Moving on with our clinical series we will wrap things up with the elbow and wrist. The elbow and wrist are similar almost the equivalent of our knee and ankle of the upper extremity. However, there are some functional differences particularly in the comparison of the elbow and knee.
Elbow and Wrist Anatomy & Function
Anatomically, the elbow is where our upper arm bone (humerus) and our two lower arm bones (radius and ulna) meet. It is the joint that connects our upper arm to our forearm. Just like the knee, the elbow moves primarily in the direction of flexion (bending the elbow) and extension (straightening the elbow). Unlike the knee, the elbow also is able to rotate with motion known as supination (turning the palm of the hand up) and pronation (turning the palm of the hand down). This difference from the knee makes sense as it relates to increased freedom and function of our hand, which is not necessary for our foot. There are 3 ligaments of the elbow: the radial collateral ligament, the ulnar collateral ligament, and the annular ligament. The radial collateral ligament attaches the humerus to the radius, the ulnar collateral ligament attaches the humerus to the ulna, and the annular ligament attaches the two bones of the forearm (radius and ulna) together near the elbow.
The primary muscles of the elbow include the biceps and triceps. The biceps (technically known as the biceps brachii) consist of two heads (the long and short head). It is the primary muscle that creates flexion (bends) the elbow. The triceps consist of three heads (the long head, the lateral head, and the medial head). It is the primary muscle that extends (straightens) the elbow. Additional muscles of the elbow include the brachialis, brachioradialis, anconeus, and the pronator teres. The brachialis and the brachioradialis assist the biceps in elbow flexion, while the anconeus assists the triceps in elbow extension. The pronator teres as the name suggests pronates the forearm (turns the palm down), it also assists in elbow flexion.
The wrist is composed of 8 small bones known collectively as the carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate) along with the distal portion of the two forearm bones, radius and ulna. There are 3 primary joints of our wrist the distal radioulnar joint , which connects the two forearm bones, radius and ulna near the wrist. The radiocarpal joint connects the radius to 3 of the carpal bones (scaphoid, lunate, and triquetrum). The midcarpal joint connects these 3 carpal bones to the remaining carpal bones. Â ( The wrist being composed of 8 small bones allows for the freedom needed to bend and rotate our wrist as necessary to assist with use of our arm and hand, along with structural support when we need to increase stability at the wrist. As a result of the wrist consisting of 8 small (about the size of a large pebble) bones, there are numerous ligaments of the wrist connecting all of the carpals together. We will not review each of these ligaments, as they are beyond the scope of this post.
There are 4 motions that occur at our wrist: flexion, extension, abduction (radial deviation), adduction (ulnar deviation). Given the mobility of the wrist it makes sense that there are many muscles of the wrist to allow for its mobility. These muscles are often bundled into common groups: flexors, extensors, abductors, and adductors. We will refer to these muscles in this manner as specific muscles of the wrist are beyond the scope of this post.
Don’t Forget about the Shoulder & Neck!
Functionally, the use of our elbow, forearm, and wrist seems pretty straightforward as they are all involved in allowing for positioning of our hand to help with gripping and lifting objects to assist in many of our daily activities of living such as bathing, getting dressed, cooking, cleaning, typing, and many others. Just as we have discussed multiple times in the past, distal mobility such as that of the elbow, wrist, and hand requires good proximal stability. In other words, shoulder (scapular) stability is very important to proper function of our elbow, wrist, and hand. Without proper stability of our shoulder (scapula) we will displace a significant amount more stress on our elbow, forearm, and wrist with any activities that require lifting, pushing, or pulling. Over time this will increase the amount of strain to these areas increasing our risk of pain and injury to these regions below the shoulder. In addition to directly displacing more stress to this region, poor shoulder (scapular) stability often puts us into positions of poor posture, which also can place more awkward stress on our elbow and wrist with activities involving the use of our arm.
Another common factor that needs to be considered whenever we are experiencing pain in our elbow, wrist, and/or hand is the neck. The elbow, wrist, and/or hand are common regions where pain can either be referred to from our neck or we can experience pain related to a pinched nerve in our neck. In more cases that involve a pinched nerve it is also possible to experience tingling or numbness in these regions and in more severe cases weakness or loss of muscle tone in these regions.
Common Injuries of the Elbow & Wrist
Most of the common injuries of the elbow and wrist are due to repetitive stress. Let’s review some of the more common injuries of these regions.
