Mechanical dysfunctions in the joints of the elbow are not uncommon. Their importance in painful syndromes and disturbances of usage varies, but is often a factor that can be addressed by osteopathic treatment. From a mechanical viewpoint the elbow poses various problems. There are rather small but important ranges of accessory movement and it is necessary to use these in treatment techniques. They may be difficult to control. Other problems are posed by the fact that the joints will tend to escape from corrective forces if the grip is not firm enough. However, an excessively firm grip will produce pain and even more resistance. A balance between force, direction and amplitude is critical. The joint complex must be considered as a whole; the elbow, radio-humeral articulation, and distal articulation at the wrist all work together. Often individual joint dysfunction will not be corrected until a suitable balance is obtained between all the relevant joints and soft tissues. The fascial state is also important as poor circulation, healing and myofascial tone may be part of the equation.
Special precautions need to be considered to exclude the possibility of myositis ossificans, which sometimes affects the brachialis muscle in the presence of a haematoma after trauma. The ulnar nerve is vulnerable to damage on the medial side of the ulna. An ulnar neuritis takes a very long time to heal when traumatic-ally induced. It would be very hard to do this in treatment, but an existing condition could be irritated by injudicious technique. It is essential to avoid excessive force, particularly into extension as there is a possibility of damage to the floor of the olecranon fossa.
26.1 • Kneading of lateral tissues supine Clasp the arm between your body and forearm and knead the extensor muscles on the lateral side of the arm. The hands share the pressure in opposite directions to reduce the amplitude of movement necessary in each.
Tips: Try varying the angle of shoulder abduction and rotation; this will change the initial tension in the muscles before they are kneaded. If there is extreme tenderness, try holding the muscles on some tension and moving the arm back and forth rather than the muscles themselves.
26.2 • (bottom left) Kneading of medial and anterior tissues supine Fix the patient's forearm to your side with your forearm and then apply a kneading and stretching to the medial compartment muscles with both thumbs. It is possible to reach deep into the cubital fossa with this hold.
Tips: Take care to protect the brachialis and brachial artery from excessive pressure.
26.3 • (bottom right) Kneading of lateral compartment muscles supine Sit on the edge of the table. Put some tension on the muscles with the proximal hand and then, while maintaining this pressure, pronate the forearm with your other hand to generate the kneading force.
Tips: Try varying the angle of elbow flexion and adding components of traction or circumduction to the hold. As an alternative, the operator can perform this technique standing.
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