Val Jones - Elbow Instab€¦ · Prevent elbow flexion contractures (Protzman et al JBJS 1978,...
Transcript of Val Jones - Elbow Instab€¦ · Prevent elbow flexion contractures (Protzman et al JBJS 1978,...
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Elbow stability – is anconeus the driving force?
Val Jones Lead Physiotherapist Sheffield Shoulder & Elbow Unit
The elbow
Incidence
! 6-13 per 100,000
! Males
! Chronic instability in 35-40% cases (Eygendaal et al JBJS 2000, Mehloff et al JBJS 1988)
! Sports related – up to 50 % (Kinter et al JSES 2000)
Presentation
! Acute
! Acute on chronic
! Chronic overload
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Presentation
! PLRI (O’Driscoll et al JBJS 1991)
! Valgus PMRI (Sanchez-Sotelo et al JSES 2005)
! Medial – usually chronic overload
Chronic overload
! Medial – repetitive over head
! Usually only on throwing
! Lateral – crutch walking
! Affects ADL
Incidence of injuries
! Baseball 22–26%
! Rugby 3%
! Gymnastics 3-8%
! Tennis 6%
! Power lifting 6%
! Snowboarding 2%
Pattern of injuries during throwing
VEO
Shear/torsion Posterior
Compression lateral
Tensile stress Medial
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Forces during throwing
! Anterior band MCL – 260N
! Overhead pitch - 300N (MacWilliam et al AJSM 1995)
! Elbow ext velocity 1300 – 2000 deg/sec (Fleisig et al Sport Biomech 2003, Werner et al JOSPT 1993)
General rehabilitation guidelines
! Conservative or post-surgery
! Sequential and progressive
! Aim is to return athlete to functional level safely and quickly
Presentation
! PLRI (O’Driscoll et al JBJS 1991)
! Valgus PMRI (Sanchez-Sotelo et al JSES 2005)
! Medial – usually chronic overload
General rehabilitation guidelines
! Conservative or post-surgery
! Sequential and progressive
! Aim is to return athlete to functional level safely and quickly
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Phase 1: Early motion
! Minimise effects of immobilisation ! Prevent elbow flexion contractures
(Protzman et al JBJS 1978, Melhoff et al JBJS 1988)
! Decrease pain ! Prevent muscle atrophy ! Benefits – articular cartilage and
collagen synthesis (Cyr & Ross JHT 1998)
Elbow range
! Establish pre-injury baseline
! Comparing contralateral unreliable
! Professional asymptomatic throwers – loss of flexion and extension (Wright et al AJSM 2006)
Position for mobilisation
! Early mobilisation in protected range essential
! Patient position for exercises and mobilisation techniques is as important as timing
Overhead position
! Supine overhead ! Shoulder flexed 90 ! Active pronation/
supination ! Active extension ! Progress range as
stability allows
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Benefits of overhead mobilisation
! Gravity reduces distractional force at UH joint in supine overhead (Lee et al JSES 2013)
! Gravity in sitting destabilises at all flexion angles
! Increased in hinged brace
Other benefits of overhead mobilisation
! EMG activity in stiff or painful v normal elbow (Page et al JHS 2003)
! Marked increase in biceps activity during flexion & extension
! Inhibits triceps and limits active range, especially extension
EMG activity in biceps
! Marked EMG increase in supine or sitting
! Massive increase activity with weight on forearm
! DO NOT STRETCH
Phase 1 - muscular rehabilitation
! Isometrics ! Elbow ! Forearm ! Shoulder –
caution with extremes of rotation
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Elbow stability (O’Driscoll et al 2000) Secondary restraints
! Medial group – passive stability in supination
! Lateral group – passive stability in pronation
! Due to increase in passive tension (Seiber et al JSES 2009, Dunning et al JBJS 2001)
Secondary constraints - activity
! FPM – generates varus motion reducing load UCL (Lin et al 2007, Park et al 2004)
! FCU> FDS> PT
! PT – recruited at high speeds, high load, small effect on stability (Basmjian & Travill 1961)
Secondary restraints
! Extensor supinator mass ! Produce valgus strain reducing
lateral ligament load (Lin et al JSESJ 2007)
! Supinator – inefficient force production
