The elbow complex consists of three joints, forming a bridge between the shoulder and the hand, and it's an exciting and challenging region to treat.
Anatomy Doesn’t Lie
If you have a patient presenting with posteriorlateral elbow pain, a diagnosis of lateral epicondylitis, and a history of trauma you may want to consider the lateral ulnar collateral ligament (LUCL) as a potential culprit. It has an interesting anatomy (I think) and here are some facts about it …
- The LUCL is deep to and distal to the origin of the common extensor tendon.
- The posterior part of the radial/lateral collateral ligament goes beyond the annular ligament to attach to the supinator crest on the ulna.
- This ligament is blended with supinator and extensor carpi radials brevis (and is therefore a potential source of nociception from the region of the lateral elbow epicondyle).
- Degeneration and rupture of this ligament can contribute posterolateral (radio-capitellar) elbow instability. (O’Driscoll 2000) will present further details if you would like an in depth article. http://radsource.us/lateral-ulnar-collateral-ligament/
The Body Heals in a Predictable Manner
Every synovial joint needs to go through their FULL ROM multiple times a day to stay healthy. And, outside of systemic causes or genetic predisposition, a joint can become osteoarthritic in only a couple other ways. 1) Through trauma 2) Through denial of the articular cartilage, the natural imbibition it requires to exchange nutrients and metabolic waste. Explaining to your patients that one easy way to heal an area is to move it habitually is of utmost importance.
We see osteoarthritis in multiple joints. It is a natural course of aging, but the prevalence of hip, knee and shoulder replacements potentially indicate that these joints are denied natural imbibition and undergo more routine trauma. But we do not see many total elbow replacements. Unlike the aforementioned joints, the elbow is one of the few that does not routinely become osteoarthritic, most likely because it goes through its complete ROM multiple times a day.
Pain is in the Brain
To continue on the above thought, when talking to patients, I use the illustration to the right, focused on the elbow, and relate it to other joints. I let them know that some of the pain they have is because they are not moving enough. I am not sure who to attribute the quote “Motion is Lotion” to, but it's a useful quote when educating patients.
This is not to negate the fact that there can be centrally mediated elbow pain. Lateral epicondylitis is an example of a condition which is often centrally mediated, with the cause typically not intrinsic to the elbow. But sometimes simple is better, explaining to a patient that they need to move more.
We are Prone to Clinical Reasoning Errors During a Busy Clinic Day
Occam’s (or Ockham’s) razor is a philosophical principle which states if there are two explanations for an occurrence, the simpler one is usually the correct answer. I find that in the clinic, with a busy patient day and/or following a routine can prevent therapist’s from looking outside the simplest solution. A vigilance which is required, circling back to all solutions is necessary daily, especially if the results are not favorable.
In the case of the elbow, the tendency will be to treat a loss of elbow flexion by mobilizing the ulnar humeral joint. But that is only one possible contributor to elbow flexion. Success can be found in assessing and treating the radiohumeral joint in combination with the ulnar humeral joint.
In the below video, I describe this mobilization (Radio Ulnar Mobilization for Flexion).
Treat the Person and you Win Every Time
Apparently I'm full of quotes this week :) ...for good reason! "If you want others to be happy, practice compassion. If you want to be happy, practice compassion." -Dalai Lama
I will refer you to the O’Driscoll article cited above--it is worth taking the time to read this piece on the Lateral Ulnar Collatoral Ligament.
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