MSK I: elbow pathology

Key patient history indicators for elbow pathology

1. prior elbow and forearm injuries

2. prior upper extremity surgeries

3. systemic diseases

4. onset of symptoms

5. Chief complaint/concern

6. Personal factors

7. Symptom location

Prior elbow and forearm injuries

Childhood fractures can lead to degenerative changes as adults 

Prior upper extremity surgeries

• Can injure peripheral nerves

  1. Traumatic injuries: peripheral nerve injury

  2. Overuse injuries: peripheral nerve entrapment

elbow pathologies Systemic diseases

• Rheumatoid arthritis

• Gout

elbow pathology onset of symptoms

• Fracture needs to be ruled out if injury was traumatic 

• Overuse injuries need to be considered with athletes and certain occupations

• Insidious onset in older adults … OA?

elbow pathology chief complaint/concern

• Mechanical?

  1. Catching, clicking, locking = intra-articular pathology 

• Nerve related?

  1. Numbness, tingling, shooting symptoms

  2. Muscle atrophy or motor weakness

• Feelings of instability?

  1. Ligamentous pathology

mechanical

Catching, clicking, locking = intra-articular pathology 

nerve related

• Numbness, tingling, shooting symptoms

• Muscle atrophy or motor weakness

feelings of instability

Ligamentous pathology 

elbow pathology personal factors

• Hand dominance 

• Sports 

  1. Throwing

  2. Overhead movements

  3. Cycling

• Occupation

  1. Computer jobs

  2. Mechanics 

  3. Construction

  4. Etc…

elbow pathology symptom location

• Many symptoms in the elbow can be palpated

  1. Tennis elbow: lateral epicondyle

  2. Golfer’s elbow: medial epicondyle 

• Vague or poorly localized symptoms

  1. Referred pain due to nerve compression

elbow outcome measures

• General outcome measures:

  1. DASH: Disabilities of Arm, Shoulder and Hand Questionnaire

  2. Patient-specific functional scale

• Elbow-specific outcome measures:

  1. Patient-rated elbow evaluation

     1. Commonly used for OA, post-op, and epicondylalgia 

     2. Subscales for pain and function

  2. American shoulder and elbow surgeons elbow form

     1. Commonly used for OA, post-op, and various elbow pathologies 

     2. Subscales for pain, function, and satisfaction

  3. Oxford elbow score

     1. Commonly used for OA

     2. Subscales for pain, elbow function, and social/psychological

General outcome measures:

• DASH: Disabilities of Arm, Shoulder and Hand Questionnaire

• Patient-specific functional scale

Elbow-specific outcome measures

• Patient-rated elbow evaluation

  1. Commonly used for OA, post-op, and epicondylalgia 

  2. Subscales for pain and function

• American shoulder and elbow surgeons elbow form

  1. Commonly used for OA, post-op, and various elbow pathologies 

  2. Subscales for pain, function, and satisfaction

• Oxford elbow score

  1. Commonly used for OA

  2. Subscales for pain, elbow function, and social/psychological

Patient-rated elbow evaluation

• Commonly used for OA, post-op, and epicondylalgia 

• Subscales for pain and function

American shoulder and elbow surgeons elbow form

• Commonly used for OA, post-op, and various elbow pathologies 

• Subscales for pain, function, and satisfaction

Oxford elbow score

• Commonly used for OA

• Subscales for pain, elbow function, and social/psychological

Red Flags for elbow pathology

• Elbow fracture

  1. Must be ruled out for any individuals with traumatic onset of symptoms

     1. Elbow extension and flexion test

        1. Patient needs to be able to fully flex and extend following a trauma

        2. Positive test: inability to full actively extend or flex elbow 

        3. Negative tests have been shown to effectively rule out elbow fractures in children and adults

elbow joint specific examination

1. structure

2. ROM

3. muscle length

4. muscle performance

5. sensory tests

6. reflexes

7. neurodynamic tests

8. accessory motions

9. special tests

10. palpation

11. gait, transfers, mobility

12. functional testing

structure

• Excessive carrying angle?

  1. Medial structures are hypermobile → causes compression laterally

• Swelling

• Hyperextension

• Claw hand

• Atrophy

ROM

• AROM + Overpressure + End feel

• PROM + End feel

• Elbow ROM testing must include the wrist due to many 2 joint muscles 

• Mechanical symptoms with ROM?

