for many elbow fractures. However, some elbow fractures do not require surgery and can be treated in a cast. Non-displaced fractures of the medial epicondyle, lateral epicondyle, or the coronoid process can be treated in a cast, as can fractures of the radial head or radial neck that are minimally displaced. The cast serves to protect and immobilize the joint until healing reaches a stage where it is safe to begin elbow movement.

The cast is usually applied from above the elbow to the wrist. If it is necessary or desirable to prevent rotation of the forearm then the wrist should be included in the cast. Often this is not necessary and a simple splint bent at the elbow is enough. There are also many commercially available braces that can be used in place of a cast. Braces and splints allow the arm and elbow to swell without getting compressed inside the cast.

The “bag of bones” philosophy of treatment for severe elbow fractures was common in the past and may still be applied when there are major risks to undertaking surgery. In this approach, no attempt is made to stabilize the fracture; instead the focus is on regaining as much movement as possible early in the recovery period. Movement gained in the first week after the fracture is hardly ever lost even if the joint is severely disrupted. The bone fragments heal in the position that allows this movement. The elbow function recovered after this type of treatment, however, is never normal and usually is much less than one can expect from surgery.

Surgery

Surgery is required for all open fractures, and recommended for displaced fractures of the epicondyles and coronoid process, for olecranon fractures, for nearly all intra-articular fractures of the humerus, for Monteggia fractures, and for displaced fractures of the radial head or neck.

Open Fractures. Open fractures will require surgery as soon as possible after the injury. The operation includes cleaning out the wound by removing all dead and contaminated tissue including detached bone fragments (called debridement,) and then irrigating the wound to remove particles of dirt and drainage. It may not be desirable to close the wound immediately if this would increase the pressure on the recovering tissues so the wound is left open. Sometimes special antibiotic beads are placed in the wound to obtain a high local concentration of the drug. In many situations it is appropriate to undertake definitive treatment of the fracture at the same time as the debridement. If this is not possible, however, the wound is cleaned up first and work on the fracture is delayed, at times even for several days.

Displaced avulsion fractures. Fractures of the epicondyles and the coronoid process are usually avulsion fractures. This means that the piece of bone was pulled off by a muscle or ligament. Usually, the fracture fragment is still being pulled away from the correct position after the injury. This may prevent the bone from healing back to the correct location when it is immobilized. If the bone fragment is not in an adequate position for healing, it should be replaced and fixed by surgery.

In the case of a medial epicondyle fracture, the bone fragment is sometimes trapped in the elbow joint. The joint must be opened up and explored to remove the fragment(s). If these injuries are part of a more complex combined injury, there is even more reason to fix them back into position. After stable fixation of these fragments, the elbow can more safely be moved to prevent stiffness. Activity should be guarded until the bone has healed.

Olecranon Fractures. The fragments of this fracture are nearly always pulled apart by the pull of the triceps muscle. Surgery is indicated to restore the joint surface accurately and to fix the fracture in the reduced position. The olecranon process is just under the skin and easily exposed surgically. The fracture is often held in position by pins and a figure-of-eight wire.

The elbow can be protected in a splint for a short period after the operation for comfort, but recovery of early motion without loading the elbow is desirable. The fixation is left in place until the fracture is strongly healed (usually 3 months). If the fixation is irritating or painful it can be removed once the fracture has healed.

Capitellum Fractures. With this injury there is a high likelihood of intra-articular loose bodies that may jam in the elbow joint and damage it. The joint may be opened to retrieve the loose fragments or this may be done with an arthroscope. If the fragment is one large piece and has enough bone attached, it may be possible to fix it back in position with a screw buried into the bony part of the fragment. In this case it is often desirable to remove the screw once the fracture has healed. Healing may take some time as the bony part of the fragment has lost its blood supply (avascular) and is dead. The dead bone forms a framework on which new living bone grows to support the joint surface again but this takes time. It is not unusual to have a poor long-term result from a capitellum fracture with arthritis of this part of the elbow joint.

Intra-Articular Distal Humerus Fractures:  These are the most challenging fractures of the region to treat. Each fracture is different; however the rationale for most fractures is to restore the joint surface exactly then fix the joint to the shaft of the humerus securely. If the reduction is aligned as anatomically correct as possible it forms a stronger and better fix, but this alignment is not as important as the restoration of the joint surface itself where some inaccuracy is permissible. There are usually pins or screws extending from one condyle to the other, which join the joint fragments, and plates along the columns to fix the joint to the shaft of the humerus.

The fixation should be rigid enough to allow unloaded hinge movement of the elbow joint and rotation of the forearm. The earlier this is achieved, the better it is for the nutrition and recovery of the joint surface. The bone itself takes several months to heal and should not be loaded during this period. Often there are avascular joint fragments that take even longer to heal fully. As the fixation is just beneath the skin, it can be uncomfortable and it is common to remove the fixation once the fracture has healed and good function has been recovered.

Monteggia Fracture of the Ulna. With a Monteggia fracture it is important to reduce the ulna fracture anatomically otherwise the elbow is prone to dislocate again. It is therefore recommended to do an ORIF operation on the bone. The shaft of the ulna lies just under the skin on the back of the forearm and can easily be exposed. The fracture is extended out to the correct length, re-aligned and rotated as necessary and is then fixed with a plate and screws. Often this treatment is all that is needed for the dislocation but if the radial head or neck is also damaged then this may also need treatment (see next section). When resting one’s forearm on anything it is on the subcutaneous border of the ulna so the plate in this position is often very annoying. For this reason it is common for the plate to be removed once the injury has recovered and the bone has healed.

Radial Head and Neck Fractures. Many of these fractures do not need surgery. However, where the broken segment of the radial head is large or the amount of angulation or displacement is significant it is better to do an ORIF operation. As the bone fragments of this fracture are small and have usually lost their blood supply, this is a challenging operation. The results from surgery to repair the fracture may not be that good. It used to be popular to remove the radial head completely when it was badly injured however this operation has been shown to affect the functioning of the forearm and wrist, so many surgeons attempt to preserve the radial head or in some situations replace it with a prosthetic head. In the case of radial neck fractures, the blood supply of the fragments may be intact. In these cases, closed reduction to restore the position may be a good solution, as the bone will heal. Unfortunately, any residual angulation at the neck may cause problems with rotation of the forearm.

Total Elbow Replacement: Replacing the elbow with an artificial elbow replacement is the “fall-back” operation if treatment of an elbow fracture fails and the elbow is stiff, sore and arthritic. With some very severe elbow fractures one can see “failure” coming right from the beginning. A few surgeons advocate elbow replacement immediately if the elbow is fractured too badly to expect a good outcome with ORIF. If you have pre-existing arthritis of the elbow and a severe injury it may be worth discussing this option with the treating team.

 

What happens as I recover?

Bone takes six weeks to heal to 50% of its normal strength, three months to achieve 80% strength, and continues to get stronger for up to 18 months post injury. If casting was the primary treatment it may be continued for six weeks. After six weeks the ongoing use of braces or slings may be advisable for selected operative and non-operative cases.  X-rays will be taken to assess the progress of healing and rehabilitation with a Physical Therapist at First Choice Physical Therapy will begin as soon as your orthopaedic specialist deems it appropriate to begin.  Generally Physical Therapy can begin once the cast or splint is removed around 6 weeks post injury. While you are immobilized simple finger and shoulder movements, will be your only exercises. If your wrist is not fully immobilized, gentle bending, rotation, and gripping exercises will be encouraged.

If you have had surgery to fixate your elbow fracture then rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon recommends it. Again, based on normal bone healing, this is often around the 4-6 week mark.  Surgical fixation aims to make the fracture site stable therefore in most cases the gentle exercises mentioned above for your fingers, wrist, and shoulder are safe to do early on and will often be recommended even immediately after surgery. In some cases, however, no exercise will be recommended until after the bone has shown some evidence of healing on X-ray; finger and gentle shoulder movements are the only exercises permitted.  Each surgeon will set his or her own specific restrictions based on the type of fracture, the surgical procedure used, personal experience, and whether the fracture is healing as expected.

Even if extensive Physical Therapy for your elbow does not begin immediately, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  If your elbow has been surgically repaired, maintaining general cardiovascular fitness can be done with lower extremity fitness activities such as walking or using a stationary bike or stepper machine.

After surgical fixation, weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing elbow fracture are strictly abided by. Generally, lifting even light weights with your injured limb will not be allowed and will be difficult as your elbow heals so you may require a friend to assist you with your workout setup if you are keen to continue while your bone heals.  Your Physical Therapist at First Choice Physical Therapy can discuss the most appropriate way for you to maintain your fitness as well as provide a general fitness program specific to your needs while abiding by your doctor’s restrictions.

When the cast is removed or following surgery, you may experience some pain when you start to move your shoulder, wrist, elbow and forearm. This pain is from not using the joints regularly and also likely from concurrent soft tissue injury that occurred when you fractured your elbow. If you have had surgery, the pain may also be from the surgical process itself. Your Physical Therapist at First Choice Physical Therapy will focus initially on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the fracture site, anywhere along the forearm, or into the shoulder or hand. We may also use massage for the neck, shoulder, elbow, forearm, or wrist to improve circulation, assist with the pain, and make moving the entire upper extremity easier.

The next part of our treatment will focus on regaining the range of motion, strength, and dexterity in your wrist, hand, elbow, and shoulder. If you have been casted or splinted, your arm will look and feel quite weak and atrophied once this is removed. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of light weights or Theraband for resistance work of your wrist, elbow and shoulder. Soft balls or gripping devices may be used to encourage the return of your grip strength. Regularly measuring this strength with a hand-held dynamometer will be one of the ways we determine the progress of your rehabilitation at First Choice Physical Therapy.

