Property of VOMPTI, LLC UCL Sprain/Tear www.vompti.com M EDIAL E LBOW P AIN Kristin Kelley, DPT, OCS, FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Valgus Instability/Ulnar Collateral Moving Valgus Stress Test Ligament Sprain • History • Differential Diagnosis • (+) pain 70 to 120 deg – Acute rupture-OH athletes elbow flex – Flexor/Pronator Strain – Persistent pain indicates – Medial Epicondylalgia • Elbow moved quickly partial tear • Physical Exam from max flex to ext • Treatment – (+)TTP of anterior UCL with valgus force – Immobilize elbow – Valgus stress test at 25 deg elbow flexion – Strengthen Pronator • Mimics late – Moving valgus stress Teres cocking/early test( O’Driscoll 2005) – Gr III = Ortho Consult acceleration • (+) btw 70-120 deg flexion • Sn 1.0, -LR 0.0 • Sp .75, + LR 4.0 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 1
Property of VOMPTI, LLC Cubital Tunnel Syndrome Cubital Tunnel Syndrome • History • Differential Diagnosis – 2nd most common – Cervical Radiculopathy neuropathy in UE – TOS – Sensory changes 4th-5 th – Ulnar compression at digits wrist – Medial elbow pain – 1st rib syndrome Physical Exam • • Treatment – Elbow Flexion Test – Rest, avoid elbow – Wartenberg’s Sign flexion ADLs – Ulnar Nerve Compression Test – Night splinting in elbow flex < 30 deg 4-6 weeks – Froment’s Sign Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Cubital Tunnel Syndrome Special Tests Cubital Tunnel Syndrome Special Tests • Elbow Flexion Test • Ulnar Nerve Compression Test (Novak, 1994) – 60 second hold, (+) – Pressure to nerve in 20 deg for paresthesias flexion for 60 seconds – Sn .89, -LR .11 • Sn .75, -LR .25 – Sp .98, +LR 44.5 • Sp .99, +LR 75 • Froment’s Sign – Key chuck grip of paper b/w thumb and index finger • Wartenberg’s Sign – Weakness of Adductor Pollicis and 1st Dorsal – Inability to adduct Interosseous allows paper 5th digit to be pulled Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 2
Property of VOMPTI, LLC The Prevalence of Medial Epicondylitis Among Patients With C6 Medial Epicondylalgia and C7Radiculopathy; Sports Health: A Multidisciplinary Approach 2010, American Orthopaedic Society for Sports Med • History • Differential Diagnosis • 102 pts initially diagnosed with cervical – Common with valgus – Ulnar neuropathy radiculopathy. activities – UCL sprain – FCR and PT tendons • They were then examined for medial epicondylitis. – Pronator Syndrome commonly involved • 55 pts diagnosed with medial epicondylitis – Cervical Radic • Physical Exam • Treatment – (+)TTP medial epicondyle – 44 pts with C6 and C7 radiculopathy, – Pain with RSC wrist flex – Stretching wrist flexors – 11 with only C6 radiculopathy. and forearm pronation – Eccentric strengthening – Grip strength usually exercises unaffected – Shoulder – Ulnar nerve symptoms stabilization/core often coexist training Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com The Prevalence of Medial Epicondylitis Among Patients With C6 Valgus Extension Overload Syndrome and C7Radiculopathy; Sports Health: A Multidisciplinary (Posteromedial Impingement via Ulno-humeral Compression) Approach 2010, American Orthopaedic Society for Sports Med • History • Medial epicondylitis presented with cervical – “locking, catching” and medial elbow pain radiculopathy in slightly more than half the – Typically present patients. w/throwing and serving in sports • Hypothesized weakening of the FCR and pronator • Physical Exam teres and imbalance of the flexor and extensor – Flexion contracture muscles from the C6 and C7 radic allow for easy – Painful active extension onset of medial epicondylitis. w/crepitis • Patients with medial epicondylitis should be – PROM painful in pronation, valgus, examined for C6 and C7 radiculopathy to ensure extension proper treatment – TTP posteromedial olecranon Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 3
Property of VOMPTI, LLC VEO Syndrome VEO Test Combined motion of valgus Passively extend pt’s elbow • • pressure with powerful from 30 deg flex to full extension of the elbow extension while maintaining during acceleration phase of a moderate valgus stress throwing. • Attempts to stress a potential Leads to posterior posteromedial osteophyte • osteophyte formation due to abutting medial trochlea and impingement of the posterior olecranon fossa medial aspect of the ulna Meant to simulate stresses • against the trochlea and during acceleration phase of olecranon fossa throwing • Can be chondromalacia in (+) Test is reproduction of • the medial groove of trochlea pain at posteromedial elbow which preceeds osteophyte formation Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com VEO Pattern Recognition • Subjective • Physical Exam – “locking, catching” and – Flexion contracture medial elbow pain – Painful active extension – Typically present w/crepitis w/throwing and – PROM painful in serving in sports pronation, valgus, extension – TTP posteromedial olecranon Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 4
Property of VOMPTI, LLC Research on Kinetic Chain Factors Research on Kinetic Chain Factors Influencing Elbow Joint Mechanics Influencing Elbow Joint Mechanics Marshall and Elliot, J Sports Sci 2000 • Kinetic Chain Factors • Long-axis Rotation – Coupled motion creating rotation around the – Efficient proximal segment activation minimizes almost-straight long axis of the arm, running from the need for high force generation in the distal the shoulder to the hand segments – Minimizes valgus loads at elbow • Anticipatory Postural Adjustments (APA’s) in the LE and trunk allow proximal stability in order – Without elbow elevation and extension before max for the distal segments to have max mobility shoulder rotation--increased tensile loads at elbow ligaments during arm acceleration. • In tennis players between 63% and 74% of the kinetic energy and force delivered to the hand – “Dropped elbow,” --term for the elbow being was developed by the hip/trunk or shoulder positioned below the level of the shoulder in the segments acceleration phase. Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Research on Kinetic Chain Factors Research on Kinetic Chain Factors Influencing Elbow Joint Mechanics Influencing Elbow Joint Mechanics Long-axis Rotation • Glenohumeral Internal Rotation Deficit (GIRD) – Elbow valgus load is primarily developed by the interactive moment generated by shoulder internal rotation. Coupled shoulder internal rotation and – 20/20 consec professional baseball pitchers forearm pronation, to maximize w/elbow symptoms were found to have GIRD of centripedal arm motion and minimize > 25 deg. valgus strain at the elbow joint. – Correction of the 25 deg deficit correlated Key biomechanical event just before w/relief of symptoms ball release/ball impact Morgan C.D. American Shoulder and Elbow Surgeons Mtg October 2002 Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com For Use of Participants Only. No Use or Reproduction Without Consent 5
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