  1. Clicking, locking 

  2. Crepitus → OA?

muscle length

• Biceps

• Extensor carpi radialis longus (ECRL)

• Extensor carpi radialis brevis (ECRB)

• Flexor carpi radialis 

• Flexor carpi ulnaris

muscle performance

• Manual muscle testing

  1. MMT differentiations for muscle groups 

     1. Biceps vs. brachioradialis vs. brachialis

     2. Pronator teres vs. pronator quadratus 

     3. Biceps vs supinator 

• Grip strength 

• Pinch strength 

reflexes

• C5 - Biceps

• C6 - Brachioradialis 

• C7 - Triceps

biceps

which is C5 reflex

brachiradialirs

which is C6 reflex

triceps

which is C7 reflex

neurodynamic tests

• ULTT

• Nerve compression tests

Factors that can cause lesions in peripheral nerves

• Entrapment 

  1. When a nerve crosses a narrow passage

  2. Elbow is the most common location for nerve entrapment

• Sustained postures 

• Direct trauma

• Extremes of motions

  1. Ex: pitchers

Entrapment 

• When a nerve crosses a narrow passage

• Elbow is the most common location for nerve entrapment

• Positioning, inflammation, or a space-occupying lesion (cancer)

• Low level of compression over a long period of time

• Intermittent compression

• High degree of compression over a short time

entrapment can occur due to

• ulnar nerve (C8-T1)

• median nerve (C6-T1)

• radial nerve (C6-T1)

locations for nerve compression

ulnar nerve (C8-T1) entrapment

• Cubital tunnel (elbow) – 2nd most common nerve entrapment 

• Between the 2 heads of the FCU

• Near the fascia of the FDS

• Guyon’s canal (wrist)

median nerve (C6-T1) entrapment

• Between the heads of the pronator teres 

• Proximal arch of the FDS

• Origin of the FCR or FDS

• Deep to the pronator teres head

• Carpal tunnel

radial nerve (C6-T1) entrapment

• Mid-humerus

• Between triceps and brachialis 

• Proximal edge of ECRB

• Between the heads of the supinator 

• Beneath brachioradialis

Accessory motions 

• Tested when AROM and PROM are both limited 

• Humeroulnar lateral tilt

  1. Facilitate elbow extension

• Humeroulnar medial tilt

  1. Facilitate elbow extension

• Humeroulnar distraction

  1. Global joint mobility 

• Humeroradial distraction

  1. Global joint mobility 

• Proximal radioulnar dorsal glide

  1. Facilitate pronation and extension

• Proximal radioulnar ventral glide

  1. Facilitate supination and flexion

• Distal radioulnar dorsal glide

  1. Facilitate supination

• Distal radioulnar ventral (palmar) glide

  1. Facilitate pronation

• Humeroulnar medial tilt

• Humeroulnar lateral tilt

Facilitate elbow extension

• Humeroulnar distraction

• Humeroradial distraction

Global joint mobility 

Proximal radioulnar dorsal glide

Facilitate pronation and extension

Proximal radioulnar ventral glide

Facilitate supination and flexion

Distal radioulnar dorsal glide

Facilitate supination

Distal radioulnar ventral (palmar) glide

Facilitate pronation

common elbow pathologies

• cubital tunnel syndrome

• median nerve compression

• radial nerve compression

• lateral epicondyalgia (tennis elbow)

• medial epicondylagia (golfers elbow)

• elbow dislocation & instability

• elbow OA

cubital tunnel syndrome patient demographics

• Male

• Occupations with repetitive elbow flexion

• Direct pressure over elbow 

• Increased carrying angle (cubital valgus)

• Common in throwers and long-range cyclists 

• Can occur after elbow fracture or dislocation

cubital tunnel syndrome key patient history indicators

• Medial elbow aching and pain

• Fatigue with repetitive tasks

• Clumsiness or loss of fine motor coordination

• Difficulty crossing fingers

• Decreased pinch/grip strength

• Symptoms worsened with activities that require prolonged or repeated elbow flexion

cubital tunnel syndrome key examination findings

• Motor:

  1. Weakness in ulnar innervated muscles 

     1. Grip strength, pinch strength 

     2. Wrist flexion, ulnar deviation

     3. Index finger abduction

     4. Thumb adduction

  2. Fine motor dexterity loss

  3. Atrophy of first dorsal interossei or hypothenar eminence 

  4. Clawing of 4th and 5th digits 

  5. Generally, motor weakness is a late symptoms

• Sensory:

  1. Changes in ulnar distribution

     1. Ulnar side of hand (dorsal and ventral)

     2. Tested along pinky finger

• Possible positive ulnar nerve ULTT

• Positive special tests

  1. Elbow flexion test

  2. Tinel’s sign

motor exam findings for cubital tunnel

• Weakness in ulnar innervated muscles 

  1. Grip strength, pinch strength 

  2. Wrist flexion, ulnar deviation

  3. Index finger abduction

  4. Thumb adduction

• Fine motor dexterity loss

• Atrophy of first dorsal interossei or hypothenar eminence 

• Clawing of 4th and 5th digits 

• Generally, motor weakness is a late symptoms

sensory exams findings for cubital tunnel

0 Changes in ulnar distribution

1. Ulnar side of hand (dorsal and ventral)

2. Tested along pinky finger

• ULTT

• elbow flexion test

• tinels sign

what tests can be positive for cubital tunnel syndrome

cubital tunnel syndrome differential diagnoses

• Cervical radiculopathy (C8/T1)

• Thoracic outlet syndrome

• Ulnar nerve compression and Guyon’s canal (ulnar tunnel)

• Medial epicondylalgia

cubital tunnel syndrome interventions

• Rest

• NSAIDs

• Elbow pads for work 

• Progressive strengthening 

• Manual therapy 

• Evaluation of sport-specific biomechanics

median nerve compressions

• pronator syndrome

• anterior interosseous syndrome

• carpal tunnel syndrome

pronator syndrome

Median nerve compressed between 2 heads of pronator teres 

pronator syndrome patient demographics

• Pitchers

• Tennis players

• Weight-lifters

• Occupations requiring repeated gripping

  1. Carpentry

  2. Cooking

  3. Assembly line work

pronator syndrome key patient history indicators

• Aching pain in volar forearm 

• Paresthesia in median nerve distribution (digits 1-3 and ½ 4)

• Loss of pinch strength, fine motor skills 

• Overall hand clumsiness 

• Aggravated with repetitive forearm pronation and wrist flexion

  1. Activation of pronator teres

pronator syndrome key exam findings

• motor

• sensory

• special tests

motor exam findings for pronator syndrome

• Weakness in median nerve muscles 

  1. Pronation

  2. Flexion/radial deviation of wrist 

  3. Thenar atrophy

  4. Inability to oppose/flex thumb

sensory exam findings for pronator syndrome

Changes in median nerve distribution, including thenar eminence

• Tinel’s sign

• Pronator compression test

what are special tests for pronator syndrome

pronator syndrome differential diagnoses

• Cervical radiculopathy

• Brachial plexus injury 

• Medial epicondylalgia 

• Ulnar collateral ligament injuries

pronator syndrome interventions

• NSAIDs

• Activity modification

• Soft tissue mobilization

• Biomechanics assessment 

• Progressive strengthening

Anterior interosseous syndrome

• Symptoms are purely motor

  1. No sensory changes

• Compressed at FDS arch

Anterior interosseous syndrome Key patient history indicators

• Proximal forearm pain

• Muscle weakness

• Lack of dexterity

Anterior interosseous syndrome key exam findings

• Unable to form a circle with the thumb and index finger

• No sensory loss

• Special tests

  1. Tear drop pinch test

Tear drop pinch test

what is a special test for Anterior interosseous syndrome

Anterior interosseous syndrome differential diagnoses

• Cervical radiculopathy

• Brachial plexus injuries 

• Rupture of flexor pollicis longus

Anterior interosseous syndrome interventions

• NSAIDs

• Activity modification

• Soft tissue mobilization

• Biomechanics assessment 

• Progressive strengthening

radial nerve compressions

• Radial tunnel syndrome

• Posterior interosseous nerve (PIN) syndrome

Radial tunnel syndrome patient demographics

• Repeated forearm rotation

  1. Tennis players

  2. Swimmers

Radial tunnel syndrome key exam findings

• Localized tenderness over radial tunnel 

• pain is the only symptom

• Vague pain in lateral elbow, dorsal forearm

• Resisted supination of the forearm with the elbow extended should reproduce pain

• Pain with radial ULTT

• Only nerve compression syndrome in which signs and symptoms are not based on the distribution

  1. No motor loss

  2. No sensory loss

Radial tunnel syndrome interventions

• NSAIDs

• Activity modification

• Soft tissue mobilization

• Biomechanics assessment 

• Progressive strengthening

Posterior interosseous nerve (PIN) syndrome patient demographics

• Weight lifters 

• Tennis players

• Gymnasts

Posterior interosseous nerve (PIN) syndrome key exam findings

• Weakness of ECRB and EDC with sensation intact

  1. Weak wrist extension 

  2. Generalized hand weakness 

• Positive radial ULTT

• motor symptoms, unlike radial tunnel which is purely pain

Posterior interosseous nerve (PIN) syndrome interventions

• NSAIDs

• Soft tissue mobilization

• Activity modification

• Biomechanics assessment 

• Progressive strengthening

radial nerve differential diagnoses

• Brachial plexus injuries 

• Lateral epicondylalgia

Lateral epicondylalgia (“tennis elbow”)