If necessary, your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your elbow, and wrist to move gradually into their normal range of motion. Early mobilization and range of motion exercises are particularly important in the rehabilitation of the elbow as without them, a fractured elbow can easily become stiff and lose important range of movement. Regaining the ability to bend your elbow and rotate your forearm is crucial in order to be able to do simple daily activities such as bringing food to your mouth or holding change in your hand. Regaining elbow extension, while also important, is not as crucial to the activities of daily living in comparison to elbow flexion. In other words, losing some extension of the elbow due to stiffness following an elbow fracture will not affect your everyday function as much as the loss of elbow flexion. That being said, for those participating in sport, loss of any elbow extension can be extremely detrimental to the functioning of their upper limb and can severely limit them in the participation of their sport. For this reason, the return of full elbow range of motion, in any situation, is one of the goals of Physical Therapy at First Choice Physical Therapy. We will keep a close watch on the improvements in your ability to bend and straighten your elbow as well as rotate your forearm by measuring these angles repeatedly over time.

You will notice improvements in the functioning of your elbow even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your healing fracture allows. Graduated heavier exercises and endurance work will be added in concordance with the known healing time of bone in order to ensure these stresses can be withstood.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility will add to this decline. Although your elbow is not traditionally thought of as a weight-bearing joint of the body, even an activity such as assisting yourself with your arms to get out of a chair, pulling a glass from a cupboard, or pushing a door open requires weight to be put through your elbow and for your body to be proprioceptively aware of your limb. If you are an athlete, then proprioception of your upper extremity is paramount in returning you to your sport after an elbow fracture. For this reason, proprioceptive exercises will be part of your rehabilitation regime at First Choice Physical Therapy.  Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up overhead while bending and straightening your elbow, or pushups on an unstable surface. Advanced exercises may include activities such as ball throwing or catching.  For athletes we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in. Your Physical Therapist at First Choice Physical Therapy will liaise with your surgeon regarding the optimal time to start any of these advanced proprioceptive exercises.

Generally, the strength and stiffness one experiences after an elbow fracture responds extremely well to the Physical Therapy we provide at First Choice Physical Therapy. In regards to returning to activity, most elbow fractures require some limitation of activity for at least three months. People who undertake heavy manual labor or participate in sports that load the arms may take considerably longer. As explained above, some elbow fractures are more complex with joint surface damage, multiple bone fragments, or lost blood supply to bone fragments. These complexities all cause the process of healing and rehabilitation to take longer, and full recovery of range of motion and strength is not always possible which then affects the overall long term functioning of the joint.

Fortunately in most uncomplicated elbow fractures your elbow will return to near normal levels of performance.  With our initial one-on-one Physical Therapy treatment along with the ongoing exercises of your home program, the strength, range of motion, endurance and proprioception gradually improve towards near full recovery/function over a period of 4-6 months even though the actual final stages of bone healing won’t occur for another 12-18 months after that. If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist at First Choice Physical Therapy would expect, we will ask you to follow-up with your surgeon or doctor to confirm that the fracture site is tolerating the rehabilitation well and to ensure that if you have had surgery, there are no hardware issues that may be impeding your recovery.

What are the potential complications of this fracture?

Complications are problems with the process of healing of your fracture. The aim of health care professionals is to manage the treatment of fractures in order to avoid complications. Here we will consider the complications that are most common to elbow fractures.

Stiffness

Injury often causes bleeding into a joint. This blood clots (coagulates) but remains in the joint. Eventually the clot is transformed into scar tissue. If the joint remains immobile while this scar tissue forms, it will adhere to different parts of the joint and bind them together (adhesions). This will result in loss of range of motion (stiffness) of the joint and sometimes pain when the scar is stretched.

Malalignment of a complicated fracture can also result in joint stiffness. As mentioned above, if optimal restoration of the joint surfaces and anatomical alignment cannot be achieved due to a complex fracture, this will also result in a stiff joint.

Unfortunately, some stiffness cannot be avoided as in most cases the bones need to remain immobile while they heal. Excessive stiffness and range of motion loss is a problem and interferes with the normal functioning of your elbow.  Physical Therapy at First Choice Physical Therapy will help to avoid any unnecessary stiffness developing in your elbow. At the earlier stage of healing the tissue has less strength and can easily be stretched. Later on in the healing process, the tissues become stronger and more resistant to stretching and can also be more painful to stretch. Thus, regaining early motion (as allowed by your doctor and Physical Therapist) is the best form of treatment to avoid elbow stiffness. Avoiding the long-term complication of stiffness is the reason that you are urged to move a sore elbow, which you would much rather keep still.

Hardware Removal

As mentioned above, the hardware required to stabilize an elbow fracture is often close to the skin’s surface as there is not a lot of muscle bulk around this joint. A secondary operation of “hardware removal” may be needed if this hardware is causing symptoms or is thought to be restricting the movement of the joint.  The prospect of an operation for implant removal is worrying to patients who fear that it will be as painful as the original fracture treatment. Much of the pain from the original fracture, however, not only comes from the fracture but also from torn muscles, broken bones, and bleeding. Since the bone and muscle damage have both healed by the time of the second operation, the discomfort after hardware removal is much less and recovery is rapid. The operation does need an anesthetic but can often be done as outpatient, or day surgery.

Malunion

If the bone heals but the fragments are not in the correct position the fracture is said to be mal-united. Often this can be accepted, but in the case of joints, malunion is something preferably avoided in order to ensure that maximum range of motion returns to the joint.  In addition, ridges, steps or other irregularities in the joint surface are very likely to cause wear-and-tear arthritis (post traumatic arthritis) down the road. Surgery has the best chance of avoiding this complication, hence why it is so often recommended for intra-articular fractures. It is not guaranteed, however, that the surgeon can restore the joint surface to smoothness or that the fixation will hold everything in place.

Trying to achieve perfection through surgery may lead to even more problems and it may be necessary to compromise in order to get the best overall result. Malunion of the joint gives varying symptoms of clunking, catching, or giving way. Fortunately it may be quite silent clinically (not noticed by the patient) and only be evident from examination of the x-rays.

The management of malunion is complex and depends very much on the individual case. If there is early failure of fixation and it is clear that the joint surface will be irregular if it heals in the current position, a re-operation may be indicated. Once everything has healed it is a major undertaking to take down a united fracture and recreate the joint surface. This procedure amounts to a new fracture and is not be undertaken lightly. More often one would accept the malunion and later treat any subsequent symptoms arising due to it (see post traumatic arthritis below).

Infection

After an open fracture there is a small risk (2% or less) that the contamination at the time of the injury will result in a bacterial infection of the surgical site.

If the wound remains swollen, tender, and red longer than normal an infection must be suspected. A fever may occur and pus may accumulate in the wound or drain from it. Your doctor and Physical Therapist will closely monitor how your surgical wound is healing to watch for these signs of infection, which require immediate attention.  A culture of the pus or blood cultures may isolate the bacteria causing the infection. High doses of antibiotics for an extended period are required if an infection is present.

If there is an infection it is often necessary to repeat surgery to remove contaminated and non-viable tissue, wash out the wound and drain it. Antibiotic beads are often placed in the wound so there is a high local concentration of the drug.

With early aggressive management it is usually possible to suppress or eliminate the infection until the fracture heals. At that point removal of any remaining metal implants usually allows the infection to heal completely without long-term consequences. Where an infection of bone is incompletely resolved, it may be quiescent for some years and flare up later when the patient is stressed.

Heterotopic Ossification (HO)

Under certain circumstances scar tissue that forms in injured muscle turns into bone. The exact reason for this is not known; it seems to be related to an inflammatory process. Risk factors include surgery and seeding the area with bone fragments and immobility. Since elbow fractures can tear muscle, often spread bone fragments into the muscle, and are frequently followed by surgery it is not surprising that this complication is relatively common at the elbow. If HO develops the patient experiences pain and swelling at the elbow in excess of normal but does not have signs of infection. There is an increasing stiffness and eventually bone shows up on x-ray in the tissues outside the normal area. The pain and inflammation settle down but the bone remains and may block movement. Further surgery to remove the bone risks flaring up the process.

Methods to avoid this complication include Non Steroidal Anti Inflammatory medication (NSAIDs) and radiation. Both these have side effects to a degree that they are not used routinely to protect against heterotopic ossification however they may be used in high risk cases. Management consists of maintaining as much movement as possible until the inflammatory period has passed. After about 18 months it is then possible to do surgery to remove the bone without flaring up more HO.

Post Traumatic Arthritis

This complication has been mentioned frequently in this guide. If the elbow joint suffers damage to the articular cartilage, if the joint surface is irregular with pits, ridges, or gaps, or if the elbow is kept immobile for a prolonged period wear-and-tear arthritis of the joint is sped up. The joint becomes aching and painful to move and it may lose range of motion or grind or grate. An x-ray shows loss of the gap between the bones of the joint and may show spur formation. In addition, loose bodies may form in the joint. In functional terms the elbow becomes painful to use, weaker, swollen, and stiff.

The first line of treatment for elbow arthritis is medication, pain relievers, and NSAIDs. Sometimes an operation to remove spurs and loose bodies is helpful. In progressive cases an elbow replacement is the best solution.

Fractures of the elbow include a spectrum of injuries from quite minor fractures that heal well with minimal treatment through to complex injuries affecting the joint and causing major loss of function. The aim of treatment is to restore a smooth joint surface as soon as possible and enable early motion. If this is successful the outlook for these injuries is favorable.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow Issues

Welcome to First Choice Physical Therapy’s guide to osteoarthritis of the elbow.

The elbow joint is injured less often than many other joints in the body. The most common injuries of the elbow joint are fractures and dislocations.  Fortunately most elbow injuries tend to heal fairly well at the time of injury.

Sustaining an elbow injury, however, can lead to problems with the joint later in life.  This is true for any injury to a joint but the elbow is one of the joints particularly sensitive to developing problems later on.  The initial injury can change the way the joint works just enough to cause extra wear and tear to the surfaces of the joint. Over time, the joint degenerates, causing pain and difficulty with daily activities. This condition is called osteoarthritis (OA), degenerative arthritis, or posttraumatic arthritis.

This guide will help you understand:

• how the condition develops
• how health care professionals diagnose the condition
• what can be done to ease the pain and regain elbow movement
• what First Choice Physical Therapy’s approach to rehabilitation is

 

What parts of the elbow are affected?

