Elbow anatomy explained
The elbow is a joint comprised of 3 bones – the upper arm (humerus) and two bones in your forearm (radius and ulna). Tendons from muscles in the upper arm (biceps and triceps) cross the elbow joint and result in elbow flexion (bending) and extension (straightening).
Muscles in the forearm that control hand and wrist movements also cross the elbow joint and provide stability. Nerves from the cervical spine traveling to the forearm, wrist, and hand also cross the elbow and can become compressed or entrapped, causing pain, numbness/tingling, or weakness in the hand.
Common elbow injuries
The elbow’s most common injuries are soft tissue in nature. Most injuries are related to the muscles, tendons, ligaments, and nerves that cross the elbow joint and provide stability to the elbow, and control wrist/hand motion.
Distal Biceps Strain/Tear
The bicep muscle is the powerful muscle on the front of your upper arm. Its primary function is to bend the elbow, although it also has a role in forearm supination (hand up) and shoulder movement.
A strain/tear of the distal biceps tendon can occur with forceful elbow extension against a load. Most distal biceps injuries are sudden injuries resulting in tearing of the tendon of varying degrees.
A partial tear of the distal biceps tendon may be treated conservatively with physical therapy.
Your physical therapist will strengthen other muscles to compensate for a loss of strength associated with tendon integrity disruption. They will also use soft tissue mobilization techniques to ensure proper tissue healing (instrument-assisted soft tissue mobilization).
A complete tear of the distal biceps tendon requires surgery.
A distal biceps surgical repair can repair a complete rupture of the distal biceps tendon. Various techniques for repair exist and should be discussed with your surgeon. The sooner surgery can occur following the injury, the better.
Following surgery, you will be immobilized for a period of time before physical therapy will begin. It’s a slow process because of the soft tissue injury and repair. Therefore initial treatment will focus on the protection of the repair and regaining ROM.
As your recovery progresses, active motion and strengthening will be incorporated into your treatment plan. Eventually, functional activities will resume, and therapy will focus on your goals and the return to activity.
Triceps Strain/Tear
The triceps is the powerful muscular complex on the back of your upper arm. Its primary function is to extend (straighten) the elbow. With various attachments on the humerus, the triceps’ three heads come together to form the triceps tendon, which attaches to the olecranon (the pointy part of your elbow).
A minor strain of the triceps tendon will generally resolve with rest. Should therapy be needed, treatment will include soft tissue mobilization, strengthening exercises, and activity modification.
The triceps’ strain or tear is rare, although injury can be related to overuse or a sudden change in activity such as a new weight lifting program. Additionally, triceps tears can occur in sporting environments such as football when the elbow is forcefully bent against resistance.
Distal Triceps Repair
A surgical procedure to repair/reattach the triceps tendon to the olecranon using anchors. Post-operative rehabilitation is a slow process and will typically follow a period of immobilization.
Initial therapy will focus on protection and the restoration of motion. As the tissue heals, gentle strengthening and resistive exercises will begin. During the final phases of recovery, more aggressive treatment and return to activity progression will occur.
Lateral Epicondylitis
Also known as “tennis elbow,” this condition is caused by inflammation of the wrist and finger tendons (tendonitis) attached to the outside of the elbow. Caused by overuse or repetitive stress, symptoms of this condition include pain with gripping, especially with the elbow in an extended position.
If chronic, the condition can lead to degradation of the tissue or tendinosis.
Symptoms include pain or burning on the outer part of the elbow at rest or during activity. Activity may worsen the symptoms. Patients may also notice a weakening of grip and the inability to perform routine daily activities like holding a jug of milk.
Treatment is mostly conservative, including physical therapy interventions. Treatment will include rest, splinting, activity modification, and evaluation of activities resulting in symptoms.
Instrument-assisted soft tissue mobilization and other hands-on techniques like trigger point dry needling can also be effective. Specific strengthening and exercises focused on the entire upper extremity kinetic chain should also be incorporated into the treatment program.
Medial Epicondylitis
Medial epicondylitis, also known as golfer’s elbow, causes inflammation of the forearm and fingers’ tendons at the inside of the elbow. Causes are related to gripping and forceful wrist flexion or forearm rotation overuse.