Lateral Epicondylitis (Tennis Elbow)
Lateral Epicondylitis is a condition that involves tendinitis (or tendinosis) of one of the tendons close to our elbow (known as our common extensor tendon, which is formed from all the muscles that work to extend our wrist) that inserts into the lateral epicondyle of the elbow. Though this condition is known as tennis elbow, and can occur with racquet sports, the majority of people that experience this condition have never played tennis. It more frequently is seen in painters, plumbers, carpenters, mechanics, butchers, and cooks; and in many cases there is not a known form of repetitive stress as many activities that we perform on a daily basis increase strain to this area. The most common symptoms of lateral epicondylitis include pain in the outer portion of your elbow (that is typically worse with gripping and the use of the hand, especially when having to lift or hold anything) and possibly a loss of grip strength.
Just like we previously discussed with other forms of tendinitis (Achilles in our Ankle & Foot Pain post). These conditions are typically the result of wear and tear to the tendon that results in a breakdown of the tendon with ensuing inflammation and pain. It is at this point that one can often be diagnosed with lateral epicondylitis with a treatment focusing on reducing the pain and inflammation (with the use of anti-inflammatories and avoiding the potential aggravating activity), which is appropriate, however the often-bigger issue with these types of conditions can be neglected. The bigger issue is the high risk of recurrency if we do not address proper rehabilitation of the tendon to assist in rebuilding its functional and tensile strength. Without proper rehabilitation, it is likely that the tendon will continue to weaken with stress increasing the risk of recurrency and potential chronic pain. As a result, once the goal of decreasing pain and inflammation has been reached, the next focus should be rehabilitative care through the use of soft tissue treatment and therapeutic exercise. This will help to regain the functional and tensile strength of the tendon and restore its ability to tolerate life’s daily activities while reducing the risk of recurrency.
Medial Epicondylitis (Golfer’s Elbow)
Medial Epicondylitis is the equivalent of Lateral Epicondylitis just to the opposite side of musculature. It is a condition that involves tendinitis (or tendinosis) of the common flexor tendon, which inserts into the medial epicondyle of the elbow. Just like lateral epicondylitis, though this condition can commonly occur in golfer’s, medial epicondylitis has many other causes unrelated to playing golf. It most commonly occurs as a result of repetitive stress. All of the occupations that are at an increased risk of lateral epicondylitis are also at an increased risk of medial epicondylitis. In addition, medial epicondylitis commonly occurs in throwing sports such as football, baseball, and field sports like javelin and shotput. Symptomatically, it presents similar to lateral epicondylitis just on the opposite side of the elbow. Treatment is typically the same as lateral epicondylitis.
Elbow (Olecranon) Bursitis
Just like the shoulder and hip, we can experience bursitis in our elbow. A bursa is a fluid filled sac that helps to provide cushion in many areas throughout our body. Occasionally, these sacs can become swollen and inflamed. The region that is affected in our elbow is at the bony tip in the back of our elbow (known as the olecranon process). It makes sense that we have a bursa that overlies this area to help reduce pressure to this area. Common causes of elbow bursitis include trauma such as falling on our elbow or hitting the elbow on a hard surface. It can also occur as a result of sustained pressure due to prolonged resting on the elbow (such as when typing on a keyboard or resting on your elbows). Symptoms of elbow bursitis include swelling, pain, redness, and/or warmth in the backside of the elbow over the olecranon process.
Treatment of elbow bursitis includes avoiding pressure to the elbow along with compression to the region. Since it is an inflammatory condition, anti-inflammatories can be effective in help to reduce pain and swelling. Occasionally, a needle aspiration may be necessary to help drain fluid from the bursa or a cortisone injection may be needed to control the inflammation.
Nerve Entrapment Syndromes of the Elbow & Wrist
The arm including the elbow and wrist are common areas for nerve entrapment. Some of the most common peripheral nerve entrapment conditions occur in this region, carpal tunnel, cubital tunnel, and pronator teres syndrome.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) is probably the most common of all nerve entrapment syndromes. It occurs at our wrist (at the carpal tunnel) and involves the entrapment (compression) of a nerve in this region, referred to as our median nerve. The median nerve provides sensation and muscle function to the majority of the muscles in our fingers and the palm of our hand, particularly the thumb, index, middle, and the outer portion of the ring finger. Since the median nerve serves this portion of our hand, common symptoms of carpal tunnel syndrome include pain, tingling, and/or numbness in this portion of our hand and fingers along with a possible loss of grip strength. It typically is a result of repetitive stress with activities such as writing, typing, painting. It is also commonly associated with poor posture as the median nerve originates from our neck and passes through our shoulder, therefore poor posture can cause some compression to the median nerve in these regions that exacerbates the symptoms of carpal tunnel syndrome.
Treatment focuses on improving the wrist’s mobility and spacing of the carpal tunnel, so the pressure is relieved on the median nerve. Hands-on treatments mobilize tight joints and stretch tight ligaments. Ultrasound and other modalities can reduce deep swelling, relieving pressure on the nerve. Finally, strengthening and range of motion exercises can support the wrist and maintain good posture, helping the normal function of the median nerve.
