CHAPTER 8: The Elbow and Forearm
CHAPTER 8:
Clinical Chiropractic: The Elbow and Forearm



This is Chapter 8 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Clinical Chiropractic: Upper Body Complaints”


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Clinical Briefing
  Functional Considerations 
  Clinical Analysis

Elbow Nerve Compression Syndrome

Forearm Strains

Lateral Epicondylitis (Tennis Elbow)

Little League Elbow

Medial Epicondylitis (Golfer's Elbow)

Olecranon Bursitis

Traumatic Inflammation of the Elbow

Chapter 8: The Elbow and Forearm

CLINICAL BRIEFING


      Functional Considerations

The arm and forearm are joined by a joint that serves as both a hinge and a pivot. The semilunar notch of the ulna is hinged with the hyperboloid trochlea of the humerus. The proximal head of the radius pivots with the spherical capitulum of the humerus and glides against both the proximal and distal ends of the ulna.

The distal end of the humerus can be viewed as two columns: a larger one medially that articulates with the semilunar notch of the ulna, and a smaller one laterally that articulates with the head of the radius. The pulley-like trochlea apparatus has:
(1) a depression at the front that lodges the coronoid process of the ulna and
(2) a depression at the rear that holds the olecranon process of the ulna when the elbow is extended.

The olecranon process restricts hyperextension of the elbow and protects the ulnohumeral articulation posteriorly. The concave head of the radius glides against the spherical capitulum of the humerus. The capitulum and trochlea are separated by a bony crest that fits into the opening between the proximal ulna and the radius and serves as a fixed rudder to guide elbow motion. The elbow flexors originate from the medial epicondyle, and the extensors originate from the lateral epicondyle. This structural arrangement should be visualized during examination to discriminate normal from abnormal articular motion.

The basic range of elbow joint motion involves elbow flexion (135°) and extension (0°), and forearm supination (90°) and pronation (90°). If a motion block is found in active motion, passive motion should be checked and the type of restriction and its degree noted.


      Clinical Analysis

The elbow joint was not made to be used as an organic battering ram, but it often is: purposefully in sports; by accident in falls. For this reason, the vast majority of elbow disorders has trauma as their origin or precipitating factor.

The common causes of arm, elbow, and forearm pain are shown in Table 8.1. Note that many neurologic etiologies manifest referred symptoms such as in a cervical IVD syndrome or subluxation complex, scalenus anticus syndrome, thalamic syndrome, or trigger-point phenomena.

Inflammatory disorders of the elbow and forearm are frequently seen. The cause will usually be attributed to trauma. Olecranon bursitis, tennis elbow, tenosynovitis, Kienboeck's disease, and brachialis calcification may or may not be the result of extrinsic injury. Less frequently seen are nerve compression syndromes. These may occur at either the elbow (musculospiral, radial, ulnar) or the wrist (median, ulnar). Deformities of the elbow and forearm are rarely seen. When present, the cause is usually an effect of severe trauma -or rarely the result of acromegaly or rickets.

Motion restriction during pronation can suggest a lesion in the elbow, the radioulnar articulation at the wrist, or (rarely) the forearm proper. Restriction during supination may be related to either a disorder at the elbow or in the distal radioulnar articulation. Scars and thickened tissues may cause compression symptoms. Nerve injury is generally secondary to severe trauma or epicondyle fracture.


     Table 8.1. Common Causes of Arm, Elbow, and Forearm Pain
                                                                         Endocrine
Traumatic        Inflammatory      Neurologic           Vascular         Metabolic   
Dislocation      Bursitis          Carpal tunnel syn-   Angina pecto-    Diabetic
Fracture         Cellulitis         drome                ris              neuropathy
Muscle or nerve  Herpes zoster     Cubital tunnel       Arterial embo-   Gout
 contusion       Local infection    syndrome             lism            Pseudogout
Spinal cord in-  Lymphadenitis     IVD syndrome         Dissecting
 jury            Osteomyelitis     Peripheral neuri-     aneurysm
Sprain           Rheumatoid arth-   tis                 Myocardial in-
Strain            ritis            Scalenus anticus      farction
Tendon rupture   Septic arthritis   syndrome            Thrombophlebi-
                 Tendinitis        Subluxation syn-      tis
                 Tennis elbow       drome
                 Tuberculosis      Thalamic syndrome
                                   Trigger point

                 Degenerative                       Allergic
Neoplastic       Deficiency        Congenital       Autoimmune         Toxic       

Lymphoma         Osteoarthritis    Cervical rib     Dermatomyositis    Toxicosis
Metastasis       Spondylosis                        Multiple sclerosis
Myoma
Pancoast's tumor



     Elbow Nerve Compression Syndrome

Radial or ulnar nerve entrapment may occur in the elbow area, and acute musculospiral contusion is frequently experienced. The latter is common. Radial compression has only a slightly higher incidence than ulnar compression.