The elbow joint is made up of three bones: the humerus bone of the upper arm, and the ulna and radius bones of the forearm.

The ulna and the humerus meet at the elbow and form a hinge. This hinge allows the arm to straighten and bend. The large triceps muscle in the back of the arm attaches to the point on the end of the ulna (the olecranon). When the triceps muscle contracts, it straightens out the elbow. The biceps muscles in the front of the arm contract to bend the elbow.

The connection of the radius to the humerus and the ulna allows the forearm to rotate. The upper end of the radius is round. It turns against the ulna and the humerus as the forearm and hand turn from palm down (pronation) to palm up (supination).

In the elbow joint, the ends of the bones are covered with articular cartilage. Articular cartilage is a slick, smooth material. It protects the bone ends from friction when they rub together as the elbow moves. Articular cartilage is soft enough to act as a shock absorber.  At the same time it is also tough enough to last a lifetime, if it is not injured.

 

 

What causes OA?

OA is caused by degeneration of the articular cartilage of a joint. Degeneration is wear that happens over time. Doctors use the term degenerative arthritis to describe the wear and tear of a joint over many years. Degenerative arthritis is another term for OA. Some doctors use the term degenerative arthrosis.  Arthrosis means that the joint is wearing out.

A bad sprain or fracture can damage the articular cartilage. The cartilage can also be bruised when too much pressure is put on the cartilage surface.  In some cases OA may be idiopathic which means there isn’t a known reason for the condition, but most of the time, elbow OA is linked with excess use of the arm or a previous injury.

At the time of injury the cartilage surface may not look any different if it has not been directly injured. The injury to the cartilage often doesn’t show up until months later. In some cases, however, the damage to the cartilage with the initial injury is severe. Pieces of the cartilage can actually be ripped away from the bone and these pieces do not grow back. Usually they must be surgically removed otherwise they cause problems with the functioning of the joint. If the pieces aren’t removed, they may float around in the joint, causing it to catch. These pieces are referred to as loose bodies or joint mice.  In addition to catching in the joint they can also cause a lot of pain and do more damage to the joint surfaces if left inside the joint.

Unfortunately the human body does not do a good job of repairing these holes in the cartilage surface of joints. The holes fill up with scar tissue. Scar tissue is not as slick or rubbery as the articular cartilage so the joint mechanics suffer.

An injury doesn’t have to directly damage the articular cartilage to start the process of OA. Any injury to the elbow joint can change the way the joint works which then starts the cycle of wear and tear on the joint. For example, after an elbow fracture the bone fragments may not line up exactly.  If this is the case they then heal in a slightly different position from prior to the injury, which may only mildly modify how the joint works, but is enough to change the wear and tear on the cartilage.

A dislocation can also cause lasting damage to the elbow joint. After the ligaments have been injured in a dislocation, the elbow joint may move differently. This change in movement alters the forces on the articular cartilage.  Similar to how a machine works, if one mechanism is out of balance, there can be more friction between the moving parts and it wears out faster.

Over many years, this imbalance in joint mechanics can damage the articular cartilage. Since articular cartilage cannot repair itself very well, the damage adds up. Finally, the joint can no longer compensate for the damage, and the elbow begins to hurt.

OA of the elbow is a similar process to that which occurs in the hip or knee, however, more often in the elbow, the articular cartilage itself isn’t damaged with an initial injury, whereas in the hip or knee it often is. In the elbow the biggest changes occurring after an injury are hypertrophic osteophyte (bone spur) formation and capsular contracture.

Capsular contracture refers to the process by which the capsule dries out and tightens up. The capsule has two layers: a fibrous covering that surrounds the joint and an inner lining. The inner layer is called the synovium. The synovial layer holds the lubricating fluid inside the joint.  If this fluid dries up, or the joint capsule contracts, the mechanics of the elbow joint change, and this in turn applies more pressure to the articular cartilage and wears it out quicker.

What symptoms does OA cause?

Pain and stiffness are the main symptoms of OA of any joint, including the elbow. At first, the pain comes only with activity. Most of the time the pain lessens while doing the activity, but after resting for several minutes pain and stiffness increase. As the condition worsens, you may feel pain even when resting. The pain may interfere with sleep.

You may have swelling around your elbow. Your elbow joint may fill with fluid and feel tight, especially after using it.  If the OA is to the stage where all the articular cartilage is worn off the joint surface, you may begin hearing a squeak and feel a creak in the joint when you move your elbow. This creaking sound or sensation is called crepitus.

OA eventually affects the elbow’s motion. The elbow joint is one of the most sensitive joints in the body to injury. It quickly becomes stiff and loses motion. The first thing most people notice is that it becomes hard to completely straighten the arm. Later they find it hard to bend.

Loss of motion leads to weakness and decreased function. Carrying heavy objects at the side of the body with the elbow straight is especially difficult.

How will my health care professional know if I have OA?

The diagnosis of OA of the elbow begins with an extensive history of the problem. Your health care professional will ask questions about your pain, including where exactly it is, which activities aggravate or ease it, and how your pain affects your daily activities.  Being that OA develops over a long time, you may even be asked questions about previous injuries you had or regular activities you participated in a long time ago.  For example, throwing athletes (such as baseball pitchers) have a higher risk of developing osteoarthritis of the elbow later in life. Men with a history of heavy use of the arm, such as manual laborers and weight lifters, are also at risk.

After taking a thorough history your health care professional will do a physical examination of the elbow and possibly other joints of your upper limb. It is important that they determine exactly where and when you feel your pain. Your health care professional will also feel for any catching as the joint moves. As mentioned above, loose fragments of cartilage and bone may cause this catching.

In order to help determine if OA is present you will probably need to get standard X-rays. X-rays are usually the best way to see what is happening with your bones if OA is suspected. X-rays can help your health care professional assess the damage and track how your joint changes over time. X-rays can also help your health care professional see how many bone spurs are present and if there are any loose bodies in the joint. X-rays also show the size of the joint space and how much articular cartilage is left.

A CT scan may also be ordered. CT scans can reveal osteophytes that don’t appear on plain X-rays.  CT scans give a 3-D view, which will show the size and location of any bone spurs present. CT scans also show the surgeon how close any bone spurs are to the ulnar nerve of the elbow, which is important information if surgery is planned to remove the spurs.

Your doctor may order blood tests if there is any question about the cause of your OA. Blood tests can show certain systemic diseases, such as rheumatoid arthritis.

What can be done to get rid of my pain?

Nonsurgical Treatment

In almost all cases, doctors try nonsurgical treatments first. Surgery is usually not considered until it has become impossible to control your symptoms.

Your doctor may recommend non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control swelling and pain.

An injection of cortisone into the elbow joint can give temporary relief. Cortisone is a powerful anti-inflammatory medication. It can very effectively relieve pain and swelling. Its effects are temporary, usually lasting several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Finally, Physical Therapy has a critical role in the non-surgical treatment of elbow OA.

What should I expect during rehabilitation for my elbow?

Nonsurgical Rehabilitation

The main goal of nonsurgical Physical Therapy treatment at First Choice Physical Therapy for OA in your elbow is to help you manage your pain, maintain your elbow range of motion and strength, and to teach you how to use your elbow without causing more harm.

During the first few appointments at First Choice Physical Therapy your therapist will focus initially on relieving your pain.  Your therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around your elbow or anywhere along the forearm, at the shoulder, or into your hand. Your therapist may also use massage directly around your elbow or for your neck, shoulder, forearm, or wrist to improve circulation, assist with the pain, and make moving your entire upper extremity easier. To assist in getting rid of your pain, you may also need to modify or limit your activities that irritate the elbow. Your Physical Therapist will advise you on how best to do this.

Resting the joint can help ease pain and inflammation especially if the joint is very irritable.  A relative rest, where certain irritating activities are limited but others are allowed, may be enough to calm the symptoms down. Your Physical Therapist may also suggest that you use a special elbow splint to immobilize and protect the elbow.  Taping the elbow may also provide some relief.  Some patients with OA also find relief when they use a topical rub.  Your Physical Therapist can advise you on if there would be any benefits to using braces, taping, creams or rubs in your individual case.

Next your Physical Therapist will prescribe a series of stretching and strengthening exercises for your elbow. If you have lost any range of motion (ROM) in your ability to bend, straighten, or rotate your elbow your Physical Therapist will measure this. They will also measure your grip strength on both sides.  ROM and grip strength measures are very useful in order to track improvements and to ensure that the elbow is not declining further in function.  Depending on the progression of OA in your elbow, simply not having a decline in ROM or strength may be considered very successful rehabilitation.  In other words, sometimes as long as your symptoms, ROM, and strength are not getting worse over time, even though they may not be getting better, rehabilitation can be deemed a success.

Several stretching exercises for your elbow will be prescribed. If you have lost some ROM these exercises will be used to assist in re-gaining this ROM. Usually full ROM will not be achieved if you have already lost a significant amount of motion, but improvements can most often be made. If you have not lost any ROM then the stretches are used to maintain your range, and also to maintain the length of the muscles that cross your elbow joint. Tight muscles can be detrimental to the joint as they add pressure to the articular cartilage inside.  If needed, your Physical Therapist will mobilize your elbow joint. This hands-on technique is used to encourage the elbow to move into its normal ROM. With OA, mobilizing the joint can be particularly useful.  Sometimes gaining even just a few degrees of ROM allows you to use your elbow more easily and eases symptoms.