In more advanced cases of carpal tunnel or those left untreated more invasive procedures including injections and surgery may be necessary, however the vast majority of cases can be treated conservatively.
Pronator Teres Syndrome
Pronator Teres Syndrome can present similar to Carpal Tunnel Syndrome as it is another condition that involves entrapment of the median nerve. Pronator Teres syndrome occurs in our forearm region rather than our wrist. If we recall from the anatomy of the elbow, the pronator teres is one of the main muscles of the elbow that allows for pronation (or turning our palm up). Symptoms of pronator teres syndrome can mimic carpal tunnel syndrome but can also include pain in the forearm region. It is differentiated from carpal tunnel syndrome through an appropriate clinical examination.
Treatment focuses on manual therapy to release the pronator teres muscle to help relieve pressure off of the median nerve. Rarely does pronator teres syndrome require further invasive care. Occasionally, it could require splinting to allow the pronator teres to rest.
Cubital Tunnel Syndrome
Cubital Tunnel Syndrome is a nerve entrapment syndrome that involves compression of the ulnar nerve at the elbow. The ulnar nerve supplies the inner portion of the ring finger and our pinky as well as the volar and palmar side of the hand and wrist in this region as well. In other words, it supplies most of our hand and wrist that is not supplied by our median nerve. Common causes of cubital tunnel are related to displacing prolonged pressure on your elbow, with activities such as typing, or keeping your elbow bent for extended periods of time, such as when sleeping or talking on the phone. Symptoms of cubital tunnel syndrome include inner elbow pain and similar to the other nerve entrapment syndromes pain, numbness, and tingling; however the distribution of cubital tunnel syndrome follows the path of the ulnar nerve, which as described above includes the inner portion of the ring finger and pinky as well as the lateral aspect of the volar and palmar side of the hand and wrist. Whereas carpal tunnel syndrome affects the thumb, index, and middle finger.
Treatment of cubital tunnel syndrome often involves soft tissue treatment including myofascial release and nerve glides, or flossing can be very beneficial for cubital tunnel syndrome. In addition, modification of aggravating activities including improving ergonomics with sitting and laying can be beneficial. Bracing the elbow to limit its ability to fully bend with sleep has been shown to be beneficial. Rest and anti-inflammatories have also been shown to be helpful. In more severe cases, cortisone injections and surgical release may be necessary.
Other Causes of Elbow & Wrist Pain
Just like any other joints in our body, elbows and wrists can be affected by arthritis. In addition to osteoarthritis, rheumatoid arthritis can be a common form of arthritis, particularly in our wrists (and hands). Rheumatoid arthritis is an auto-immune condition that causes inflammation and damage to our joints, and often results in more erosion of our joints and joint deformity compared to the wear-and-tear damage that is osteoarthritis. Rheumatoid arthritis typically requires medical intervention to help with its management. Unfortunately, there really is no cure for autoimmune conditions. Though, there is no cure for osteoarthritis, it is a much more manageable form of arthritis as we can help to improve support or reduce stress to joints that are affected by osteoarthritis since it is more associated with wear-and-tear versus being a pathological condition. In other words, if we live long enough, we all will experience some form of osteoarthritis, whereas rheumatoid arthritis is a much less common form of arthritis that is not associated with age related wear-and-tear.
Other injuries of the wrist and elbow are typically related to injury or trauma, such as sprains, strains, dislocations, and fractures. Sprains and strains can be a result of repetitive stress, often seen in sports that involve throwing (baseball, field sports, football) and activities that involve use of the hands and arms. Dislocations and fractures are most common from falling onto an outstretched arm or crush type of injuries.
Obviously, injuries of the hand and wrist can be very problematic to our daily lives, as they can impact our ability to use our upper extremities and limit our ability to perform many of our daily activities. Therefore, just as with any other pain it is very important to have pain in these regions properly evaluated to limit their ability to impact our quality of life. Unfortunately, do to the amount of use of our upper extremities (shoulders, elbows, wrists, and hands) in our daily activities and lives injuries of the elbow and wrist can persist and often do not self-resolve. In addition, they will commonly lead to compensation and increased stress to other areas which can increase injury risk to these other regions.
Experiencing Elbow or Wrist Pain?
If you are experiencing elbow or wrist pain and want to know if there are other options besides pain management (anti-inflammatory medications, cortisone injections) or surgery that may be able to help you and restore your ability to move and live a more active life, please consider scheduling an appointment with our office. Let us help you get back to the life that you deserve!
…Till Next Time!