The radial nerve courses fairly superficial in the musculospiral groove along the lateral aspect of the distal one-third of the humerus. Because of this, it is subject to contusion. Repeated injury may lead to entrapment by scar tissue or adhesions. Injury to the ulnar nerve in this area usually occurs at the superficial inner side of the elbow, where it is vulnerable in its course along the elbow's posteromedial aspect.

      Background

Musculospiral contusion produces sudden radiating pain throughout the distal radius and extensor paralysis (dead arm). These symptoms ease within a few minutes, and the effect is rarely permanent. In the more serious compression syndrome of the radial nerve, chronic radiating pain and paresthesia arise than can easily be confused with De Quervain's disease, especially if the superficial branch is involved. If the deep branch of the radius is compressed, the pain is localized at or below the lateral epicondyle (mimicking tennis elbow). A tender nerve will be found near the origin of the extensors, and the pain is aggravated by active finger extension. If the elbow is extended and the 3rd finger is actively extended against resistance, the pain is acutely increased because the extensor carpi radialis inserts at the base of the 3rd metacarpal. The wrist drop test will be positive.

Traumatic ulnar compression (cubital tunnel syndrome) features a characteristic "claw hand" with sensory loss along the medial side of the hand and little finger. Early signs are an inability to separate the fingers and numbness of the 4th and 5th fingers. In most cases, the medial ligament must rupture during elbow dislocation or a medial epicondyle fracture must occur to allow the ulnar nerve to become compressed.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential    Peripheral vascular        Spinal roentgenography
    Elbow x-ray              studies                   Thermography
    EMG                     Sedimentation rate         Wrist x-ray
    Nerve conduction        Shoulder x-ray             VD serology

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–11, LI–15, LU–5, PC–3, TH–10 (Table 16.21).

  • Treat auriculopoints 22, 37, 55, 66 (Figs 16.3 4).

  • Treat hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the anconeus, triceps, brachialis, brachioradialis, and extensor and pronator muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.1.

      Nutritional Therapy

Supplemental nutrients B1, B6, C, niacin, P, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Helpful modalities include contrast baths, interferential therapy (Tables 16.39 41), iontophoresis with magnesium (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, or high-voltage therapy (Table 16.38). When the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Note: Do not use ice massage on the elbow.



     Forearm Strains

As in traumatic inflammation of the elbow, the most common forearm strain is the result of forced supination or pronation against resistance. Direct blows and falls are also common causes. Ulnar neurapraxia may be a complication. Trigger points are commonly found just below the antecubital crease, over the heads of the proximal radius and ulnar.

      Background

With many forearm strains, an associated injury to the brachialis anticus muscle with contracture is seen. Avulsion-type injuries will reveal sharp point tenderness at the site of tendon or ligament attachment. In children, a strip of periosteum may be torn from the anterior humerus. This will be followed by a callus and restricted joint motion. Local myositis ossificans may also develop in the tendon of the brachialis anticus.

Specific points of tenderness may reveal pertinent diagnostic evidence. For example, tenderness over the medial collateral ligament as it arises from the medial epicondyle is a sign of valgus sprain. Muscle tenderness in the wrist flexor-extensor group is characteristic of flexor-pronator strain.

The extensor muscles of the forearm often exhibit tenosynovitis, which may be of traumatic or infectious origin. Features include pain along the dorsal forearm, crepitus along the extensor tendons, swelling (palpable and visible), and possibly hypertrophy of the extensors and abductors of the thumb. Signs of warmth and redness progressing upward suggest a spreading inflammatory process for which referral for antibiotics is usually indicated.

In wrist severe sprains, radiographs should be taken of the wrist, elbow, shoulder, and possibly the upper thorax. In a fall on the outstretched hand, for example, all joints in the kinematic chain become involved. Injury to the proximal radioulnar articular by sudden wrist overpronation or excessive supination commonly occurs.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential   Sedimentation rate        Thermography
    Elbow x-ray            Shoulder x-ray            Urinalysis
    EMG                    Spinal roentgenography    Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Articular Adjustment

Contributing spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–11, LI–15, LU–5, LU–7, GB–21 (Table 16.21).

  • Treat auriculopoints 37, 55, 66, 95 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the anconeus, biceps, triceps, brachialis, brachioradialis, and extensor and pronator muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.2.

