Rehabilitation of Elbow Injuries
by Kim D. Christensen, DC, CCSP, DACRB
The elbow is the anatomic area that joins the hand to the shoulder. In spite of being anatomically analogous to the knee, it is injured far less often. This is primarily due to the lower levels of force that are found in a non-weightbearing joint. In some sports, however, the elbow joint does function in a closed kinetic chain, and in a few (such as gymnastics), it does have to bear the weight of the body.
The main functions of the joints, muscles, and connective tissues of the elbow are to precisely position the hand, and to impart or resist a force (such as throwing a baseball or javelin, punching a face, blocking a tackle, lifting a box, or twisting a screwdriver).  The elbow joint does not act in isolation; it 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 of the Elbow
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. 
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 interosseous 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, brachioradialis, and pronator teres), or the ulna (brachialis, triceps, and anconeus). Two additional muscles (supinator and pronator 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) should be assessed.
Causes of Elbow Injury
The elbow can be injured by direct trauma, or (frequently) from overuse due to repetitive arm 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.
• Medial epicondylitis (golfer’s elbow) – overuse tendinosis of the wrist flexors.
• Triceps tendinitis – acute or repetitive strain of the triceps insertion on the olecranon.
• Nursemaid’s elbow – forced radial head dislocation in a young child (2 to 4 years).
• Little League elbow – repetitive pitching microtrauma can cause permanent damage.
• Osteochondrosis (Panner’s disease) – overuse causes avascular damage to capitellum.
• Olecranon bursitis – acute or repetitive direct trauma to the bursa over 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 generally must be restricted or modified to prevent further damage. Once the ligaments have undergone sufficient early repair, controlled passive motion, gentle sustained stretches, 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 proximal stability at the shoulder should also be included, especially for athletes. 
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 may include the use of a counterforce 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. 
An effective elbow rehabilitation program starts with a consistent isotonic exercise routine, using elastic tubing, to perform resisted Pronation (Fig. 1) 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 Extension, 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.
A factor that is often overlooked is the influence of shoulder girdle stability and cervicothoracic posture on elbow function. Specific postural distortions such as thoracic kyphosis and cervical anterior translation (Fig. 2) -- 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 arm and help prevent musculotendinous overload at the elbow. 
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) documents the longterm results and effectiveness of the rehab procedures.
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 requires 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 biomechanical 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.
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