Next your Physical Therapist will prescribe some strengthening exercises for your elbow. By maintaining the strength in the muscles surrounding your elbow, the pressure is minimized on the elbow joint. Strength in your wrist as well as in your shoulder and shoulder blade area are also important in order for the elbow to function optimally. The shoulder blade is the upper extremity’s link to the torso so strength and control of this area is particularly crucial in being able to stabilize the arm so that the elbow can work well.  Gripping exercises, although done with the hand, primarily use the muscles of the forearm, which connect to the elbow and are therefore an important part of your rehabilitation program. You will be pleased when your grip strength improves as daily activities such as twisting door handles or pulling or lifting heavier items such as shopping bags will become easier and less painful.
The use of free weights or elastic bands may be incorporated into your exercise routine in order to build up the strength of the muscles supporting your elbow, shoulder, and wrist.  As your elbow becomes strong, eccentric exercises will be added. Eccentric exercises are ones where weight is applied as the muscles are lengthening.  An example of this is holding a weight in your hand and moving from a bent elbow position to a straight one. Eccentric exercises are crucial in preparing the muscles and tissues around the elbow joint to take the load of everyday activities, such as lifting a tea kettle up and then lowering it onto the stove. As you get even stronger, your Physical Therapist will increase the speed of your strengthening exercises in order to further build up the strength and more closely simulate the every day activities your elbow will be required to perform.

Exercises to improve your proprioception will also be added.  Proprioception is the ability to know where your body is without looking at it.  Receptors in your joints and ligaments primarily control proprioception so an injury to the joint will have a significant impact on one’s proprioception.  Any period of immobility of the joint will add to this decline.  Even activities such as assisting yourself with your arms to get out of a chair, pulling a glass from a cupboard, lifting a pot, or pushing a door open requires weight to be transmitted through your elbow and for your body to be proprioceptively aware of your limb.  Participating in sporting activities with your upper extremity requires an even higher level of proprioceptive control. For this reason, proprioceptive exercises will be an important part of your rehabilitation regime at First Choice Physical Therapy and your Physical Therapist will be strict about your technique with these exercises in particular.  As mentioned above these exercises will also include ones for the shoulder and shoulder blade, which is the elbow’s link to the torso. Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up overhead while bending and straightening your elbow, or push-ups on an unstable surface. Advanced exercises may include activities such as throwing or catching a ball.

In order to reduce your pain or assist with the biomechanics of your elbow joint, your Physical Therapist may use some tape on your elbow. In some cases this can be quite useful to decrease your pain, which then allows you to strengthen the joint more easily.  The tape can also allow you to do more everyday activities without discomfort.  Some braces for the elbow can do the same thing. Your Physical Therapist will advise you if taping or bracing may be useful in your situation.

We highly recommend maintaining the rest of your body’s fitness with regular exercise while you rehabilitate your elbow.  Maintaining general cardiovascular fitness can be done with lower extremity fitness activities such as walking or using a stationary bike or stepper machine.  Weights for your other arm or lower extremities can also be done but you may require a friend to assist you in the gym as lifting any weight, even just to prepare a machine could be detrimental to your elbow rehabilitation and should not be undertaken until your Physical Therapist deems it appropriate.

If non-surgical treatment is not successful, or if over time the elbow gets worse or sustains further injury, eventually, it may be necessary to consider some type of surgical treatment. There are several operations to treat advanced OA of the elbow. Your surgeon will consider many factors when deciding which procedure is best for you, including the severity of joint degeneration, your age, your activity level, and how you use your elbow.

Arthroscopic Debridement

If you are in an early stage of OA, your doctor may recommend arthroscopic debridement. Other names for this procedure include arthroscopic ulnohumeral arthroplasty or osteocapsular arthroplasty.

Arthroscopic procedures use an arthroscope, which is a tiny TV camera that is inserted into the joint through a very small incision. The arthroscope allows the surgeon to watch on a TV screen what he or she is doing inside the joint during the procedure.

In arthroscopic debridement, the surgeon makes other small incisions for inserting special tools to get rid of bone spurs, remove loose bodies, or to smooth the cartilage. Sometimes a capsular release is needed.  An incision is made in the tissue and the anterior (front) of the capsule is removed.

Your surgeon may also do lavage of the joint. Lavage involves rinsing the joint with a sterile saltwater solution, which helps remove tiny debris that may be irritating the joint.

The majority of patients treated with arthroscopic debridement for elbow OA have less pain and more motion after surgery. Symptoms may come back in some patients, but they are usually less severe.

Interposition Arthroplasty

Before the invention of high-quality artificial joints, surgeons used many techniques to keep the bone surfaces of arthritic joints from rubbing against each other. One of these techniques is distraction interposition arthroplasty. This procedure involves placing a piece of tendon or fascia between the bony surfaces of the elbow joint.  Fascia is a connective tissue, similar to tendon that lies in a flat sheet. It covers the muscles and acts as a divider between different compartments of the body.

As the joint heals, the tendon or fascia forms a cushion of thick, tough tissue between the bones. The tissue pads the ends of the bones and reduces pain while still allowing the elbow to move.

Interposition arthroplasty is rarely indicated but may be used in rare cases.  This procedure works fairly well in the elbow but doesn’t work very well in the weight-bearing joints of the hip, knee, and ankle.

Elbow Fusion

A fusion surgery (also called arthrodesis) eliminates pain by making the bones of the joint grow together, or fuse, into one solid bone. Fusions were very common before the invention of artificial joints. Even today, joint fusions are commonly used in many different joints to get rid of the pain of arthritis.

An elbow fusion will greatly decrease the motion in your arm however, it does leave you with a strong and pain-free elbow. People who need a good range of motion in their elbow should consider another type of operation, such as an elbow joint replacement.

Elbow Joint Replacement

Elbow joint replacement or total elbow arthroplasty (TEA) is not nearly as common as hip, knee, or shoulder replacement. This is true for a couple of reasons. Firstly, OA in the elbow is not as common as osteoarthritis in weight-bearing joints.  Secondly, elbow joint replacement also has a higher complication rate than the more common replacement surgeries. Infection and slowed healing in the surgical incision are two complications of this type of procedure. Fracture, dislocation, and loosening are other problems reported with TEA.

Elbow joint replacement, however, is a good choice for patients who need improved motion rather than strength. Older patients who don’t need as much strength will probably prefer the results of elbow replacement surgery, however, they must be willing to accept low levels of activity involving the elbow. Patients with advanced rheumatoid arthritis are also good candidates for TEA.

Immediately after surgery your elbow will be bandaged with a well-padded dressing and put into an elbow splint with a sling for support.  You may see a Physical Therapist while in the hospital who starts you with some exercises, but this depends on what procedure you have had done and whether or not your surgeon recommends it.  If exercises are prescribed immediately post-surgery generally they are only simple range of motion exercises for your hand, fingers, and shoulder.  In some cases simple elbow exercises will also begin.

Once you are discharged from the hospital, Physical Therapy at First Choice Physical Therapy can begin as soon as your surgeon recommends it.  Each surgeon will set his or her own specific restrictions based on what was done during surgery, personal experience, and whether the elbow is healing as expected.  Physical Therapy at First Choice Physical Therapymay be required for up to 3 months post-surgically, and in order to maximize rehabilitation you will need to continue your home program for an even longer period after that.

Even if extensive Physical Therapy for your elbow is not immediately indicated, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise during the initial period after surgery.  Maintaining general cardiovascular fitness can be done with lower extremity fitness activities such as walking or using a stationary bike or stepper machine.  Weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing elbow are strictly abided by.  Initially lifting even light weights with your surgical limb will not be allowed and will be difficult as your elbow heals so you may require a friend to assist you with your weights setup if you are keen to continue while your joint heals.  Your Physical Therapist at First Choice Physical Therapy can discuss the most appropriate way for you to maintain your fitness as well as provide a general fitness program specific to your needs while abiding by your surgeon’s restrictions.

Once you begin to use your elbow after surgery you will experience some pain in your elbow and forearm, and possibly even when you move your wrist or shoulder.  This is considered normal. This pain is from both not using the elbow regularly and the surgical process itself. Your Physical Therapist at First Choice Physical Therapy will focus initially on relieving your pain.  They may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling around the surgical incision, along the forearm, or into the shoulder or hand. They may also use massage for your neck, shoulder, elbow, forearm, or wrist to improve circulation, assist with the pain, and make moving the entire upper extremity easier.

As the elbow tolerates it, rehabilitation after surgery for OA will follow along similar lines of that listed under non-surgical rehabilitation. Exercises to improve and regain ROM, strength, endurance, and proprioception will be prescribed as part of an exercise program you will do in the clinic and also as part of your home exercise program.  These exercises will be advanced as your elbow heals in order to ensure that your elbow is improving as quickly as it can and that you can return to your work and recreation activities as soon as possible.  Doing your rehabilitation, exercises in a pool can be useful particularly after surgery as the warmth and hydrostatic properties of the water can often allow you to gain more range of motion with less discomfort.  Your therapist can advise you whether or not pool exercises may be useful in your situation.  In any case, following the guidance and advice of your therapist is crucial in avoiding unnecessary pain or strain on your healing elbow.

Your Physical Therapist will provide hands-on treatment as needed after surgery in order to improve your range of motion and minimize your pain.  It should be noted that depending on which surgical procedure you have had done, your elbow range of motion may not improve, or may remain severely limited.  In these cases, maximizing this limited range of movement is still a goal, but a decrease in pain and an improvement in strength are the more important outcomes measured and used as indicators of a successful surgery and rehabilitation regime.

Most patients with elbow OA, whether treated non-surgically or surgically, do very well with the rehabilitation we provide at First Choice Physical Therapy.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your doctor or surgeon to confirm that the elbow is tolerating the rehabilitation well and to ensure that if you have had surgery, there are no hardware issues that may be impeding your recovery.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow Issues

Welcome to First Choice Physical Therapy’s guide to elbow dislocation.

 

When the joint surfaces of an elbow are forced apart, the elbow is dislocated. The elbow is the second most commonly dislocated joint in adults (after shoulder dislocations). Elbow dislocations can be complete or partial. A partial dislocation is referred to as a subluxation. The amount of force needed to cause an elbow dislocation is enough to cause a bone fracture at the same time. These two injuries (fracture-dislocation) often occur together.

This guide will help you understand:

• how the condition occurs
• how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

 

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. Most people don’t realize that there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.

