Elbow: Examination

what is important to consider when taking the history?

• age, work hx, sport or activity hx, hx of falls or trauma

• MOI

• hand dominance

• neurological signs

• hx of injuries across several joints, cervical, shoulder, hand

• numbness, tingling, weakness, heaviness

• other exacerbating and alleviating factors

• functional limitations

• duration of symptoms

• comorbidities

• medication review

where is the most common location in the elbow for edema?

in the triangle of the lateral epicondyle, radial head and olecranon

what is the functional arc for pronation/supination?

50 degrees supination and 50 degrees pronation

what is the functional arc for flexion/extension?

30-130 degrees flexion

how do you do a length test of the biceps?

supine, full shoulder extension, then elbow extension, look for supination of the forearm

how do you do a length test on the triceps?

seated or supine, full shoulder flexion, then elbow flexion

how do you check muscle length of wrist flexion and extension?

• full elbow extension, full flexion or extension of wrist and finger to check opposite motion

which muscles cross the elbow and assist in flexion?

brachialis, biceps brachii, brachioradialis

which muscles cross the elbow and aid in extension ?

triceps brachii, anconeus

which muscles cross the elbow and aid in rotation?

pronator teres, supinator

what are some of the otehr muscles that cross the elbow and move the wrist/hand?

• FCR

• palmaris longus

• FCU

• FDS

• FDP

• ECRB and ECRL

• ED

• EDM

• ECU

how do you assess joint play?

with with radial deviation (varus) ulnar and radius on humerus, or ulnar deviation (valgus) ulna and radius on humerus

how do you assess joint play uding distraction of the olecranon from the humerus?

have the pt in supine with the U-H joint in open packed position (70 degrees flexion and 10 degrees of supination), fixate the humerus with one hand while you palpate the joint line laterally with your thumb. with the other hand grab onto the ulna and pull dorsally and distally

how do you perform an anteroposterior glide of the radius on the humerus to assess joint play?

with the patient sitting with the arm supported and the radiohumeral joint in open packed position, fixate the humerus with one and position the other on the radial head. can then perform a PA glide toward the pt’s chest, or an AP glide distal and caudal (sink through the extensor mass)

which tests are used to assess ligamentous instability?

• lateral pivot shift test of the elbow

• ligamentous valgus instability test

• ligamentous varus instability test

• milking maneuver

• moving valgus stress test

which tests are used for biceps rupture?

hook (distal biceps) test

popeye sign (proximal long head of the biceps)

which tests are for lateral epicondylitis ?

• Cozen's test

• Mill's test

which tests are for plica (Elbow synovial fold syndrome (or elbow plica syndrome) occurs when a normal embryonic tissue fold inside the elbow joint becomes inflamed, thickened, or pinched)?

• extension-supination plica test

• flexion-pronation plica test

which tests are for posterior impingement?

• arm bar test

• extension impingement test

which tests are for neurological dysfunction of the elbow?

• elbow flexion test (ulnar nerve)

• pinch grip test (anterior interosseous branch of the median nerve)

• tinel sign at elbow (ulnar nerve)

what is the varus stress test?

• test LCL structure

• pt in upright position, elbow flexed to 20-30 degrees, stabilize the distal humerus, and give varus force to distal forearm.

• stabilize rotation components and palpate the gapping side

• positive is excessive laxity or soft end fee, indicates a sprain or posterolateral instability (LUCL)

what is the valgus stress test?

• tests the MCL structure

• upright position, elbow flexed to 20-30 degrees, stabilize the distal humerus, ang give valgus force to the distal forearm, making sure to stabilize the rotational components and palpate the gapping side

• positive is excessive laxity or soft end feel

does the valgus stress test position (20-30 degrees of elbow flexion) exploit the maximum elbow instability?

no, that would occur at 70 degrees of flexion and neutral rotation

what is the moving valgus stress test?

• tests the MCL structure

• upright position, shoulder in 90 degrees abduction, max ER and apply a quick, constant valgus force from full flexion to 30 degrees flexion, make sure to ensure stabilization and palpate the MCL

• positive is reproduction of pain over the MCL between 70 and 120 of flexion, which is reminiscent of throwing between the late cocking and early acceleration phases

what is the milking maneuver?

• tests anterior MCL structure

• upright position, shoulder ER and elbow flexed to 70 degrees, valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line

• positive is reproduction of the pt’s pain

what is the lateral pivot shift?

• assesses posterolateral rotatory instability of the elbow (maybe due to tear of LUCL)

• performed with the patient in supine, full ER and supination. apply valgus and axial force as the elbow is flexed

• positive test is apprehension, relocation clunk at 40-70 degrees, dimple proximal to radial head may be present at 40 degrees due to dislocation

what is important to note about the sensitivity of the lateral pivot shift test?

is 100% sensitive in anesthetized patients but only 38% in awake patients!

what is the hook test?

• evaluates for biceps tendon rupture.

• With the patient's arm in a neutral position, the examiner inserts their index finger under the biceps tendon at the antecubital fossa and attempts to "hook" it, assessing the integrity if there is a palpable defect.

• positive test is the absence of a cord-like structure

what is popeye’s sign ?

refers to the noticeable bulging of the biceps muscle when there is a rupture of the biceps tendon at the shoulder

what is mill’s test?

