Physical Examination of the Elbow

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Physical Examination of the Elbow
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Components of Physical Exam

• History
• Inspection
• ROM
• Palpation
• Strength/Neurovascular
• Stability
• Special Tests

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The Athletes 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

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History

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

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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

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Inspection

• Normal carrying angle in adult
• Male 10-11 degrees valgus
• Female 13 degrees valgus
• Not uncommon for throwers to have gt 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

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Inspection
13 degrees Valgus
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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

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Inspection
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Inspection

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

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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

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Full Extension
Full Flexion
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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

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Range of Motion

• Loss of motion in athlete attributable to
• Capsular contracture
• Capsular strain
• Musculotendinous contracture or strain
• Loose body
• Osteophyte formation
• Scar tissue

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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
• gt 50 of throwing athletes have some degree of
  elbow flexion contracture
• King et al, Clin Ortho 1969

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Palpation

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

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Palpation of medial side
Palpation Posteriorly
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Lateral Side Palpation
Lateral epicondyle Radial Head Lateral
olecranon Soft spot
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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

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Epicondylitis

• Medial Epicondylitis (Golfers 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

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Palpation

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

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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

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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

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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

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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

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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

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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

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UCL InjuryNon-Contact

• History
• - Acute medial pain
• - Onset during throwing, inadequate warmup
• - Pop heard or felt
• - Previous Hx of pain, steroid injection

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UCL InjuryNon-Contact

• Physical exam
• - Medial elbow ecchymosis
• - Ulnar nerve symptoms
• - Tender at ant. bundle
• - Difficult exam
• /- instability, dynamic???
• X-ray arthrogram, stress view

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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)

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

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UCL Stress Test - Seated
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UCL Stress Test - Supine
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UCL Stress Test - Prone(ODriscoll)
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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

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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

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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

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Tinnels 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

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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

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Testing Flexion Strength
Brachioradialis
Biceps
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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

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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

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Pivot Shift Test for PLRI
Supine, flexed to 70 degrees, axial load with
valgus stress
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Valgus Extension Overload

• Medial stress
• Lateral compression
• Forced extension

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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

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Mechanism of Injury
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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

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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

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Repeatedly move elbow into full extension with
valgus stress
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Diagnostic Imaging
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Arthroscopic Stress View forUCL Laxity
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Stress Radiography

• Graded stress x-rays in evaluation of injury to
  the UCL of the elbow

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MRI of Torn UCL
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Summary

• Develop a system and follow it
• Cover all bases
• A thorough history will help guide and direct
  physical exam
• Compare to non-affected side
• Supplement info with radiographic studies

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Thank You