      Nutritional Therapy

Supplemental nutrients B1, C, RNA, calcium, and magnesium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and massage with eucalyptus oil in the early stage, followed by spray and stretch, and tendon friction massage of involved muscles. Helpful modalities during rehabilitation are moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37) for heat and massage at the cellular level, hot needle-spray showers, interferential therapy (Tables 16.39 41), iontophoresis or phonophoresis with proteolytic enzymes (Table 16.43), local vibration-percussion (Tables 16.19 20), alternating current (Table 16.27), or high-voltage therapy (Table 16.38).

An arm sling may be necessary in the early stage to rest the muscles and enhance healing. After the acute stage, demonstrate progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures.



     Lateral Epicondylitis (Tennis Elbow)

The term tennis elbow refers to a combination of traumatic effects of which epicondylitis or radiohumeral bursitis is the major component. The syndrome is not restricted to tennis but is a common injury in that sport. The precipitating cause is attributed to repeated violent elbow extension combined with sharp twisting supination of the forearm against resistance (as in making a tennis backhand shot). The resulting inflammatory process is the effect of severe irritating contraction of the extensor-supinator muscles of the forearm.

      Background

In this injury, pain slowly arises during strenuous activity about the lateral epicondyle of the humerus as the result of from microscopic to macroscopic tears and avulsions at the origin of the common extensor tendon of the forearm. The area is warm, tender, and some degree of swelling will be found. Pain is prominent over the involved condyle but may radiate. This is especially true during active forearm supination against resistance. The pain is dull and diffuse at rest, becoming sharp and lancinating when exertion affects the involved tendons and ligaments. Grip strength is weak, and Cozen's and Mill's tests will be positive.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood electrolytes      EMG                   Spinal roentgenography
    CBC and differential    R-A test              Thermography
    Chest x-ray             Sedimentation rate    Urinalysis
    Elbow x-ray             Shoulder x-ray        Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Contributing spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–10, LI–11, LU–5, LU–7 (Table 16.21).

  • Treat auriculopoints 37, 55, 66 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the triceps, supraspinatus, anconeus, brachioradialis, extensors, and supinator muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.3.

      Nutritional Therapy

Supplemental nutrients C, B6, niacin, P, copper, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and spray-and-stretch therapy during the acute stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37), interferential therapy (Tables 16.39 41), iontophoresis with salicylate (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, high-voltage therapy (Table 16.38), or tendon friction massage of involved muscles. A firm but not tight strap applied around the circumference of the forearm just below the antecubital crease will afford protection to the injured tissues and relief during healing. An elastic bandage offers little therapeutic value. When swelling and tenderness have disappeared, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Little League Elbow

This syndrome, so named because of its high incidence in preadolescent pitchers, consists of either a stress fracture through the olecranon growth plate and/or an avulsion of the ossification center of the medial condyle. During pitching motions, especially with poor form, pain, tenderness, and possibly swelling appears in the area of the medial condyle.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood electrolytes     EMG                       Thermography
    CBC and differential   Sedimentation rate        Tuberculin test
    Chest x-ray            Shoulder x-ray            Urinalysis
    Elbow x-ray            Spinal roentgenography    Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Contributing spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high- velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–11, LI–15, LU–5, LU–7, GB–21 (Table 16.21).

  • Treat auriculopoints 37, 55, 66 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the triceps, pronators, and pectoral muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.4.

      Nutritional Therapy

Supplemental nutrients C, B6, niacin, P, copper, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Casting is usually necessary. Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and spray-and-stretch therapy during the acute stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37), interferential therapy (Tables 16.39 41), iontophoresis with salicylate (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, high-voltage therapy (Table 16.38), or tendon friction massage of involved muscles. When swelling and tenderness have disappeared, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Medial Epicondylitis (Golfer's Elbow)

This disorder presents a clinical picture that is opposite that of tennis elbow which affects the opposite epicondyle. Here, excessive forces have been applied to the medial condyle and the flexor-pronator muscles of the forearm. The syndrome is not restricted to golf but is a common injury in that sport. The precipitating cause is attributed to violent elbow extension combined with sharp twisting pronation of the wrist against resistance (as in hitting the ground strongly during a golf swing or repetitiously throwing a wide curve in bowling).

