Making the Clinical Diagnosis in Elbow Injury · Medial elbow pain reproduced with valgus stress...
Transcript of Making the Clinical Diagnosis in Elbow Injury · Medial elbow pain reproduced with valgus stress...
Making the Clinical Diagnosisin Elbow Injury
Christian Veillette MD MSc FRCSCAssistant Professor, University of TorontoShoulder & Elbow Reconstructive Surgery
Toronto Western Hospital @ University Health NetworkUTOSM @ Women’s College Hospital
Email: [email protected]
Objectives
• to understand the important clinical history to distinguish from other diagnoses
• to understand the physical examination maneuvers that differentiate between causes of elbow pain
• to understand how the physical tests work
Introduction
• Cause of elbow pain often misdiagnosed
• Physicians often rely on MRI/US to “diagnose” elbow problems
• Physical examination of the elbow remains unsolved problem for many physicians
– Lack of familiarity with the elbow anatomy– Wide variety of elbow diseases
http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html
History is the key!
• Each question should have specific purpose that affects decision-making
• 7 “Questions”1. Demographics (Age, Handedness, Occupation) – How old are you?
What hand do you write with? What do you do for a living?2. Duration/Onset/Trauma – When did the pain start? What were you
doing? Has the pain gotten worse or better? (Acute, Chronic, Gradual, Progressive)
3. ***Location - Point with 1 finger where the pain is the worst?4. Severity - Does the pain keep you up at night? What % of normal is
your elbow?5. Precipitating factors – What activities make your pain worse? What
activities are you unable to do because of the pain?6. Treatment – Have you had any treatment? – NSAIDs, Physio, Injection7. Associated symptoms – Do you have any numbness or tingling in your
hand or neck pain?
Elbow ROM
Medial elbow pain
• 25 yo male, RHD college pitcher
• Medial elbow pain with throwing
• Progressively worsened over last 3 starts
• Unable to pitch• Loss of velocity – 10-15 mph• Intermittent tingling small
finger with pitching
Medial elbow pain DDx
• 6 causes of medial elbow pain1. Medial collateral ligament insufficiency2. Medial epicondyl”itis”/FPO tear3. Ulnar neuritis4. Subluxating/snapping medial triceps5. Posteromedial trochlear chondral lesion6. Posteromedial impingement/Fractured
osteophyte/Loose bodies
1. Medial collateral ligament insufficiency
Presentation• Overhead athlete (throwing
sports, tennis)• Medial sided elbow pain
– Insidious (acute “pop” uncommon)– Only when playing/throwing
• Late cocking/early acceleration phase
• Loss of control / velocity / performance
• May be associated with ulnar neuritis
Exam• Tenderness at MCL• +/- pain on static valgus stress• Positive MVST/milking
maneuver• Often have additional findings
of DDx
• Diagnostic Test(s)– Moving Valgus Stress Test– Milking maneuver
Moving Valgus Stress Test (MVST)
• Medial elbow pain reproduced with valgus stress while moving elbow from flexion to extension (shear angle 120o –70o, max at 90-95o)
• Biomechanical rationale for MVST– Recreates internal shear stresses in MCL of throwing
• Algorithm for diagnosing MCL in medial elbow pain
– Is pain coming from MCL? – MVST– Is the MCL lax? – Valgus stress test– Is MCL torn (partial/complete)? – Surgical exploration
O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medialcollateral ligament tears of the elbow. Am J Sports Med. 2005 Feb;33(2):231-9.
Moving Valgus Stress Test
O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medialcollateral ligament tears of the elbow. Am J Sports Med. 2005 Feb;33(2):231-9.
2. Medial epicondyl”itis”/FPO tear
Presentation• Pain with activities requiring
active wrist flexion / forearm pronation
• History of non-throwing overuse
• Acute episode resisted eccentric wrist flexion /forearm pronation
Exam• Tender “medial epicondyle”• Palpable defect at origin• Pain pressing against cheek
with extended middle finger• T.E.S.T (Tennis Elbow Shear
Test)
3. Ulnar neuritis
Presentation• Pain radiates into medial
forearm and hand• Paresthesia / dysesthesia /
hypoesthesia in 4th and 5th
fingers• Occasional hand clumsiness
and weakness
Exam• Tinels• Tenderness – 3 locations• Subluxation
4. Subluxing/Snapping medial triceps
Presentation• History of weight-lifting• Painful posteromedial snaps
with elbow flexion• May be associated with ulnar
neuritis
Exam• Subluxation• 2 snaps• Push-Up Test• Tenderness posteromedial –
usually at intermuscular septum
Snapping medial head of triceps
Spinner RJ, Goldner RD. Snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve. Anatomical and dynamic factors. J Bone Joint SurgAm. 1998 Feb;80(2):239-47.
