D espite being anatomi-eally analogous to the knee, the elbow is injured far less often. This is due, in large part, to the lower levels of force found in a non-wcightbearing joint. However, the elbow joint does function in a closed kinetic chain in a few sports (such as gymnastics), where it does have to bear the body's weight. Primary Functions The main function of elbow joints, muscles, and connective tissues is to precisely position the hand, and to impart or resist a force (such as throwing a ball or spear, striking a punching bag, blocking a tackle, lifting a box, or twisting a screwdriver).1 The elbow joint is an integral part of the upper extremity kinetic chain. Problems in the shoulder joint and cervicothoracic region can contribute to elbow joint dysfunction. Thus, when analyzing the source of elbow pain, looking beyond the elbow, itself, is critical: and any elbow rehabilitation program must address deficits in the scapular stabilizer and cervicothoracic extensor muscles, as well as proper head and shoulder posture. Biomechanics The humeroulnar and humeroradial articulations permit flexion and extension. The proximal radioulnar joint allows rotation (pronation and supination). Most normal activities of daily living can be performed even with partial limitation of any (or even all) of these elbow movements. However, compensations will tend to occur in adjacent body segments (such as the shoulder and spine), and performance levels in most sports will quickly decrease.2 While the elbow is an inherently stable joint, connective tissues do provide necessary additional support. These include the medial collateral ligament (the major stabilizer against valgus stress), the annular ligament (encircling the head of the radius), and the intcrosseous membrane (which prevents separation of the radius and ulnar shafts). Any of these connective tissues can be injured, resulting in an elbow sprain. Most of the muscles involved in elbow function and movement originate on the humerus and insert on either the radius (biceps, bracliioradialis, and prona-tor tercs), or the ulna (brachialis, triceps, and anconeus). Two additional muscles (supinator and prona-tor quadratus) form a radioulnar group. And two very important elbow muscles primarily move the hand and wrist—the extensor carpi radialis (wrist extensors) and the flexor carpi radialis (wrist flexors). Manual testing can, often, quickly identify which of these muscles are weakened and painful upon contraction, indicating an elbow strain. If there is non-painful muscle weakness around the elbow and/ or wrist, a neurological condition of the lower cervical nerves (C5-8) must be considered. Causes of Injury The elbow can be injured by direct trauma, or (frequently) from overuse due to repetitive ami and hand movements. While both types of injuries can be quite individual and complex, several common elbow injury patterns are usually identified:' • Lateral epicondylitis (tennis elbow)— overuse tendinosis of the wrist extensors. Little League elbow—repetitive pitch ing microtrauma can cause permanent damage. Medial cpicondylitis (golfer's elbow)— overuse tendinosis of the wrist flexors. Stockard reports overuse injuries "are more common among amateur golfers than among professional golfers.""* Nursemaid's elbow—forced radial head dislocation in a young child (2-to-4 years). Olecranon bursitis—acute or repetitive direct trauma to the bursa over the ole cranon. Osteochondrosis (Panner's disease)— overuse causes avascular damage to capitcllum. Triceps tendinitis—acute or repetitive strain of the triceps insertion on the olecranon. Rehabilitation of Elbow Sprain Injuries Trauma damage to one-or-more of the connective tissues of the elbow can result in decreased joint stability and eventual degenerative changes. Sports and work activities must be restricted to prevent further damage. Once the ligaments have undergone sufficient early repair, controlled passive motion, gentle sustained stretches (see Elbow Flexion Stretch), and friction massage will prevent the formation of adhesions. Resistance exercises are introduced to stimulate a stronger repair and to assist in the remodeling process. Isometric is progressed to isotonic forms of resistance, based on the patient's tolerance for joint motion. Exercises for grip and for proxi- Here are some easy-to-do exercises mal stability at the shoulder should also be included, especially for athletes.5 Rehabilitation of Elbow Strain Injuries Since overuse and repetitive strain are the most common sources of injury to the muscles and tendons around the elbow, a brief period of support and