Articular cartilage is the material that covers the ends of the bones in a joint. Articular cartilage can be up to one-quarter of an inch thick in the large, weight-bearing joints. It is a bit thinner in joints such as the elbow, which don’t support weight. Articular cartilage is white, shiny, and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. In the elbow, articular cartilage covers the end of the humerus, the end of the radius, and the end of the ulna.

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones and are the main anatomical feature that creates stability in a joint. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

In the elbow, two of the most important ligaments are the medial collateral ligament (MCL) and the lateral collateral ligament (LCL). The MCL of the elbow is on the inside edge, and the LCL is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus and bends the elbow. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury to or dislocation of the elbow. If they do not heal correctly the elbow can be too loose, or unstable.

There is also another important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring-shaped. The annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.

 

 

 

What causes this condition?

Elbow dislocation is usually the result of trauma. The most common trauma resulting in an elbow dislocation is a fall onto an outstretched arm and hand.  For example, if you are pushed over you naturally try to break your fall by putting your hand out onto the ground. When the hand hits the ground, the force is transmitted through the forearm to the elbow. This force pushes the elbow out of its socket.  This injury can also result in a fracture-dislocation.

About half of all elbow dislocations in teens and young adults occur as a result of a sports activity.  Commonly elbow dislocations are associated with sports such as gymnastics, cycling, roller-blading, or skateboarding, but any sport where you have the potential to fall and consequently put your hand out to stop you can result in an elbow dislocation.

An elbow dislocation can also occur from a sideswipe injury. This type of injury occurs when the driver of an automobile has the elbow out the open window during a car accident. The force of the impact causes a severe fracture-dislocation of the elbow.

 

What are the symptoms?

If the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Pain can be intense until the arm is relocated. The pain is often significantly relieved immediately after the joint is put back in place but there will be residual tenderness around the joint.

There will be some swelling and bruising around the elbow; the exact amount depends on how badly the soft tissues around the joint have been damaged or if there was also a fracture. Bruising is often not immediately obvious but appears several days after the injury. Injury to any of the three nerves that cross the elbow (median, ulnar, or radial nerves) can cause neurologic symptoms such as numbness, tingling, and/or weakness of the forearm, wrist, and hand. If a bone fracture is also involved the fracture can cut or damage a nerve causing temporary or permanent paralysis.

Pain and an inability to straighten the elbow or pain when turning the palm up (supination) is typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body).

How do health care professionals diagnose this condition?

The history and physical examination are probably the most important tools the health care professional uses to guide his or her diagnosis. As mentioned, a traumatic event has generally occurred to cause this injury.  Moving the elbow both passively and actively is often very limited and painful, especially extension and supination. The health care professional will check for any signs of injury to the nerves or blood vessels and will observe for any signs of the dislocation such as the dimpling of the skin.

X-ray is the best way to confirm a dislocation or fracture-dislocation.

After the elbow is relocated it is important to get an X-ray in order to determine if there has been a fracture from the dislocation itself or sometimes from the process of putting it back into place (relocating the joint.)  Other imaging studies may be ordered to look for damage to the joint cartilage, bone, ligaments, and other soft tissues. If bone detail is difficult to identify on an X-ray, a computed tomography (CT) scan may be done. If it is important to evaluate the ligaments, a magnetic resonance image (MRI) can be helpful.

What treatment options are available?

Nonsurgical Treatment

It is possible for the elbow to relocate by itself. This is more likely when there is a subluxation, rather than a complete dislocation. Sometimes a trained medical person can reduce the elbow by applying a quick motion to the forearm. There are several different methods used for manual (closed) reduction. Closed reduction refers to the fact that the elbow can be put back in joint without surgery. An open incision is not needed.

As the bones can be fractured and the soft tissue damaged from the relocation process itself, it is extremely important that this is done by a trained medical professional in order to avoid or minimize further injury.  Manual reduction can be done in an emergency on site (e.g., at an athletic event or car accident) but usually the procedure is done in a clinic or hospital setting where you can be given medications first to help with the pain, and X-rays can be obtained immediately afterwards.

What should I expect?

Nonsurgical Rehabilitation

After suffering from an elbow dislocation that does not require surgery, your arm may be immobilized for 10 to 14 days to allow the ligaments to heal. Intermittent gentle range of motion (ROM) and basic muscle tightening exercises (isometric exercises) with your arm out of the sling may be allowed during this time but you should rely on your physician to advise you whether this is suitable in your case. The type of activities and movements allowed are determined according to the extent of injury that is present.

Physical Therapy at First Choice Physical Therapy can begin as soon as you are allowed to start ROM exercises or as soon as your doctor advises it.

When the sling is removed, you will experience some pain when you start to move your elbow and forearm. This pain is from not using the joints regularly over the period of immobilization and also commonly from concurrent soft tissue injury that occurred when you dislocated your elbow. Your therapist will assess how much soft tissue injury is present by testing the stability of your ligaments as your elbow tolerates it.  Unfortunately with a lot of ligament damage, your elbow is at risk of frequently dislocating or being unstable.  If a lot of scar tissue builds up, however, the elbow will become too stiff and this affects the normal functioning of the joint.  The elbow joint is particularly sensitive to injury and easily becomes stiff.

Your treatment at First Choice Physical Therapy will focus initially on relieving any pain or swelling you may have.  Your therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around your elbow or anywhere along the forearm, at the shoulder, or into your hand. Your therapist may also use massage for your neck, shoulder, elbow, forearm, or wrist to improve circulation, assist with the pain, and make moving the entire upper extremity easier.

The next part of our treatment will focus on regaining the ROM, strength, and overall function of your elbow.  Most elbows are stiff after a period of immobilization, but one of the main goals of immobilizing the elbow is to allow the ligaments to heal as scar tissue forms.  With scar tissue in place the joint regains some of its stability, but stiffness is to be expected.  If you have also lost ROM in your wrist, hand, or shoulder due to the period of immobilization or due a concurrent injury, exercises will also be prescribed for these joints.  If your elbow is particularly stiff, your therapist may suggest you work on the range of motion in a pool where the water properties of warmth, buoyancy, and hydrostatic pressure often make it easier and less painful to move your joint.

Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program. These exercises may include the use of light weights or exercise tubing to add resistance for your elbow, wrist and shoulder. Soft balls or gripping devices may be used to encourage the return of your grip strength. Regularly measuring your grip strength with a hand-held dynamometer will be one of the ways we determine the progress of your rehabilitation at First Choice Physical Therapy.

If necessary, your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your elbow, and wrist or shoulder (if necessary) to move gradually into their normal ROM. Early mobilization and ROM exercises are particularly important in the rehabilitation of the elbow.  Without these types of exercises an elbow that has been dislocated can quickly become too stiff and lose important ROM, which may be difficult to gain back over a longer period of time. Regaining the ability to bend your elbow and rotate your forearm is crucial in order to be able to do simple daily activities such as bringing food to your mouth or to hold change in your hand. Regaining elbow extension (straightening), while also important, is not as crucial to the activities of daily living in comparison to elbow flexion. In other words, losing some straightening of the elbow due to stiffness following an elbow dislocation will not affect your everyday function as much as the loss of a lot of elbow flexion. That being said, for those participating in sport, loss of any elbow extension can be extremely detrimental to the functioning of their upper limb and can severely limit them in their sport.  For this reason, the return of full elbow range of motion, in any situation, is one of the goals of Physical Therapy at First Choice Physical Therapy.  Your therapist will keep a close watch on the improvements in your ability to bend and straighten your elbow as well as rotate your forearm by measuring these angles repeatedly over the course of your rehabilitation.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility will add to this decline.  Even an activity such as assisting yourself with your arms to get out of a chair, pulling a glass from a cupboard, or pushing a door open requires weight to be transmitted through your elbow and for your body to be proprioceptively aware of your limb. If you are an athlete, then proprioception of your upper extremity is paramount in returning you to your sport after an elbow dislocation. For this reason proprioceptive exercises will be an important part of your rehabilitation program at First Choice Physical Therapy.  Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up overhead while bending and straightening your elbow, or push-ups on an unstable surface. Advanced exercises may include activities such as throwing or catching a ball.  For athletes we will encourage exercises that mimic the quick motions of the sports or activities that you participate in.  Proprioceptive exercises for the shoulder blade may also be included, as this area of the upper extremity needs to be well controlled in order for the elbow to function optimally.  The shoulder area is the elbow’s connection to the torso and creates a stable base for the elbow to work from.  For this reason maximum control of the shoulder is extremely important in order to optimize your elbow function.

If your elbow dislocation results in an elbow that is too loose, or unstable, rehabilitation will focus even more around controlling the elbow joint using the muscles around the elbow and the shoulder.  Very extensive and advanced proprioceptive exercises will be prescribed along with several strengthening exercises.  Taping and bracing (as discussed below) can assist with keeping the joint stable. Your therapist will educate you on common activities that can re-dislocate your elbow, and these activities should be strictly avoided.  Minor to moderate laxity can usually be well controlled with Physical Therapy.  Severe laxity will likely require surgical intervention.

In addition to specific exercises for your elbow and upper limb, we highly recommend maintaining the rest of your body’s fitness with regular exercise while you rehabilitate your elbow.  Maintaining general cardiovascular fitness can be done with lower extremity fitness activities such as walking or using a stationary bike or stepper machine.  Weights for your other arm or lower extremities can also be done but you may require a friend to assist you in the gym as no weight should be lifted by your injured elbow until the tissues have had a chance to heal, and your therapist allows it.  In fact, while your elbow is healing it is best to avoid any further traction on it at all.  Pulling a door open, carrying a heavy purse in the crux of your elbow, or lifting a weighted backpack are a few examples of activities and movements that put a traction force through the elbow.  Your therapist may use these traction-type activities as your therapy advances in order to strengthen your elbow and prepare it for everyday use.  Early on, however, it is best to avoid them.

Your therapist will add graduated heavier exercises and endurance work as soon as your elbow can tolerate it.  Following the strict advice of your therapist when adding or advancing exercises is necessary as it is crucial to ensure these stresses can be withstood by the elbow before returning to any heavy work duties or sporting activities.