      Background

The patient usually exhibits synovitis, fibrositis, a variable degree of tearing of the fibrous origin of the muscles and ligaments at the medial epicondyle, and possible subperiosteal hematoma. Entrapment of the radial nerve may be involved. The medial aspect of the elbow is warm, tender, and some degree of swelling will be found. Pain is prominent over the involved condyle but may radiate, but the swollen bursa is rarely tender unless greatly distended. Pain occurs especially during active forearm pronation against resistance. The pain is dull and diffuse at rest, becoming sharp and lancinating when exertion affects the involved tendons and ligaments. Grip strength is weak.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood electrolytes      EMG                   Spinal roentgenography
    CBC and differential    R-A test              Thermography
    Chest x-ray             Sedimentation rate    Urinalysis
    Elbow x-ray             Shoulder x-ray        Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Contributing spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high- velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–11, LI–15, LU–5, LU–7, GB–21 (Table 16.21).

  • Treat auriculopoints 37, 55, 66 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the triceps, pronators, and pectoral muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.5.

      Nutritional Therapy

Supplemental nutrients C, B6, niacin, P, copper, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include contrast baths and spray-and-stretch therapy during the acute stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37), interferential therapy (Tables 16.39 41), iontophoresis with salicylate (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, high-voltage therapy (Table 16.38), or tendon friction massage of involved muscles. A firm but not tight strap applied around the circumference of the forearm just below the antecubital crease will afford protection to the injured tissues and relief during healing. An elastic bandage offers little therapeutic value. When swelling and tenderness have disappeared, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Note: Do not apply ice massage to the elbow.



     Olecranon Bursitis

Smooth mobility of the elbow is provided by the olecranon bursa. Besides a direct blow, this fluid-filled pouch is exposed to injury when the elbow is repeatedly pressed against a firm surface. Excessive intrinsic forces also may cause inflammation, synovial thickening, and the formation of excessive fluid. Repetitive friction of extensor tendons may initiate the inflammatory process. It is for this reason that olecranon bursitis is often a part of the clinical picture of epicondylitis (medial or lateral), forearm strains, and traumatic inflammation of the elbow. Thus, the disorder may be primary or secondary.

      Background

Posterior elbow swelling, pain, and tenderness are exhibited. Active flexion and extension are restricted. Most cases of olecranon bursitis will heal spontaneously in a few days once the irritating factor is removed, but proper clinical management will speed the process and prevent secondary infection from converting the inflammation into an abscess.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential   Sedimentation rate        Thermography
    Elbow x-ray            Shoulder x-ray            Urinalysis
    EMG                    Spinal roentgenography    Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Contributing spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI–11, LI–15, LU–5, LU–7, GB–21 (Table 16.21).

  • Treat auriculopoints 37, 55, 66 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the triceps, extensors, and serratus posterior muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.6.

      Nutritional Therapy

Supplemental nutrients B1, B6, C, niacin, P, manganese, and zinc are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include contrast baths during the acute stage, followed by interferential therapy (Tables 16.39 41), iontophoresis with proteolytic enzymes or hyaluronidase (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, or high-voltage therapy (Table 16.38). An elastic pressure bandage around the elbow will help control the swelling. When swelling and tenderness have disappeared, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Note: Do not apply ice massage to the elbow.



     Traumatic Inflammation of the Elbow

Injury to the proximal radioulnar articulation occurs by sudden overpronation or excessive supination. The injury is followed by joint pain and restricted rotation. The clinical picture somewhat resembles a combination of tennis elbow and forearm strain, but take care not to overlook the possibility of a spontaneously reduced dislocation of the head of the radius.

      Background

Forced movement beyond the normal range of joint motion in any position may produce a rupture in the capsule and its supporting ligaments. If this occurs, the capsule will be tender and likely distended with blood. Movement in the direction of injury will aggravate the pain, and motion will be voluntarily restricted.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential   Sedimentation rate        Thermography
    Elbow x-ray            Shoulder x-ray            Urinalysis
    EMG                    Spinal roentgenography    Wrist x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Articular Adjustment

Associated spinal majors will likely be found at C6-C7. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints PC–3, LI–11, LI–15, LU–5, LU–7, HT–3 (Table 16.21).

  • Treat auriculopoints 34, 55, 13 (Figs 16.3 4).

  • Treat contralateral hand points LI–4, LI–5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the anconeus, triceps, brachialis, brachioradialis, and extensor and pronator muscles (Tables 16.28–31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 8.7.

      Nutritional Therapy

Supplemental nutrients B1, B6, C, niacin, P, copper, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include rest, temporary support, contrast baths, comfrey ointment, and spray-and-stretch therapy during the acute stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), ultrasound (Table 16.37), interferential therapy (Tables 16.39 41), iontophoresis with hydrocortisone (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, high-voltage therapy (Table 16.38), or tendon friction massage of involved muscles. When pain and tenderness have subsided, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

Note: Do not apply ice massage to the elbow.

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