5. Posteromedial trochlear chondral lesion
Presentation• Young athlete with joint laxity• Baseball / volleyball / tennis –
shear injury• Medial pain mostly in
deceleration / follow-through
Exam• “Trochlear Shear Test” – pain
on MVST at 40-10o
6. Posteromedial impingement/Fracture osteophyte/Loose bodies
Presentation• Posteromedial pain mostly in
terminal extension• Loss of elbow extension• Mechanical symptoms
(catching/locking)
Exam• “Posterior Impingement Test” –
pain on passive terminal extension
Lateral elbow pain
• 25 yo female, soccer player• Fall onto outstretched arm
during slide tackle• Immediate pain, primarily
laterally• Swollen, painful ROM x weeks• Told “sprained” elbow• Lateral elbow pain lifting
backpack• Feels “click/pop” when
pushes up with it• Doesn’t trust her elbow
Lateral elbow pain DDx
• 6 causes of lateral elbow pain1. Posterolateral rotatory instability2. Lateral epicondyl”itis”/CEO tear3. P.I.N entrapment4. Radiocapitellar plica5. Capitellar OCD6. Radiocapitellar arthritis
1. Posterolateral rotatory instability
Presentation• History of:
– Previous trauma (dislocation, fracture-dislocation, sprain)
– Chronic attrition (long-standing cubitusvarus deformity, long-term crutch walkers)
– Iatrogenic injury (previous lateral sided elbow surgery)
• Instability may manifest as:– Recurrent dislocation– Subjective instability– Mechanical symptoms (snapping,
popping, catching)– Lateral sided elbow pain
• Difficulty with resisted elbow extension (pushing-up from seat)
• May be associated with lateral epidondylitis
Exam• Diagnostic Test(s)
– Posterolateral Rotatory Drawer Test
– Lateral Pivot-Shift Test– Lateral Pivot-Shift Apprehension
Sign– Push-Up Test
Posterolateral Rotatory Drawer Test
O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clinical Orthop Related Res. 2000 Jan;(37):34-43.
Lateral Pivot-Shift Test
O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow.J Bone Joint Surg Am. 1991 Mar;73(3):440-6.
2. Lateral epicondyl”itis”/CEO tear
Presentation• Chronic overuse (laborers,
computer use)• Pain with resisted wrist
extension/forearm supination• No history of instability• Acute episode of resisted
eccentric wrist extension / forearm supination
• Previous positive response to injections
• PLRI and lateral epicondylitis may coexist in the same patient
Exam• Tenderness lateral epicondyle
(ECRB origin)• Pain resisted wrist extension• Palpable defect at origin• Pain lifting laptop/folders out of
bag• T.E.S.T (Tennis Elbow Shear
Test)
3. PIN entrapment/Radial tunnel syndrome
Presentation• Pain located distal and radial
to the lateral epicondyle• Motor symptoms may occur
(rare)– Weakness in MCP joint extension– Radial deviation of the wrist when
wrist extension attempted
Exam• Tender 5-6 cm distal and
anterior to lateral epicondyle
4. Radiocapitellar plica
Presentation• Frequent history of trauma
(sprain, radial head fracture)• Normal range of motion• Painful lateral-sided
snapping/clicking– Usually between 90-110o of elbow
flexion with the forearm in pronation
Exam• Anterior
– Flexion-Pronation Plica Impingement Test
• Posterior– Extension-Supination Plica
Impingement Test
Anterolateral Plica - Flexion-Pronation PlicaImpingement Test
Antuna SA, O’Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy, 2001.
5. Capitellar OCD
Presentation• More common in pediatric
population• Throwing sports/Gymnastics• Associated stiffness (loss of
extension) and crepitus• Posterolateral pain• Occasional mechanical
symptoms (loose bodies)
Exam• “Capitellar Shear Test”
– valgus stress while moving, pain at ~45o
• Like MVST but in more extension and pain is lateral
6. Radiocapitellar OA
Presentation• Lateral elbow pain worsened
with gripping + rotation• Pain typically felt proximal
extensor muscles• Clicking and grinding with
rotation
Exam• Tender radiocapitellar joint• Crepitus with rotation• Resisted gripping + rotation
reproduces symptoms
Conclusions
• Physical examination of the elbow is a fundamental tool in the clinical diagnosis of elbow disorders
• The tests have to be performed correctly in order to be effective and preserve their accuracy
• Diagnosis of elbow pain can be determined with careful history and physical examination without need for imaging in most scenarios
Questions?
Anterior elbow pain
• 36 yo male, professional hockey goaltender
• Extended arm trying to make save
• Felt tearing sensation across arm
• Developed bruising down arm
• Anterior elbow pain with turning forearm
Anterior elbow pain DDx
• 5 causes of anterior elbow pain1. Distal biceps tear – partial or complete2. Cubital bursitis3. Bicipital tendonitis4. Anterior impingement syndrome5. Pronator syndrome
Distal biceps rupture
Presentation• Male patient• History of heavy weight-lifting• Sudden load on biceps
(usually eccentric)• Pop, tearing sensation• Anterior pain and weakness• Ecchymosis (proximal forearm)
delayed
Exam• May have altered biceps contour
(retracted)• No movement with pro-
supination (if rupture is complete)
• Bruising acutely• Weak supination – terminal• Pain/cramping with strength
testing/endurance• Diagnostic Test(s)
– “Hook Test”– Biceps crease interval– Squeeze test
Hook Test
O’Driscoll SW, Goncalves LBJ, Dietz P: The hook test for distal biceps tendonavulsion. Am J Sports Med. 35(11):1865-1869, 2007.
• Elbow flexed 90o, forearm fully supinated actively –examiner reaches under biceps tendon with index finger to “hook” tendon
• Abnormal hook test (no tendon to hook) = biceps rupture
Biceps Crease Interval
ElMaraghy A, Devereaux M, Tsoi K. The biceps crease interval for diagnosing complete distal biceps tendon ruptures. Clin Orthop Relat Res. 2008 Sep;466(9):2255-62. Epub 2008 Jun 13.
Normal BCI 4.8 +/- 0.6 cm, BCR 1.0 +/- 0.1BCI >6 or BCR >1.2 Sensitivity 96%
Squeeze Test
Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis ofdistal biceps tendon ruptures. Clin Orthop Relat Res. 2005 Aug;(437):128-31.