Some athletes or workers with manual jobs continue to wear a protective splint and/or use taping to stabilize the joint during the transition back into action.  A brace or tape can help protect the joint during motion and activity and can add to the proprioceptive control you feel around your joint.  Your Physical Therapist can educate you on which type of brace would be best for you and can tape your elbow to simulate a brace before you buy one, or instead of buying one.

Generally, elbow dislocations respond extremely well to the Physical Therapy we provide at First Choice Physical Therapy.  Simple elbow dislocations generally heal well with few (if any) problems. Unfortunately however, a consequence of an elbow dislocation is that osteoarthritis of the joint can occur years down the track.  With uncomplicated elbow dislocations that do not require surgery most athletes can resume some sports participation three to six weeks after the injury. The timing of return to work and sport depends on the type of work or sport (e.g., throwing sports or heavy labourers may require a longer rehab). In addition, dislocation of the dominant hand may require longer rehab before full motion and strength are restored.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Most dislocations without a fracture can be reduced without surgery however in a few cases surgery may be needed for reduction.  Surgery is often required in order to restore alignment and function if there has been a fracture or there has been severe damage to the ligaments, which would result in the joint being unstable and recurrently dislocating. The type of surgery depends on the extent of the damage. Wires, pins, or even an external fixation device may be needed to hold everything together until healing occurs.

If there is too much swelling, it may be necessary to delay surgery for a few days or even up to a week. In these cases the elbow will be reduced right away and the arm immobilized while waiting for the swelling to subside.

Post-operative immobilization is usually required following surgery for an elbow dislocation, especially for complex injuries.  A cast, dynamic splint, or a postoperative ROM brace can be used for immobilization. The adjustable ROM brace is used to improve elbow motion gradually while allowing soft tissue healing. It helps minimize scar tissue formation and may contribute to fewer complications (such as arthritis) later on.

While immobilized, simple shoulder, hand and finger exercises will likely be the only exercises you are allowed to do. If your wrist is not fully immobilized, gentle bending, rotation, and gripping exercises will be encouraged.  You may be allowed to do muscles tightening exercises while immobilized (isometric exercises.) A Physical Therapist at the hospital will teach these exercises to you and they should be strictly abided by. After the period of immobilization, Physical Therapy at First Choice Physical Therapy should begin as soon as your surgeon recommends it.  With fractures, normal bone healing occurs around the 4-6 week mark so often therapy is recommended at that point.  Each surgeon will set his or her own specific restrictions based on what was done during surgery, personal experience, and whether the elbow is healing as expected.

Even if extensive Physical Therapy for your elbow does not begin immediately, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  During the period of immobilization maintaining general cardiovascular fitness can be done with lower extremity fitness activities such as walking or using a stationary bike or stepper machine.  Weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing elbow are strictly abided by. Generally, lifting even light weights with your surgically repaired limb will not be allowed and will be difficult as your elbow heals so you may require a friend to assist you with your weights setup if you are keen to continue while your joint heals.  Your Physical Therapist at First Choice Physical Therapy can discuss the most appropriate way for you to maintain your fitness as well as provide a general fitness program specific to your needs while abiding by your surgeon’s restrictions.

Once the period of immobilization is over, you will experience some pain when you start to move your elbow and forearm, and possibly even when you move your wrist or shoulder. This pain is from not using the elbow regularly and the surgical process itself, but may also be from concurrent soft tissue injury that occurred when you dislocated your elbow. Your Physical Therapist at First Choice Physical Therapy will focus initially on relieving your pain and decreasing inflammation.  They may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or inflammation around the surgical incision, along the forearm, or into the shoulder or hand. They may also use massage for the neck, shoulder, elbow, forearm, or wrist to improve circulation, assist with the pain, and make moving the entire upper extremity easier.

As the elbow tolerates it, rehabilitation will follow along similar lines of that listed under non-surgical rehabilitation. Exercises to improve and regain ROM, strength, endurance, and proprioception will be prescribed as part of the exercise program you will do in the clinic and as part of your home exercise program.  These exercises will be advanced as your elbow heals in order to ensure that your elbow is improving as quickly as it can and that you can return to your work and recreation activities as soon as possible.

As mentioned under non-surgical treatment, some patients continue to wear a protective splint and/or use taping to stabilize the joint during the transition back into work or sport.  This is common practice as well after surgical treatment.  A brace or tape can help protect the joint during motion and add to the proprioceptive control you feel around your joint as you ease back into your normal activities.  Your therapist will advise you on whether a brace or taping would be helpful in your situation.
Also mentioned under non-surgical rehabilitation, some ROM of the elbow may be lost after this type of injury. This is true even with surgical intervention. Often due to the surgical process scar tissue builds up and causes the elbow to stiffen.  To minimize the amount of ROM lost post-surgically, your therapist will mobilize your elbow joint.  This hands on treatment assists your elbow (and wrist if needed), to move into the normal ROM.  Unfortunately, despite best efforts by the surgeon and your therapist, it is common for some range of motion to be lost either with bending or straightening (or both) of the elbow.  Sometimes rotation of your forearm (supination) can also be mildly limited.  As long as most of the range of motion has returned, most patients are not limited in everyday activities by the loss of ROM.  Obviously with high-level sports however, any limitations in ROM can be more of a problem and may affect the ability to return to pre-injury status.

Some elbows, even after surgery, can remain unstable and continue to dislocate.  If the elbow recurrently dislocates (or becomes too stiff) additional reconstructive surgery may be needed.  Again, for some patients, arthritis is a long-term result of elbow injury and this is more likely if there is a history of recurrent elbow dislocations.

Fortunately most elbow dislocations, whether treated non-surgically or surgically, do very well with the rehabilitation we provide at First Choice Physical Therapy.  If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist at First Choice Physical Therapy would expect, we will ask you to follow-up with your doctor or surgeon to confirm that your elbow is tolerating the rehabilitation well and to ensure that if you have had surgery, there are no hardware issues that may be impeding your recovery.

Physical Therapy in Lynn Haven and Panama City Beach for Elbow

Welcome to First Choice Physical Therapy’s guide to elbow anatomy.

 

At first, the elbow seems like a simple hinge-type joint, however when the complexity of the interaction of the elbow with the forearm and wrist is understood, it is easy to see why the elbow can cause problems when it does not function correctly.  Part of what makes us human is the way we are able to use our hands.  Effective use of our hands requires stable and painless elbow joints.

This guide will help you understand:

• what parts make up the elbow
• how those parts work together

 

The important structures of the elbow can be divided into several categories. These include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels

Bones and Joints

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb). The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge.  There is a second joint that makes up the elbow, where the end of the radius (the radial head), meets the humerus.

This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down.  At the same time, it has to slide against the end of the humerus as the elbow bends and straightens.  This part of the elbow is even more complex because the radius also joins with the ulna to form a joint, and this part of the radius has to slide against the ulna as it rotates the wrist as well.  The end of the radius at the elbow is shaped like a smooth knob with a smooth cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage can be up to one-quarter of an inch thick in the large, weight-bearing joints. It is a bit thinner in joints such as the elbow, which don’t support weight.  Articular cartilage is white, shiny, slippery, and has a rubbery consistency.

 

The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. It allows joint surfaces to slide against one another without causing any damage. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.  In the elbow, articular cartilage covers the end of the humerus, the end of the radius, and the end of the ulna.

 

Ligaments and Tendons

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

 

In the elbow, two of the most important ligaments are the medial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and radius, and keep the bones tightly in place as they move around the end of the humerus. These ligaments are the main source of stability for the elbow but can be torn when there is an injury or dislocation to the elbow.  If they do not heal correctly the elbow can be too loose, or unstable.

There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring shaped, and the annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.

 

There are several important tendons around the elbow. The biceps tendon attaches the large biceps muscle on the front of the arm to the radius and allows the elbow to bend with force. You can feel this tendon crossing the front crease of the elbow when you tighten the biceps muscle.  The triceps tendon connects the large triceps muscle on the back of the arm with the ulna. It allows the elbow to straighten with force, such as when you perform a push-up.

 

The muscles of the forearm cross the elbow and attach to the humerus. The outside, or lateral boney bump just above the elbow is called the lateral epicondyle.  Most of the muscles that straighten the fingers and extend the wrist all come together in one tendon to attach in this area. The inside, or medial, boney bump just above the elbow is called the medial epicondyle. Most of the muscles that bend the fingers and wrist all come together in one tendon to attach in this area. These two tendons are important to understand because they are a common location of tendonitis such as golfer’s elbow (medial common flexor tendonitis) and tennis elbow (lateral common extensor tendonitis.)

Muscles

The main muscles that are important at the elbow have been mentioned above in the discussion about tendons. They are the biceps, the triceps, the wrist extensors (attaching to the lateral epicondyle) and the wrist flexors (attaching to the medial epicondyle).

 

Nerves

All of the nerves that travel down the arm pass across the elbow. Three main nerves that innervate the arm, forearm, and hand begin together at the shoulder: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry signals from the brain to the muscles that move the arm. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

 

Some of the more common problems around the elbow are problems of the nerves.  Each nerve travels through its own tunnel as it crosses the elbow.  Due to the elbow having to bend a lot, the nerves must bend as well.  Constant bending and straightening can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the arm and hand.

 

Blood Vessels

Traveling along with the nerves are the large vessels that supply the arm with blood.  The largest artery is the brachial artery that travels across the front crease of the elbow. If you place your hand in the bend of your elbow, you may be able to feel the pulsing of this large artery.  The brachial artery splits into two branches just below the elbow: the ulnar artery and the radial artery which both continue into the hand.  Damage to the brachial artery can be very serious because it is the only blood supply to the hand.

 

 

As you can see, the elbow is more than a simple hinge-type joint. It is designed to provide maximum stability as we position our forearm to use our hand.  When you contemplate all the different ways we use our hands every day and all the different positions we put our hands into, it is easy to understand how hard daily life can be when the elbow doesn’t work well.

