Physical Examination of the Elbow

1. Physical Examination of the Elbow

2. Components of Physical Exam • History • Inspection • ROM • Palpation • Strength/Neurovascular • Stability • Special Tests

3. The Athlete’s Elbow • It is important to remember when examining the elbow of any athlete or manual laborer that adaptations to repetitive stresses induced by sport/work activities may result in “abnormal” findings which may not represent true pathology

4. History • ? Dominant hand • What, when, where, how • Work related • Any previous injury • Any previous treatment

5. History • Any Traumatic events • Falls, dislocations, lacerations, fractures • Recent athletic activity • Throwing history • When, where, how much, how well, how fast • Changes in routine or training regimen • Pain or instability with throwing • 85% of throwers with medial elbow instability complain of pain in the acceleration phase of throwing • Neurologic symptoms with throwing

6. Inspection • Normal carrying angle in adult • Male = 10-11 degrees valgus • Female = 13 degrees valgus • Not uncommon for throwers to have > 15 degrees valgus at elbow • Person with large elbow effusion will tend to hold elbow flexed 70-80 degrees as this corresponds to greatest volume of elbow joint capsule

7. Inspection 13 degrees Valgus

8. Inspection • Lateral recess, medial epicondyle, antecubital fossa, olecranon tip • Prominence of the olecranon tip may indicate posterior/posterolateral dislocation or triceps avulsion • Ecchymosis anteriorly may indicate biceps tendon rupture • Ecchymosis medially may indicate a fracture of the medial epicondyle or avulsion injury

9. Inspection

10. Inspection • Olecranon bursa should be insepcted • If enlarged may represent bursitis • Aseptic vs. septic • Ulnar nerve subluxation may be visible

11. Range of Motion • Active followed by passive ROM • Normal ROM in adult • 0 – 140 degrees +/- 10 degrees in sagittal plane • 80-90 degrees of forearm rotation in each direction • With progressive flexion, elbow moves into increasing valgus

12. Full Extension Full Flexion

13. Range of Motion • Generalized ligamentous laxity is associated with increased ROM • Distinctly uncommon in throwing athletes • Functional ROM is 30-130 degrees flexion and 50 degrees of rotation in each direction • Morrey et al, JBJS 1981

14. Range of Motion • Loss of motion in athlete attributable to: • Capsular contracture • Capsular strain • Musculotendinous contracture or strain • Loose body • Osteophyte formation • Scar tissue

15. Range of Motion • Pain, crepitus, and end feel must be assessed • End feel in extension should be “bony” • Soft endpoint may indicate contracture • End feel in flexion should be “soft” • Firm endpoint may indicate bony impingement • > 50 % of throwing athletes have some degree of elbow flexion contracture • King et al, Clin Ortho 1969

16. Palpation • Bony Palpation • Olecranon • Posteromedial tip (impingement) • Proximal shaft (stress fractures) • Epicondyles • Fractures • Epicondylitis • Radial Head • Fractures • Dislocations

17. Palpation of medial side Palpation Posteriorly

18. Lateral Side Palpation Lateral epicondyle Radial Head Lateral olecranon Soft spot

19. Bony Impingement • Impingement of the posteromedial tip of the olecranon in the olecranon fossa • Pain occurs as the elbow is snapped into extension • More common in throwing athletes

20. Epicondylitis • Medial Epicondylitis (Golfer’s Elbow) • Palpate medial muslce mass/epicondyle while resisting active pronation • Pain either within muscle belly or directly over epicondyle • Lateral Epicondylitis (Tennis Elbow) • Palpate mobile wad while resisting active supination (ECRB most common offender) • Pain within muscle belly or over epicondyle

21. Palpation • Soft Tissues • Antecubital Fossa • Mobile wad, biceps tendon, brachial pulse • Median nerve not generally palpable • Medial • Flexor-pronator mass • Ulnar nerve • UCL

22. Biceps Tendon Rupture • Palpation in the antecubital fossa • Absence of typically prominent tendon • Resisted supination will increase prominence • +/- Pain in antecubital fossa • Ecchymosis may be present

23. Ulnar Nerve Instability • Ulnar nerve held in cubital tunnel by overlying and investing fascia • Rupture or stretch of this tissue may lead to subluxation of nerve • Paresthesias • Pain with subluxation • May have pain with palpation • Ulnar nerve subluxes anteriorly with increasing flexion of elbow • Nerve “snaps” back with rapid active extension

24. Ulnar Nerve Instability • Typically the “snap” back into the cubital tunnel creates the pain or paresthetic symptoms • Compression wrap or brace may be enough to keep nerve from subluxing • Patients with paresthesias may require elective ulnar nerve transfer