• Most common lesion of the elbow – degenerative, overuse

  1. Usually affects ECRB

Lateral epicondylalgia Key patient history

• Gradual onset, lateral elbow pain

• Worsened with gripping and wrist extension

• Common in dominant arm of tennis players, laborers requiring repeated wrist extensor activation (gripping)

Lateral epicondylalgia Key exam findings 

• Tender distal to lateral epicondyle

• Painful weakness with gripping

  1. Increased weakness with elbow extended vs. elbow flexed

• Mill Test

• Maudsley Test

• Cozen test

• Grip strength

Lateral epicondylalgia special tests

Lateral epicondylalgia differential diagnoses

• Cervical radiculopathy

• Radial tunnel syndrome

• PIN entrapment 

• Humeroradial arthritis 

• Osteochondritis Dissecans/Panner disease

Lateral epicondylalgia interventions

• Stretching

• Manual therapy 

• Endurance exercises 

• Strengthening

Medial Epicondylalgia

• Degenerative, overuse

• Involves pronator flexor group

Medial Epicondylalgia key patient history indicators

• Gradual onset of medial elbow pain; may radiate into medial forearm 

• Exacerbated by wrist flexion, pronation, and pulling activities 

• Common in sports

  1. Golf, throwing, bowling, javelin, weight lifting, tennis

• Common in occupations that require repetitive wrist flexion and forearm pronation

Medial Epicondylalgia key exam findings

• Tender to palpation distal to medial epicondyle

• Tender over the pronator teres or flexor carpi radialis (FCR)

• Usually full ROM

• Pain with resisted forearm pronation and/or wrist flexion

• Occasional pain with passive forearm supination and wrist extension

• Tend to have additional musculoskeletal pathologies 

  1. Poor mechanics

  2. Rotator cuff pathology, lateral epicondylalgia 

• Special tests

  1. Tenderness to palpation over medial epicondyle

  2. Pain with resisted forearm pronation and/or wrist flexion

  3. Occasional pain with passive forearm supination and wrist extension

• Tenderness to palpation over medial epicondyle

• Pain with resisted forearm pronation and/or wrist flexion

• Occasional pain with passive forearm supination and wrist extension

what are special tests for Medial Epicondylalgia

Medial Epicondylalgia differential diagnoses

• MCL injury 

• Acute rupture of common flexor tendon

• Ulnar nerve pathology 

• Avulsion fracture in children

  1. Muscle attachment is pulled off the bone

Medial Epicondylalgia interventions

• Activity modifications 

• Symptom modulation

• Progressive loading of weakened muscles 

• Stretching, Soft tissue mobilization

common types of elbow dislocation & instability

• dislocation

• MCL sprain & valgus instability

• varus instability

• posterolateral rotatory instability (PLRI)

elbow dislocation

• 2nd most commonly dislocated joint (1st is shoulder)

• Common secondary to trauma 

• Assessment for additional injuries is necessary 

  1. Fractures, ligament ruptures, neurovascular damage

elbow MCL sprain & Valgus instability

• MCL is primary restraint against valgus stress from 20-120 degrees of flexion

• Valgus stress can be extremely high during overhand throwing 

• Can lead to posterior elbow pain

elbow MCL sprain & Valgus instability key exam findings

Tenderness over MCL

• Valgus stress test 

• Moving valgus stress test

what are special tests for elbow MCL sprain & Valgus instability

elbow MCL sprain & Valgus instability differential diagnoses

• Medial epicondylalgia 

• Pronator syndrome 

• Ulnar nerve pathology

elbow MCL sprain & Valgus instability interventions

• ROM

• Elbow strengthening

Varus instability

• Special tests

  1. Varus stress test  

• Interventions

  1. ROM

  2. Elbow strengthening

Posterolateral Rotatory instability (PLRI)

• Most common chronic elbow instability

• Result of RCL (radial collateral ligament) rupture and radial head subluxation

• Typical mechanism of injury: FOOSH

Posterolateral Rotatory instability (PLRI) key patient indicators

• Mechanical symptoms

  1. Clunking, clicking, feelings of instability 

• Complaints of lateral elbow pain

Posterolateral Rotatory instability (PLRI) key exam findings

• Generally no loss of ROM or strength 

• Special tests

  1. Chair push-up test

Posterolateral Rotatory instability (PLRI) intervention

surgery

Elbow dislocation & instability etiology

• Trauma

• Overuse

• Bony dysplasia 

• Ehlers-Danlos Syndrome

• Rheumatoid arthritis 

• After surgery