Elbow and Forearm Overuse Injuries Treatment & Management
- Author: Vincent N Disabella, DO, FAOASM; Chief Editor: Sherwin SW Ho, MD more...
In general, overuse injuries are treated using protection, rest, ice, compression, elevation, medications, and modalities (PRICEMM).[12, 14] PRICEMM is an accepted treatment regimen for overuse syndromes of the elbow and forearm, whether these conditions are nerve entrapments, tendinoses, or instability syndromes.
Protection means the athlete needs to modify his or her activity and equipment to allow proper healing and to prevent further injury. Rest does not mean cessation of activity, which can lead to deconditioning, but rather modified activity, or relative rest, which does not aggravate the injury. Ice is used to alleviate patient's pain and help control swelling. Compression is used to prevent swelling, but this should be used with caution when dealing with nerve entrapment syndromes. Elevation is used to prevent venous stasis around the injury, which can lead to increased inflammation and pain. Medications that can be used include nonsteroidal anti-inflammatory drugs (NSAIDs) and, very rarely, corticosteroids. Modalities can include ultrasound, electrical stimulation, and friction massage. Myofascial release techniques are often very helpful in reducing the soft-tissue restrictions of motion.
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Occupational therapy is appropriate when the injury is aggravated by the patient’s vocational activity. Many times, ergonomic evaluation of the workplace is needed to help treat overuse syndromes.
Cryotherapy can cause symptoms of ulnar neuropathy when this therapy is used on the medial elbow due to the close proximity of the ulnar nerve to the surface at the cubital tunnel. As previously mentioned, caution should be used when applying compression over areas of nerve entrapment (see Physical therapy in the Treatment, Acute Phase, Rehabilitation section).
In cases of olecranon impingement syndrome, surgery is often needed early in the treatment course to remove loose bodies from the joint. Surgery is also indicated early in cases of posterolateral rotatory instability. Many times, the collateral ligaments must be repaired before rehabilitation can begin. Arthroscopy or open arthrotomy is often needed to remove loose bodies and scar tissue in radiocapitellar chondromalacia cases.
Consultation with an orthopedic surgeon, preferably an upper-extremity specialist, is indicated for the above procedures.
The recovery phase begins once the patient's pain is resolved or is improved enough so that strengthening exercises can begin. Flexibility and strengthening programs are the main goals of therapy. Various modalities are used to prevent inflammation and speed the recovery from each session of therapy.
Take care not to proceed though this phase too quickly, as the overuse syndrome can return. The athlete may begin with simple ball squeezing and newspaper crumbling with the affected hand. This can cause gentle strengthening of the forearm muscles. The athlete then progresses to gentle wrist flexion and extension exercises. Instruct patients to start out doing the wrist flexion and extension exercises with a can of soup, which is about 7.5 ounces. Once these exercises can be accomplished with a very light weight (ie, 2-4 lb), the patient may progress to elbow flexion and extension exercises, along with wrist pronation and supination activities.
Recommend that patients also perform these exercises at home, possibly with a common household hammer. A hammer provides the athlete with a handle to grip, and the tool usually weighs between 18-26 ounces. Patients can also increase or decrease the resistance on pronation-supination activities by sliding their grip up or down the shaft of the handle.
One study found that athletes who reside in warm-weather climates are more susceptible to throwing-related injuries than athletes who reside in cold-weather climates due in part to the time spent participating in throwing activities.
Strengthening and flexibility of the elbow are being recovered during this time. The goal here should be progression to full activity. Proper biomechanics in the workplace or home are stressed to the athlete to help prevent reaggravation of the original injury.
During the rehabilitative phase, the athlete must take caution to not progress too rapidly. Too rapid progression can cause either the original symptoms to return or result in other overuse syndromes in the upper extremity.
Determine if conservative care is appropriate for the nerve entrapments once the initial pain is controlled. Frequently, surgical decompression of the entrapment is necessary, the discussion of which is beyond the scope of this article. In cases of tendinosis, consider surgical debridement of the degenerative tissue near the tendon to promote healing if the patient's injury fails to progress through this phase.
Neurology consultation can be warranted to rule out cervical or brachial plexus pathology in nerve entrapment syndromes that are not improving. Electromyography (EMG) and nerve conduction velocity (NCV) studies may be appropriate at this time to help isolate nerve entrapment sites when surgical intervention is being considered.
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The maintenance phase of therapy is often fulfilled with a home therapy program. In the ideal setting, the athlete can perform a preventative program with an athletic trainer or a strength and conditioning coach at regular intervals. Coaches are very important during this phase, and they must emphasize proper biomechanics, so that the athlete does not create the same stresses that caused the original overuse syndrome. The occasional use of NSAIDs or cryotherapy may be needed.
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