Golfer’s elbow symptoms include pain and tenderness at the medial elbow where the forearm and finger flexors attach. Care should be taken to evaluate other medial elbow structures to look for ligament injury and nerve compression.
Treatment options for golfer’s elbow include:
- Rest
- Activity modification
- Stretching/strengthening exercises
- Soft tissue mobilization techniques
- Pain reducing modalities *Example: ice massage
Ligament sprain/tear
On the elbow’s inner and outer sides, thicker ligaments (collateral ligaments) hold the elbow joint together and prevent dislocation. The ligament on the inside of the elbow is the ulnar collateral ligament (UCL). It runs from the humerus’s inner side to the ulna’s inner side and must withstand extreme stresses as it stabilizes the elbow during overhand throwing.
The most commonly affected ligament in the elbow is the UCL. Injuries of the UCL can range from minor sprains and inflammation to a complete tear of the ligament. Athletes will have pain on the inside of the elbow and frequently notice decreased throwing velocity. This injury is most commonly seen in overhand throwers, such as baseball/softball players and pitchers.
Conservative treatment includes rest and physical therapy. Therapy will consist of specific exercises to address strength, flexibility, and upper extremity biomechanics. Additionally, a physical therapy program will include a gradual return to throwing and a biomechanical evaluation of throwing mechanics.
Thrower’s elbow
Overhand throwing places high stress on the elbow. In baseball pitchers and other throwing athletes, these high stresses are repeated often and can lead to serious overuse injury.
Unlike an acute injury resulting from a fall or collision with another player, an overuse injury occurs gradually over time. In many cases, overuse injuries develop when an athletic movement is repeated, often during single periods of play. When these periods are so frequent, the body does not have enough time to rest and heal.
Although throwing injuries in the elbow most commonly occur in pitchers, they can be seen in any athlete who participates in repetitive overhand throwing. Throwing injuries can affect multiple structures in the elbow; therefore, careful examination is essential. Muscles, ligaments, and nerves can all be affected in the thrower’s elbow.
As such, it’s vital to assess all potential sources of injury.
- Flexor Tendonitis: Overuse and repetitive throwing can cause inflammation of the flexor/pronator tendons as they attach to the humerus. Athletes will have pain on the inside of their elbow/arm during activity and, in severe cases, at rest.
- Ulnar Collateral Ligament Sprain/Tear: This is the most commonly injured ligament in the elbow. Injuries can range from minor sprains to a complete rupture of the UCL. Athletes will notice and complain of medial elbow pain and decreased throwing velocity.
- Ulnar Neuritis: The ulnar nerve is stretched as the elbow is bent. Located on the inside of the elbow, the ulnar nerve is also referred to as the “funny bone.” The ulnar nerve can become irritated and painful in a thrower with repeated elbow flexion and forceful extension. Usually, athletes will complain of “shocks” occurring in their forearm or numbness and tingling in their pinky or 4th finger while throwing or at rest.
- Ulnar Extension Overload: The throwing motion is hard on the elbow, and the forces result in a torsion/torque on the medial elbow. This additional torque can result in wearing the articular cartilage and compensatory build-up of bone spurs (osteophytes) between the humerus and ulna to respond to the area’s added stresses. Athletes with UEO complain of medial elbow pain, swelling, and tenderness in the affected area.
- Stress Fracture: A stress fracture can occur when forces naturally absorbed by muscular contraction are transferred to the bone instead. Often this is a result of fatigue, muscle imbalance, or improper training/deconditioning. In throwers, the most common area for a stress fracture is the olecranon. Athletes will complain of diffuse, aching pain during activity and at rest.
Physical therapy and activity modification will play a large part in recovering from these injuries as part of conservative care. Therapy will focus on symptom management, strengthening the upper extremity kinetic chain (including the shoulder and scapular muscles), throwing mechanics, and a gradual return to throwing.
If conservative treatment fails, there are surgical options.
Arthroscopy
Bone spurs on the olecranon and any loose bone fragments or cartilage within the elbow joint can be removed arthroscopically. Because the arthroscope and surgical instruments are thin, the surgeon can use tiny incisions (cuts) rather than the larger incision needed for standard, open surgery.
UCL reconstruction (Tommy John)
Athletes who have an unstable or torn UCL and do not respond to nonsurgical treatment are candidates for surgical ligament reconstruction.