25. Ulnar Nerve Impingement • Anomalous bands of triceps insertion may impinge ulnar nerve as they snap over medial epicondyle • Sensation of “snapping” as the arm is actively extended with ulnar nerve symptoms • “Snapping Triceps Syndrome” • Spinner and Goldner, JBJS 1998 • Nerve is stable in cubital tunnel

26. Stability Exam • No inherent stability to Elbow • At full extension, olecranon tip/olecranon fossa articulation provides some stability against varus/valgus stresses • Radial head provides some stability against valgus laxity • Pts with radial head fractures may have increased valgus carrying angle

27. Stability Exam • Ulnar Collateral Ligament • Provides most valgus stability • Most isolated stabilizer at 70 degrees flexion • Difficult to examine due to free range of shoulder motion • Place patient in position with shoulder externally rotated • PRONE or SUPINE or BOTH

28. UCL InjuryNon-Contact History: - Acute medial pain - Onset during throwing, inadequate warmup - “Pop” heard or felt - Previous Hx of pain, steroid injection

29. UCL InjuryNon-Contact Physical exam: - Medial elbow ecchymosis - Ulnar nerve symptoms - Tender at ant. bundle - Difficult exam: +/- instability, dynamic??? X-ray: arthrogram, stress view

30. Palpation of UCL • Deep structure covered by flexor-pronator mass • Course of ligament from ME to Sublime tubercle of proximal ulna • Inserts just distal to articular surface • Flexion of elbow will move muscle mass anteriorly, uncovering UCL • Pain with palpation in this region may be indicative of UCL pathology (not specific)

31. Palpation of UCL Palpate in flexion to move flexor-pronator mass anteriorly

32. Testing the UCL • With patient supine or prone, abduct and maximally externally rotate shoulder • Elbow flexed 25 degrees • Apply valgus stress • Assess for end-feel and amount of opening • Should not induce any pain in normal elbow

33. UCL Stress Test - Seated

34. UCL Stress Test - Supine

35. UCL Stress Test - Prone(O’Driscoll)

36. Sensory Examination • Cursory sensory exam in all patients • Bilateral comparison • Subtle differences in sensory function may not represent true pathology, but may be the first indicator of more serious pathology • Musculocutaneous, MABC, LABC, Radial, Ulnar, Median

37. Sensory Examination • Musculocutaneous • Antecubital fossa • Radial • First dorsal webspace of hand • Ulnar • Ulnar aspect of 4th and 5th fingers • Median • Pad of Index and Middle

38. Neruovascular Exam • Pulses should be checked in both arms and the quality of the pulse as well as the rate should be compared. • Dampened pulses may indicate proximal obstruction • Capillary refill and general perfusion should be checked in any patient complaining of altered sensation in fingertips

39. Tinnel’s Test • Gentle percussion of the ulnar nerve above or within the cubital tunnel should not elicit pain in the normal elbow • Pain or paresthesias in the ulnar distribution is considered a positive test

40. Strength Examination • Any routine examination of the elbow should include a strength examination • Rotator cuff • Deltoid • Biceps • Triceps • Pronation and Supination • Wrist dorsal- and volar-flexion • Grip, Intrinsics, and APL

41. Testing Flexion Strength Brachioradialis Biceps

42. Lateral Ligamentous Exam • Radial Collateral Ligament and Lateral Ulnar Collateral Ligament make up lateral ligament complex • Apply varus stress with elbow flexed 15-20 degrees • Arm is internally rotated to prevent shoulder rotation • Assess any pain or increased varus laxity

43. Posterolateral Rotatory Instability • PLRI due to insufficiency of LUCL • Test for PLRI = “Pivot Shift” • Anesthetized supine patient • Forward flexion, external rotation of shoulder • Forearm supination • Axial load with valgus stress as arm is gradually flexed • Radial head subluxes posteriorly and “clunks” back into place

44. Pivot Shift Test for PLRI Supine, flexed to 70 degrees, axial load with valgus stress

45. Valgus Extension Overload Medial stress Lateral compression Forced extension

46. Valgus Extension Overload Syndrome • Symptomatic lesion in baseball pitchers • Posteromedial osteophytes abuts against the medial olecranon fossa • Results in pain & loss of control & velocity in baseball pitchers

48. Mechanism of Injury

49. Valgus Extension Overload • VEO occurs in throwers as the posteromedial tip of the olecranon process contacts either soft tissue or bone within the olecranon fossa as the elbow rapidly extends during the acceleration phase of throwing

50. Test for VEO • Forearm in neutral rotation • Elbow repeatedly brought forcefully into full extension while a valgus stress is applied • Pain at posteromedial olecranon tip or pain with palpation of posteromedial olecranon tip is considered a positive test