• evaluates for lateral epicondylitis

• clinician palpates the lateral epicondyle with one hand with passively pronating the pts forearm and flexing the wrist with the elbow extended

• positive is reproduction of lateral elbow pain

is mills a sensitive or specific test?

specific! (100% specificity)

what is maudsley’s test?

• evaluates lateral epicondylalgia

• with the pt sitting, elbow extended, and forearm pronated the clinician palpates teh lateral epicondyle and resists extension of the 3rd finger at the proximal phalanx, this loads the extensor digitorum and the ECRB

• positive sign is reproduction of lateral elbow pain

• test is 88% sensitive

what is a useful cluster for lateral epicondylalgia?

• cozens

• mills

• maudsley’s

how can you use grip dynamometer to assess lateral epicondylalgia?

• with the pt seated with the arm adducted and the forearm neutral, have the pt squeeze dyna with as much force as possible first with the elbow flexed to 90 and then again with the elbow extension

• positive test is a decrease in grip strength of 5%, 8%, and 10%

where might the ulnar nerve be entrapped?

• at the cord

• in the arm at the arcade or struthers

• in the elbow at the cubital tunnel behind the medial epicondyle or between the FCU heads

• in the forearm under the FCU, dorsal cutaneous branch above the wrist

• in guyon’s canal in the wrist which splits into a superficial sensory and deep motor branch

what is claw hand?

when the 4th and 5th joints had MCP hyperextension and IP flexion, is a result of ulnar nerve palsy distally, causing dysfunction in the intrinsic muscles of the hand.

which tests are used to assess the ulnar nerve?

• elbow flexion test

• wartenberg’s sign

• tinel’s sign

• froment’s sign

• ULNT 3 (ulnar bias)

what is the elbow flexion test?

• used to assess ulnar nerve

• fully flex elbow with wrist extension, shoulder depression for 3-5 minutes (most symptoms will present within 1 min)

• positive sign in reproduction of ulnar symptoms

what is tinel’s test?

tapping over the ulnar nerve in the cubital tunnel, positive test is tingling in the ulnar nerve distribution

what is froment’s sign?

• test for weakness of adductor pollicis muscle and dysfunction of ulnar nerve

• hold piece of paper tightly in pinch grip with extended terminal phalanx of thumb and pull paper away

• positive test is terminal phalanx flexion

what are the symptoms of pronator syndrome (entrapement of median nerve between the pronator heads)?

• aching volar forearm

• parasthesias in lateral 3 ½ digits and the thenar palm

• worse with repetitive pronation and gripping

• night symptoms uncommon

what are the symptoms of AIN syndrome (anterior interosseus nerve entrapped at the proximal forearm)?

• purely motor, no sensory loss

• weak FPL, FDP index and pronator quadratus

• cannot make an OK sign, pinches with flat pulps

• vague proximal forearm pain

what is the presentation of carpal tunnel syndrome (entrapment under transverse carpal ligament)?

• night paresthesias on lateral 3 ½ digits

• shaking the hand relieves symptoms

• thenar palm sensation spared

• later: thenar atrophy, weak abduction and opposition

what is hand of benedicition?

due to proximal lesion of the median nerve, on attempt of making a fist the index and middle finger stay extended

what is ape hand?

is a hand posture resulting from median nerve dysfunction, characterized by the inability to oppose the thumb and atrophy of the thenar muscles, causing the thumb to rest in line with the fingers.

what is the pinch grip test?

• assessment of the anterior interosseus nerve

• weakness to FPL and lateral half of FDP, pronator quadratus or median nerve dysfunction

• no sensation loss

• positive sign is the inability to make the OK sign with tip to tip

what tests are appropriate for examination of the median nerve at the elbow?

• pronator compression

• OK sign/pinch

• ULNT 1 (median bias)

what are the symptoms of radial nerve entrapement at the spiral groove?

• wrist and finger drop

• weak brachioradialis and supination

• dorsoradial hand numbness

• triceps usually spared

what are the symptoms of radial tunnel syndrome (entrapment of PIN at the arcade of frohse)?

• ache in lateral forearm, distal to the epicondyle

• pain with resisted supination

• no weakness or numbness

• mimics lateral elbow tendinopathy

what are the symptoms of PIN syndrome?

• finger drop at the MCPs, weak thumb extension

• wrist extends into radial deviation (ECRL intact, ECU weak)

• no sensory loss

what are the symptoms of wartenberg’s syndrome?

• burning or numbness, dorsoradial hand and thumb

• tight watches, casts, handcuffs

• sensory only

what is wrist drop vs key split?

wrist drop is when grip is weakened even with intact finger flexors due to wrist extensor weakness; key split refers to wrist drop due to lesion above the elbow, finger drop with wrist extension points to PIN involvement

what are performance based outcome measures that may be used for elbow?

• closed kinetic chain upper extremity stability test

• functional impairment test- hand, neck, shoulder, arm

what are patient reported outcome measures that may be used?

• DASH (higher means more disability)

• QuickDASH (higher means more disability)

• DASH modules

• MEPS

• ASES-E (higher means less disability)