Most ligament tears cannot be sutured (stitched) back together. To surgically repair the UCL and restore elbow strength and stability, the ligament must be reconstructed. During the procedure, the doctor replaces the torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on. In most UCL injury cases, the ligament can be reconstructed using one of the patient’s tendons.
Ulnar nerve anterior transposition
In severe ulnar neuritis cases, the nerve can be moved to the front of the elbow to prevent stretching or snapping. This is called an anterior transposition of the ulnar nerve because it is moved (transposed) to a new elbow area (anterior). Following any of these procedures, patients will enter physical therapy. Depending on the procedure performed, rehabilitation guidelines will vary.
Nerve Compression
Two types of nerve compression in the elbow include:
- Cubital Tunnel: Compression of the ulnar nerve at the inside part of the elbow. This nerve is very superficial (also known as the “funny bone”) and can be compressed when the elbow is held in a bent position for too long. Symptoms include pain, tingling, numbness in the ring and little finger, and decreased grip strength.
- Radial Tunnel: Compression of the radial nerve at the elbow resulting in a set of symptoms that include fatigue or dull, aching pain at the top of the forearm with use. Although less common, symptoms can also occur at the back of the hand or wrist.
Fractures
Three types of fractures that commonly occur in the elbow include:
1. Radial Head Fractures: The radial head is the proximal (closest to the elbow) end of the radius. Radial head fractures often occur due to a fall on an outstretched arm or a direct blow.
Radial head fractures are common and are graded I – III based on radiographic findings. More severe fractures involve displacement of the fracture and often require surgical fixation or replacement.
Following immobilization, physical therapy will be initiated, focusing on restoring range of motion (ROM) and strength when appropriate. In some cases, a certified hand therapist may make a splint to aid in protection.
2. Olecranon Fractures: The olecranon is the pointy end of your elbow. It’s the ulna’s end that “cups” the distal humerus, creating a hinge joint. Because it’s not protected by soft tissue, the olecranon can be fractured due to a fall or direct blow.
Extremely painful, an olecranon fracture will need emergency treatment. Some fractures can be treated with casting and splinting and careful monitoring by the physician. In other cases, surgery is required using a plate and screws or wires/pins to piece the olecranon back together.
Surgery is followed by a period of immobilization in a cast or splint. However, early passive range of motion is helpful following surgery to prevent elbow stiffness, which is the most common complication following surgery. Lifting or forceful contraction of the triceps is avoided initially to allow the fracture to heal.
As therapy progresses, ROM activities will continue, as will a gradual return to functional activities. Often there is a loss of elbow extension following an olecranon fracture; therefore, physical therapists will work aggressively with the patient on maximizing ROM.
3. Distal Humerus Fractures: The humerus (upper arm) can be fractured close to the elbow joint due to either a direct blow or a fall on an outstretched arm. Distal humerus fractures are uncommon. However, when they occur, they require evaluation by a physician.
Depending on the severity of the fracture and the bone pieces’ displacement, treatment may proceed conservatively with the patient being placed in a splint or cast and monitored closely.
In contrast, the fracture is allowed to heal. In other cases, distal humerus fractures require surgery with the placement of plates/screws or pins/wires to reconstruct the humerus.
Physical therapy will be a part of your post-operative recovery, with exercises and hands-on therapy focused on motion restoration. Your therapist will be keenly aware of restrictions inactivity to protect the repair while maximizing movement and improving function.
Typically, it takes 4-6 months to begin returning to normal activities, but it can take even longer to regain full strength and mobility.
Osteoarthritis (OA)
Osteoarthritis is a degenerative process, also known as “wear and tear” arthritis, that can lead to a breakdown in the articular cartilage within the elbow joint. Arthritis in the elbow is uncommon and is usually associated with a previous fracture or trauma to the joint.
However, those with occupations that place repetitive stress on the elbow’s stabilizing ligaments can have a higher incidence of articular cartilage breakdown due to the additional stress placed upon the elbow, causing chronic instability.
Conservative treatment for osteoarthritis can include physical therapy focusing on maximizing ROM and strength through exercise and manual therapy while educating patients on joint protection techniques.
Suffering from chronic elbow pain?
An Alves & Martinez physical therapist can complete a comprehensive evaluation to determine the causes of your elbow pain and design a recovery plan that works for you.