of the Elbow Anthony A. Romeo, MD Professor, Department of Orthopedics Head, Section of Shoulder and Elbow Surgery Rush University President-Elect, American Shoulder Elbow Surgeons Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics Today 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 1
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 Palpate Median Nerve Median Nerve 2
Biceps Biceps Hook Test Palpate biceps Hook test Hook Test Lateral Elbow Lateral epicondylitis Capitellar OCD Radiocapitellar arthritis Synovial plica Contusion hit by pitch Symptoms Lateral Epicondylitis Lateral elbow pain Painful wrist flexion Painful resisted extension Decrease grip strength Tender ECRB Pain with resisted wrist and long finger extension 3
Lateral Epicondylitis Radiocapitellar Plica Plica Posterior Elbow Triceps tendinitis Posterior/posterior medial impingement Loose body Olecranon stress fracture/reaction 4
Bounce Test Arm Bar Test Ulnohumeral Chondromalacia Medial elbow UCL tear Stress reaction Flexor Strain Medial epicondylitis Ulnar nerve Snapping triceps Flexor Pronator UCL Injuries Presentation UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test 5
UCL Injuries Presentation UCL Injuries Presentation UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test O Driscoll et al AJSM 2005 Milking Maneuver Milking Maneuver 6
Moving Valgus Stress Test Moving Valgus Stress Test Compression Hypertrophy of the medial head of triceps Glousman RE, et al, 1990 Subluxation 16% of pop ulnar nerve instability Repetitive throwing causes repetitive nerve instability - neuritis Snapping Triceps Under-diagnosed Unrecognized dislocation of med head of triceps cause of failed ulnar nerve transposition Spoinner et al J Neurosurg CASE CASE: Snapping triceps 7
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 8
8 months s/p TJ surgery Post UCL Reconstruction Post UCL Cohen, MS. Elbow Instability: Surgeon s Management. Rehabilitation of the hand and upper extremity. 6th edition. Elsevier. Philadelphia, PA. 2011 54 9
UCL Injuries Presentation American Journal or Orthopedics, 2015 UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test UCL Injuries Presentation UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test UCL Injuries Presentation UCL tenderness to palpation Pain / apprehension / instability valgus stress Moving valgus stress test O Driscoll et al AJSM 2005 Compression Hypertrophy of the medial head of triceps Glousman RE, et al, 1990 10
Subluxation Test Subluxation 16% of pop ulnar nerve instability Repetitive throwing causes repetitive nerve instability - neuritis Snapping Triceps Under-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 11
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 8 months s/p TJ surgery Post UCL Reconstruction 12
Post UCL Physical Exam: Palpation Lateral lateral epicondyle radial head Medial medial epicondyle ulnar notch / ulnar nerve American Journal or Orthopedics, 2015 Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006. Physical Exam: Palpation Posterior triceps olecranon tip Anterior biceps common flexor muscle group median nerve 76 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, Physical Exam: Motion 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 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 13
Jupiter et al. The Assessment and Management of the Stiff Elbow. AAOS Instructional Course Lectures, Volume 52, 2003 79 Physical Exam: Strength Physical Exam: Stability 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 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 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 14
Elbow ROM & Subluxation Valgus Stress Test 15