Physical Therapy in Lynn Haven and Panama City Beach for Cumulative Trauma

 

Welcome to First Choice Physical Therapy’s patient resource about Cumulative Trauma Disorder.

Cumulative trauma disorder (CTD) is a broad category that includes many common diseases that affect the soft tissues of the body. CTD in itself is not a disease. Doctors use the concept to understand and explain what may have caused, or contributed to, certain conditions. Examples of the conditions that may be caused or aggravated by cumulative trauma include carpal tunnel syndrome, tennis elbow, and low back pain.

Other terms are often used to describe the concept of CTD. These include repetitive stress injury (RSI), overuse strain (OS), and occupational overuse syndrome (OOS). This document will refer to these categories generally as CTD.

This guide will help you understand:

• what factors may contribute to CTD
• how doctors diagnose conditions related to CTD
• what treatment options are available
• how to prevent CTD

What causes CTD?

Opinions abound as to what may cause CTD, but there is very little agreement. Some of the theories about how CTD starts are described below. The theories include:

• overuse
• muscle tension
• nerve tension
• psychosocial factors
• mind-body interaction
• contributing factors

Using muscles and joints after they have become fatigued, or overly tired, increases the likelihood of injury. Overloaded muscles and soft tissues without proper rest have no chance to recover fully. This problem often hampers athletes who have to throw, jump, or run repeatedly. It can also affect people who work in jobs where they keep doing the same action again and again, such as typing, gripping, and lifting.

All body tissues are in a constant state of change. Minor damage occurs continuously, which the body must repair in the normal course of a day. But the damage can occur faster than the repair mechanisms can keep up with it. When this happens, the tissues become weaker. They may begin to hurt. The weaker the tissues become, the more likely they will suffer even more damage. A cycle begins that looks like a spiral–constantly downward.

Muscle Tension

Some doctors think muscle tension causes CTD. To function, or work properly, the body and each of its parts needs a steady supply of blood, rich in oxygen and nutrients. Nutrients are the body’s fuel–glucose, for example. Cutting off or slowing the blood supply harms the tissues of the body.

Tense muscles are believed by some to actually squeeze off their own flow of energy and fuel. Muscles can get energy without oxygen, but the process produces a chemical called lactic acid. This chemical can be a potent pain-causing chemical. Lactic acid is a chemical that can produce a burning feeling when muscles are overexercised. Some physicians believe that lactic acid produced by tense muscles may cause some of the symptoms of CTD.

As pain develops, muscles tighten even further because they attempt to guard the surrounding area. Guarding is a term that is used to describe a reflex that all muscles in the body share. When pain occurs anywhere in the body, muscles around the painful area go into spasm (they tighten uncontrollably) to try to limit the movement in the area. As a result, blood flow is slowed down even more. The muscles begin to ache more. The nerves that have their blood supply reduced and squeezed by muscles begin to tingle or go numb.

Nerve Tension

This theory suggests that nerves become extra sensitive when they’ve become shortened and irritable. It is thought that poor postures used over long periods causes muscles to bulk up and interfere with blood flow. The nerves that course through the body then become shortened and may begin to stick to the nearby tissues. Moving the arm or leg puts tension on the nerve and can cause pain to radiate along the limb. The problem is thought to get worse from stress because the muscles and nerves tense up and become even tighter. Also, when the same activities are done over and over again, the tight nerve is pulled and strained to the point that it can’t heal and eventually becomes a chronic source of symptoms.

Problems with CTD tend to be more common among people who suffer from boredom, who have poor working relations, who aren’t satisfied with their jobs, and who have unhappy social circumstances. Reasons why this is so are unclear. The number of CTD cases reported may also be influenced by state worker’s compensation rules. States where claims are processed quickly and with greater benefits tend to have higher volumes of CTD cases. Both of these findings suggest that many cases of CTD may be highly influenced by the patient’s perception of the overall situation. Some patients may subconsciously, or consciously, rationalize their symptoms due to many factors that are not medical but have to do with their overall job and social situation.

A newer theory suggests that there isn’t really an injury going on in the soft tissues where symptoms are felt. Instead, the problem is said to be coming from influences within the mind. It is theorized that the brain starts producing pain signals as a cover-up for deep-rooted feelings of past emotional pain or problems. Though the idea sounds hard to believe, practitioners using this approach claim they have had success rates as high as 95 percent. Their patients are reported to have gotten swift relief from treatments aimed at the underlying and unconscious emotional triggers.

The way people do their tasks can put them at risk for CTD. Some risk factors include:

• force
• awkward or static postures
• poor tool and equipment design
• fatigue
• repetition
• temperature
• vibration

One of these risk factors alone may not cause a problem. But doing a task where several factors are present may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of developing CTD. Many different symptoms can arise from the accumulation of small injuries or stresses to the body. CTD is not so much a disease as it is a response to excessive demands these factors can place on our bodies without giving them adequate time to recover between.

What does CTD feel like?

The symptoms of CTD usually start gradually. Patients usually don’t recall a single event that started their symptoms. They may report feelings of muscle tightness and fatigue at first. People commonly report feeling numbness, tingling, and vague pain. Others say they feel a sensation of swelling in the sore limb. Some patients with arm symptoms sense a loss of strength and may drop items because of problems with coordination. Symptoms often worsen with activity and ease with rest.

When you visit First Choice Physical Therapy, our Physical Therapist will begin the evaluation by taking a history of your problem. We’ll probably ask questions about your job, such as the type of work you do and how you perform your job tasks. Answers to other questions will give us information about your work conditions, such as the postures you use, the weights you have to lift or push, and whether you have to do repetitive tasks. We may also ask about how you like your job and whether you get along with your supervisors and coworkers.

Our Physical Therapist will then do a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTD. We will first try to determine what conditions are affecting you. For example you may have symptoms of carpal tunnel syndrome or tennis elbow that need to be treated. Second, our Physical Therapist will try and determine if cumulative trauma is playing a role in your condition. If so, part of the treatment will be to try and eliminate the source of the cumulative trauma.

There are no specific tests that can diagnose CTD. There are many different tests that may be ordered as we look for specific conditions.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

Portions of this document copyright MMG, LLC.

How can I help prevent problems of CTD?

The best medicine for treating CTD is to prevent the problem from occurring in the first place. Key items to consider when attempting to prevent problems with CTD are listed below.

Use healthy work postures and body alignment. Posture can have a significant role in CTD. Faulty alignment of the spine or limbs can be a source of symptoms. Using healthy posture and body alignment in all activities decreases the possibility that CTD will strike. Incorrect posture may lead to muscle imbalances or nerve and soft tissue pressure, leading to pain or other symptoms. Most people spend many hours at their work place, and using unhealthy posture during these long hours increases the likelihood that CTD will develop.

Ergonomics

Assessing where and how a person does work is called ergonomics. Even subtle changes in the way a work station is designed or how a job is done can lead to pain or injury.

 

 

Rest and Relax

Rest and relaxation (R and R) have recently become front-line defenses in the prevention of CTD. Methods can be as simple as deep breathing, walking, napping, or exercising.

 

This strategy is useful during work and off hours. Whether at home or work, our bodies need time to recover, which simply means giving them a chance to heal. Rest and relaxation allow the body to recover and provide a way of repairing these injured tissues along the way, keeping them healthy.

The following ideas may be used to foster rest and relaxation at work:

• • Be relaxed. Try to work with your muscles relaxed by pacing your work schedule, staying well ahead of deadlines, and taking frequent breaks.

 

• • Stop to exercise. Gentle exercise performed routinely through the day helps keep soft tissues flexible and can ease tension.

 

• • Change positions. Plan ways to change positions during work tasks. This could include using a chair rather than standing or simply readjusting your approach to your job activity.

 

• • Rotate jobs or share work duties. This can be fun by offering a new work setting, and it allows the body to recover from the demands of the previous job task.

 

• Avoid caffeine and tobacco. These can heighten stress, reduce blood flow, and elevate your perception of pain.

What can I expect with treatment?

Getting treated right away for symptoms of CTD can shorten the time it takes to heal. Symptoms can sometimes go away within two to four weeks when steps are taken quickly to address the factors that may be causing your symptoms. However, people who keep doing activities when they have symptoms and don’t seek help right away may be headed for a long and frustrating recovery time, perhaps as long as a year.

At First Choice Physical Therapy many nonsurgical treatment approaches are used by our Physical Therapy and occupational therapists to reduce the symptoms of CTD-related conditions. Our Physical Therapist will want to gather more information and will further evaluate your condition. The answers you give along with the results of the examination will guide us in tailoring a treatment program that is right for you.

Our Physical Therapists often begin by teaching patients relaxation techniques which may include helping you learn to breathe deeply by using your diaphragm muscle. Taking the time to relax and breathe deeply eases tense muscles and speeds nutrients and oxygen to sore tissues.

We may suggest that you wear a splint initially to protect and rest the sore area. Anti-inflammatory drugs, suggested by your doctor, are often used together with therapy treatments, which may include heat, ice, ultrasound, or gentle hands-on stretching to reduce pain or other symptoms. Our Physical Therapist may use muscle stretching to restore muscle balance and to improve your posture and alignment. We sometimes apply stretches that are designed to help nerves glide where they course from the spine to the arms or legs. Strengthening exercises are also used to restore muscle balance and to improve your ability to use healthy postures throughout the day.

Our Physical Therapist will pay close attention to your posture and movement patterns. You may receive verbal instruction and hands-on guidance to improve your alignment and movement habits. Helping you see and feel normal alignment improves your awareness about healthy postures and movements, allowing you to release tension and perform your activities with greater ease.

We will spend time helping you understand more about CTD and why you are experiencing symptoms. Our Physical Therapist may provide tips on how to combat symptoms at work using rest and relaxation. You may also be given specific stretches and exercises to do at work. Our Physical Therapist may visit your work place to analyze your job site and to watch how you do your job tasks. Afterward, we can recommend changes to help you do your job with less strain and less chance of injury. These changes are usually inexpensive and can make a big difference in helping you be more productive with less risk of pain or injury.