restricted activity is usually necessary. This should include the use of a countcrforce brace for the elbow.'' However, controlled re-strengthening should be initiated early, with the brace on. Elastic tubing is a safe and easy method of providing progressive resistance exercises.7 An effective elbow rehabilitation program starts with a consistent isotonic exercise routine (see Forearm Supination/ Pronation utilizing dumbbell), and clastic tubing to perform resisted pronation and supination. This is, initially, performed within a limited, pain-free range-of-motion, building to full-range, as pain subsides. If the patient has lateral epicondylitis, which is an overuse strain of the wrist extensors, special attention is given to these muscles. Sustained stretches are performed, followed immediately by full-range progressive strengthening of wrist extcn- sion, with special focus on the eccentric phase of the exercise. Eventually, the entire series of elbow exercises should be performed. This inexpensive rehabilitation program should, initially, be practiced under supervision, to ensure proper performance. Once good exercise mechanics and control are demonstrated, a self-directed program of home exercises is appropriate. Outcomes Assessment In order to assess the effectiveness of an elbow treatment plan, both objective and subjective data on patient results on outcomes must be collected and documented. The data, typically, focus upon the physical changes noted at the time of consultation and in subsequent visits. Ongoing outcome assessment data utilizing the Mayo Elbow Performance Index with comparative graphs over-treatment time (available at www.outcomesassessment.org) docu- ments the long-term results and effectiveness of the rehab procedures. Overlooked Factors Two often-overlooked factors arc the connection between elbow function and shoulder stability," and the influence of cervicothoracic posture on elbow function. Specific postural distortions—such as thoracic kyphosis and cervical anterior translation (causing a "forward head")—must be addressed with corrective exercise training. An additional complicating postural factor can be the alignment of the scapula on the thoracic cage— when the shoulder is "rolled forward" (protracted). Correction of these chronic alignment faults will significantly reduce the biomechanical stress during use of the ami and help prevent museulotendinous overload at the elbow.'' Conclusion An appropriate and progressive rehab program should be started early in the treatment of patients with elbow injuries, but only after ligaments and connective tissues have repaired sufficiently. Simple, yet effective, rehab techniques are available, none of which require expensive equipment or great time commitments. A closely monitored home exercise program, using exercise tubing is recommended, since this allows the doctor of chiropractic to provide cost-efficient, yet very effective and specific, rehabilitative care. An important aspect of elbow rehabilitation is to recognize and address the bio-mechanical alignment problems and postural factors that can lead to substitution patterns and elbow overuse. This entails screening the patient for forward head and flexed (kyphotic) torso postures, as well as protracted (forward) shoulders. Failure to recognize these complicating factors can result in a patient with recurring elbow complaints. Kim D. Christensen, DC, CCSP, DACRB, founded the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Consulting, 1X604 NW 64th Avenue, Ridge/ield. WA 98642. References Wcisncr SL. "Rehabilitation of elbow injuries in sports." Pins Meet Rehahil Clin North Am 1994; 1 1:402-409. Nordin M. Frankel VH. Basic Bio- mechanics of the Musculoskeletal System. 2nd eel. Philadelphia: Lea & Febigcr; 1989. 253. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1997. 145. Stockard AR. "Elbow injuries in golf." J Am Osteopath Assoc 2001; 101(9):509-516. Kibler WB. el <;/.. Functional Re habilitation of Sports and Muscu- loskcletal Injuries. Gaithersburg: Aspen Pubs: 1998. 181. Groppel JL, Nirschl RP. "A mechanical and electromyographic analysis of the effects of various joint counterforce braces on the ten nis player." Am .1 Spoils Med 1986; 14:195. Roy S, Irvin R. Sports Medicine: Prevention. Evaluation. Management, ami Rehabilita tion. Englewood Cliffs: Premiee-Hall: 1983. 224. Abbott JH. "Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia." Man Tlwr 2001: 6(3): I 70- 177. Kibler WB. Press JM. ■'Rehabilitation of the elbow." In: Functional Rehabilitation of Sports and Musculoskelctal Injuries. Gaithersburg: Aspen Pubs; 1998. 171.