! Continuously active pro/supination ! Activated prior to biceps ! ? Stability and control (Basmajian & Griffin 1972)
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Dynamic restraints
! Cross joint ! Produce
compressive forces
! Triceps ! Brachialis ! Anconeus (O’Driscoll et
al 2000)
Anconeus anatomy
! Elbow extensor
! 15% of total isometric extension torque (Zhang & Nuber 2000)
! Deep & superficial fibres (Gibbons 2001)
! Deep – L.E., annular lig, radial collateral lig, olecranon
! Superficial –L.E., lateral olecranon, posterior ulna
Anconeus – anatomical studies
! Deep fibres adhere to lateral elbow joint capsule
! Coapts ulna to humerus, reducing varus instability (Molinier & Lafosse 2011)
! Exact role unknown
! ?Lateral stabiliser of the elbow
EMG studies
! Continually active during pro/sup and elbow extension (Basmajian 1972)
! Activated prior to triceps ! Slow – 60-70% type 1 fibres (Basmajian 1972, Lebozec 1987, Hwang et al 2004)
! Recruitment important for low load and slow movements (Le Bozec et al 1980)
! Further evidence as stabiliser
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Anconeus
! Static
! Locate
! Multiple points through range extension, pro and supination
! Low effort, long hold time, no rigidity
! Clinical evidence as muscular stabiliser
Progression – dynamic range
Phase 1 – kinetic chain (Burkhart, Craig, Kibler Arthroscopy 2003)
Ground, legs, trunk Force generators
Shoulder Funnel Force regulator
Arm Force delivery
It’s my elbow, why are you looking at my legs?
! 50%+ force in tennis serve generated by trunks and legs (McClure et al 2001)
! Decreased knee flexion in serve increases joint reaction force in elbow
! Pitchers with UCL tears –reduction in balance on stance and lead leg (Garrison et al JOSPT 2013)
! Nerve block in triceps reduced pitching speed by only 20% (Roberts 1971)
! Loss of trunk/ limb control lower control – unstable platform – risk of injury further in the chain
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Compare and contrast Assessment and treatment
! Single leg balance – pelvic stability
! Single leg dip – asses pelvic tilt /rotation
! Y balance test ! Gym ball sitting
Stage 2 rehabilitation
! Post-op range equals pre-op
! Minimal pain and tenderness
! Good power on manual muscle testing
Local strengthening
! Forearm flexors/extensors
! Pro/supinators ! GH and scapulothoracic
stabilisers ! Throwers 10 – based
on EMG studies to illicit maximum dynamic stability
! Increased throwing velocity
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Assessment of shoulder flexibility
! GIRD (Dines et al AJSM 2009, Endo et al 2013)
! Internal rotation loss limits follow through, increase pronation
! MCL strain
Advanced Strengthening – stage 3
! Progression to prepare athlete for return to sport
! Increased strength ! Power ! Endurance ! Advanced neuromuscular control
Stage 3
! Higher resistance, increased speed
! Eccentric work – biceps –stabilises follow through.
! Decelerates preventing abuttal of olecranon in fossa
Stage 3
! Professional throwers – increased FP strength 15-35% (Ellenbecker et al 1997)
! Increased biceps and triceps 10-20% (Wilk et al JOSPT 1993)
! Advanced throwers 10 ! Plyometric work – increases throwing
velocity
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Plyometric forearm work Plyometric work
Sport specific kinetic chain work Sport specific kinetic chain
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Stage 4 – interval throwing programme criteria
! Full pain free motion ! Full strength ! No local tenderness ! Good technique with 1 handed
plyometric throwing ! Good kinetic chain control
Interval throwing
! Increase distance ! Avoid overload ! Increase intensity
from 50% to 100% in 4-12 weeks
! Add in different throws – curved ball
Impact work
! Preparatory muscle activation response in falls
! Quickens with practice (Burkhart & Andrews 2013)
! May reduce injury ! Prepares for
contact sport
End stage rehab – the Sheffield way
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Thank you