Inspection of the Elbow - TRIA · Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006. American Journal or Orthopedics, 2015 Physical Exam of the Elbow Physical

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Physical Examinationof the Elbow

Anthony A. Romeo, MDProfessor, Department of Orthopedics

Head, Section of Shoulder and Elbow SurgeryRush University

President-Elect, American Shoulder Elbow SurgeonsTeam Physician, Chicago White Sox and Bulls

Chief Medical Editor, Orthopaedics Today

Physical Exam of the Elbow

Inspection

• Inspection– elbow is a subcutaneous joint

– deformity, effusion and atrophy easily detected

• Carrying angle– women 2-5 degrees > men

– changes with flexion / extension

• Lateral “dimple”– loss of lateral dimple indicative of effusion

• Posterior mass– olecranon bursitis



Elbow Physical Exam

Exam Strategy

• Divide elbow into 4 quadrants– Anterior

– Lateral

– Posterior

– Medial

• Examine each quadrant sequentially



Anterior Elbow

Anterior Elbow

• Often Vague Pain

• Humeral Stress Reaction

• Biceps tendinitis

• Cervical Radiculopathy

• Thoracic Outlet

• Median Nerve Compression

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Venous Effort Thrombosis TOS



Pronator Syndrome

Physical Exam

• Forearm percussion test

• NEGATIVE Phalen’s Test/ Cubital Tinel’s

• Weak thenar muscles

• Anterior interossei muscles (FPL, FDP) spared


Humerus and Median Nerve Palpation


Median Nerve

Palpate Median Nerve


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Biceps

• Palpate biceps

• Hook test


Biceps Hook Test


Hook TestPhysical Exam of the Elbow Lateral Elbow

• Lateral epicondylitis

• Capitellar OCD

• Radiocapitellar arthritis

• Synovial plica

• Contusion – hit by pitch


SymptomsSymptoms

• Lateral elbow pain

• Painful wrist flexion

• Painful resistedextension

• Decrease grip strength


Lateral Epicondylitis

• Tender ECRB

• Pain with resisted wrist and long finger extension

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Lateral Epicondylitis


Radiocapitellar


PlicaPhysical Exam of the Elbow

Plica

Physical Exam of the Elbow Posterior Elbow

• Triceps tendinitis

• Posterior/posterior medial impingement

• Loose body

• Olecranon stress fracture/reaction


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Bounce Test


Arm Bar Test


Ulnohumeral ChondromalaciaPhysical Exam of the Elbow Medial elbow

• UCL tear

• Stress reaction

• Flexor Strain

• Medial epicondylitis

• Ulnar nerve

• Snapping triceps


Flexor Pronator

Physical Exam of the Elbow Physical Examination

• UCL tenderness to palpation

• Pain / apprehension / instability valgus stress

• Moving valgus stress test

UCL InjuriesPresentation

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O’Driscoll et al AJSM 2005




Milking Maneuver


Milking Maneuver

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Moving Valgus Stress Test


Moving Valgus Stress Test


Ulnar NerveCompression

Hypertrophy of the medial head of tricepsGlousman RE, et al, 1990


Ulnar Nerve

Subluxation

• 16% of pop ulnar nerve instability

• Repetitive throwing causes repetitive nerve instability -neuritis


Ulnar Nerve

Snapping TricepsUnder-diagnosed

• Unrecognized dislocation of med head of triceps cause of failed ulnar nerve transposition

Spoinner et al J Neurosurg


CASE

CASE: Snapping triceps

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Ulnar NervePhysical Examination

• Palpate

• Assess subluxation

• Tinel’s sign

• Flex, abd, pron



• Elbow Flexion Test– With wrist extended,

hyperflex elbow and maintain flexion for 30 seconds

– Assess for pain, numbness, tingling

• Critical to discern UCL, VEO and flexor/pronator issues


Ulnar Nerve



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8 months s/p TJ surgery

Physical Exam of the Elbow Post UCL Reconstruction


Post UCLPhysical Exam of the Elbow



Cohen, MS. Elbow Instability: Surgeon’s Management. Rehabilitation of the hand and upper extremity. 6th edition. Elsevier. Philadelphia, PA. 2011

54

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American Journal or Orthopedics, 2015












Physical Examination





O’Driscoll et al AJSM 2005



Ulnar NerveCompression

Hypertrophy of the medial head of tricepsGlousman RE, et al, 1990

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Ulnar Nerve Subluxation Test


Ulnar Nerve

Subluxation

• 16% of pop ulnar nerve instability

• Repetitive throwing causes repetitive nerve instability -neuritis


Ulnar Nerve

Snapping TricepsUnder-diagnosed

• Unrecognized dislocation of med head of triceps cause of failed ulnar nerve transposition

Spoinner et al J Neurosurg


CASE

CASE: Snapping triceps




• Palpate

• Assess subluxation

• Tinel’s sign

• Flex, abd, pron

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• Elbow Flexion Test– With wrist extended,

hyperflex elbow and maintain flexion for 30 seconds

– Assess for pain, numbness, tingling

• Critical to discern UCL, VEO and flexor/pronator issues


Ulnar Nerve




8 months s/p TJ surgery

Physical Exam of the Elbow Post UCL Reconstruction

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Post UCL


Physical Exam: Palpation

• Lateral– lateral epicondyle

– radial head

• Medial– medial epicondyle

– ulnar notch / ulnar nerve

Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006.

American Journal or Orthopedics, 2015


Physical Exam: Palpation

• Posterior– triceps

– olecranon tip

• Anterior– biceps

– common flexor muscle group

– median nerve


1.Ruland, R. T., Dunbar, R. P. & Bowen, J. D. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin. Orthop. Relat. Res. 128–131 (2005).2.Ramsey, M. L. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg 7,

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Physical Exam: Motion

• Motion occurs in two axis– flexion - extension

– forearm supination, pronation

• Check for:– crepitus

– end points: painful?• soft - suggests soft tissue

• solid- suggests bony block

– active versus passive motion


Physical Exam: Motion

• Flexion - extension– Normal: 0 - 140 degrees ± 10 degrees

– Functional: 30 - 130 degrees

• Forearm Pronation – supination

• Measured from neutral– Control shoulder abduction

– Normal: pro75 ° sup 85 °

– Functional: pro/ sup 50°

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Jupiter et al. The Assessment and Management of the Stiff Elbow. AAOS Instructional Course Lectures, Volume 52, 2003

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Physical Exam: Strength

• Flexion / extension & pronation/supination strength testing:– conducted against resistance

– forearm in neutral : key

– elbow flexed 90 degrees

• Extension strength ~ 70% flexion strength

• Supination strength ~ 15% > pronation

• Dominant ~ 5 - 10% > nondominant

• Forces magnified ~ 10x from hand to elbow– Lever arm


Physical Exam: Stability

• Difficult to examine– especially with painful elbow

– Need relaxed patient

• Valgus instability assessed with:– humerus in full external rotation

– forearm in supination

• Varus instability assessed with:– humerus in full internal rotation

– forearm in pronation


Elbow Specific Maneuvers

1. Elbow ROM and Ulnar Nerve Subluxation Test

2. Valgus Stress test

3. Milking Maneuver

4. Moving Valgus Stress Test


Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006.

84

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Elbow ROM & Ulnar Nerve Subluxation


Valgus Stress Test


Documents

Inspection of the Elbow - TRIA · Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006. American Journal or Orthopedics, 2015 Physical Exam of the Elbow Physical