At First Choice Physical Therapy, our goal is to help you understand your condition, to look for and change factors that may be causing your symptoms, and to help you learn how to avoid future problems. When your recovery is well underway, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of practicing the strategies and exercises you’ve learned as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Surgery is rarely indicated for CTD. Specific conditions that can occur as a result of CTD may require surgery. Unless the doctor is quite sure there is a structural problem, such as a pinched nerve or severely inflamed tendon, then surgery is not usually suggested.

Physical Therapy in Lynn Haven and Panama City Beach for Upper Back and Neck

Welcome to First Choice Physical Therapy’s patient resource about Cervical Spine Problems.

Knowing the main parts of your neck and how these parts work is important as you learn to care for your neck problem.

Two common anatomic terms are useful as they relate to the neck. The term anterior refers to the front of the neck. The term posterior refers to the back of the neck. The part of the spine that moves through the neck is called the cervical spine. The front of the neck is therefore called the anterior cervical area. The back of the neck is called the posterior cervical area.

This guide gives a general overview of the anatomy of the neck. It should help you understand:

• what parts make up the neck
• how these parts work

 

The important parts of the cervical spine include: 

• bones and joints
• nerves
• connective tissues
• muscles
• spinal segments

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

Spine

 

The first seven vertebrae make up the cervical spine. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine (the chest area).

Cervical Spine

 

The base of the skull sits on top of C1, also called the atlas. Two thickened bony arches form a large hole through the center of the atlas. The opening is large because the spinal cord is wider where it first exits the brain and skull. Compared to other vertebrae, the atlas also has much wider bony projections pointing out to each side.

Atlas

 

The atlas sits on top of the C2 vertebra. The C2 is called the axis. The axis has a large bony knob on top, called the dens. The dens points up and fits through a hole in the atlas. The joints of the axis give the neck most of its ability to turn to the left and right.

Axis

Dens

 

Each vertebra is made of the same parts. The main section of each cervical vertebra, from C2 to C7, is formed by a round block of bone, called the vertebral body. A bony ring attaches to the back of the vertebral body. This ring has two parts. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord. The laminae provide a protective roof over the spinal cord.

Cervical Vertebra

 

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. These projections, called spinous processes, can be felt as you rub your fingers up and down the back of your spine. The largest bump near the top of your spine is the spinous process of C2. At the base of the neck where the cervical and thoracic spines join together, you’ll feel another large spinous process. That’s C7.

Spinous Processes

 

Each vertebra in the spine has two bony knobs that point out to the side, one on the left and one on the right. These bony projections are called transverse processes. The atlas has the widest transverse processes of all the cervical vertebrae. Unlike the rest of the spine, the neck vertebrae have a hole that passes down through each transverse process. This hole, called the transverse foramen, provides a passageway for arteries that run up each side of the neck to supply the back of the brain with blood.

Between each pair of vertebrae are two joints called facet joints. These joints connect the vertebrae together in a chain but slide against one another to allow the neck to move in many directions. Except for the very top and bottom of the spinal column, each vertebra has two facet joints on each side. The ones on top connect to the vertebra above; the ones below join with the vertebra below.

Facet Joints

 

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Neural Foramen

 

Nerves

The hollow tube formed by the bony ring on the back of the spinal column surrounds the spinal cord as it passes through the spine. The spinal cord is a similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Spinal Cord

 

The spinal cord travels down from the brain through the spinal column. Two large nerves branch off the spinal cord from each vertebra, one on the left and one on the right. The nerves pass through the neural foramina. These spinal nerves group together to form the main nerves that go to the limbs and organs. The nerves that come out of the cervical spine go to the arms and hands.

Connective Tissues

 

 

Ligaments are strong connective tissues that attach bones to other bones. (Connective tissues are networks of fiber that hold the cells of the body together.) Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones.

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

 

Muscles

The anterior cervical area is covered with muscles that run from the rib cage and collar bone to the cervical vertebrae, jaw, and skull. The posterior cervical muscles cover the bones along the back of the spine and make up the bulk of the tissues on the back of the neck.

Spinal Segment

A good way to understand the anatomy of the cervical spine is by looking at a spinal segment. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at each vertebra, and the small facet joints that link each level of the spinal column.

The intervertebral disc separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal segment is connected by a facet joint, described earlier. When the facet joints of the cervical spine move together, they bend and turn the neck.

Many important parts make up the anatomy of the neck. Understanding the regions and structures of the neck can help you be more involved in your health care and better able to care for your neck problem.

 

Welcome to First Choice Physical Therapy’s patient resource about Thoracic Spine Anatomy.

The section of the spine found in the upper back is called the thoracic spine. It goes from the base of the neck to the bottom of the rib cage. Knowing the main parts of the thoracic spine and how these parts work is important as you learn to care for your back problem.

Two common anatomic terms are useful as they relate to the thoracic spine. The term anterior refers to the front of the spine.

The term posterior refers to the back of the spine. The front of the thoracic spine is therefore called the anterior thoracic area. The back of the thoracic spine is called the posterior thoracic area.

This guide gives a general overview of the anatomy of the thoracic spine.

It should help you understand:

• what parts make up the thoracic spine
• how these parts work

The important parts of the thoracic spine include:

• bones and joints
• nerves
• connective tissues
• muscles
• spinal segments

 

 

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column is the body’s main upright support.

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, also called the lumbar spine, curves slightly inward. An inward curve in the spine is called a lordosis. An outward curve, as in the thoracic spine, is called a kyphosis. A kyphosis is shaped like a “C” with the opening at the front.

The middle 12 vertebrae make up the thoracic spine. Doctors often refer to these vertebrae as T1 to T12. The first large bump on the back of the lower part of the neck as you feel down your spine is the seventh cervical vertebra, called C7. It sits on top of T1, the next large bump. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

Each vertebra is made up of the same parts. A round block of bone, called the vertebral body, forms the main section of each thoracic vertebra from T1 to T12.  Each vertebra increases slightly in size from the neck down. The increased size helps balance and support the larger muscles that connect to the lower parts of the spine.

A bony ring attaches to the back of each vertebral body. This protective ring of bone surrounds the spinal cord, forming the spinal canal. Two bony extensions called pedicles connect directly to the back of the vertebral body. Two laminae join the pedicles to complete the ring. The laminae form the outer portion of the bony ring. When the vertebrae are stacked on top of each other, this bony ring forms a hollow tube that surrounds the spinal cord and nerves. The laminae provide a protective roof over these nerve tissues.

A bony knob projects out at the point where the two laminae join together at the back of the spine. You can feel these projections, called spinous processes, as you rub your fingers up and down the middle of your back. Bony knobs also project out from the side of the bony ring, one on the left and one on the right. These projections are called transverse processes. In the thoracic spine, all the ribs except the 11th and 12th ones attach onto these transverse processes as well as attaching onto the thoracic vertebral body. The 11th and 12th ribs connect only to the vertebral body and are therefore freer to move.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spinous process. The alignment of the facet joints of the thoracic spine allows freedom of movement as you twist, move back and forth, or lean side to side.

 

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a slick, rubbery material that covers the ends of the bones in a joint. The cartilage allows the bones to move against each other smoothly, without friction.

 

On the left and right side of each vertebra a small tunnel is formed from the stacking of vertebrae. This is called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can encroach on the opening and put pressure on the nerve. A facet joint sits in the back of the foramen on each side.

Bone spurs that form on the facet joints can also encroach into the space of the foramen, narrowing the hole and pinching the nerve.

Nerves

The hollow tube formed by the bony rings on the back of the spinal column surrounds the spinal cord. The spinal cord is like a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. In the thoracic spine, the spinal canal is narrower than in the rest of the spine, so there is very little extra space for the spinal cord as it passes through this area. Due to this, thoracic spine injuries involving the spinal cord are often more problematic than in other areas of the spine.

 

Between the vertebrae of the entire spine, including the thoracic spine, two large nerves branch off the spinal cord, one on the left and one on the right. The nerves pass through the neural foramina of each vertebra. These spinal nerves group together to form the main nerves that innervate the organs and limbs. The nerves originating from the thoracic spine mainly control the muscles and organs of the chest and abdomen.

Connective Tissue

Connective tissue is a network of fiber that holds the cells of the body together. Ligaments are strong connective tissues that attach bones to other bones to hold them in place. Several long ligaments connect on the front and back sections of the vertebrae of the entire spine, including the thoracic spine. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run the full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long and more elastic-like ligament that connects to the front surface of the lamina area of the vertebrae. Thick ligaments also connect the ribs to the transverse processes of the thoracic spine.

A special type of structure in the spine called an intervertebral disc is also made up of connective tissue. Special cells, called collagen cells, form the fibers of the disc. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made up of two parts. The center, called the nucleus pulposus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding the nucleus. If there is wear and tear or injury to the annulus, the inner nucleus can bulge out causing pain and can also irritate the nerves located nearby.

 

Discs in the thoracic spine are much thinner than in the cervical and lumbar spine. As a result, there is generally less movement between the vertebrae of the thoracic spine and less frequent bulging of the discs compared to the cervical or lumbar spine.

Muscles

The muscles of the thoracic spine are arranged in layers. Those closest to the skin’s surface run from the back of the vertebrae to the shoulder blades. Others wrap around the rib cage and connect to the shoulders. Strap-shaped muscles called erector spinae make up the middle layer of muscles. These muscles run up and down over the lower ribs and thorax (the rib cage), and cross to the low back. The deepest layer of muscles attaches along the back of the spine bones, connecting each vertebrae together. Muscles also connect from one rib to the next. The muscles of the thoracic spine have many functions including moving the thorax, as well as assisting in trunk stability.

Spinal Segment

A good way to understand the anatomy of the thoracic spine is to visualize one spinal segment in relation to the anatomy described above. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal column at each vertebra, and the small facet joints that link each level of the spinal column.

 

Many important parts make up the anatomy of the thoracic spine. Understanding the regions and structures of the thoracic spine can help you become more involved in your health care and better able to care for your own back problem.