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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
Physical Exam of the Elbow
Physical Exam of the Elbow
Elbow Physical Exam
Exam Strategy
• Divide elbow into 4 quadrants– Anterior
– Lateral
– Posterior
– Medial
• Examine each quadrant sequentially
Physical Exam of the Elbow
Physical Exam of the Elbow
Anterior Elbow
Anterior Elbow
• Often Vague Pain
• Humeral Stress Reaction
• Biceps tendinitis
• Cervical Radiculopathy
• Thoracic Outlet
• Median Nerve Compression
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Physical Exam of the Elbow
Venous Effort Thrombosis TOS
Physical Exam of the Elbow
Physical Exam of the Elbow
Pronator Syndrome
Physical Exam
• Forearm percussion test
• NEGATIVE Phalen’s Test/ Cubital Tinel’s
• Weak thenar muscles
• Anterior interossei muscles (FPL, FDP) spared
Physical Exam of the Elbow
Humerus and Median Nerve Palpation
Physical Exam of the Elbow
Median Nerve
Palpate Median Nerve
Physical Exam of the Elbow
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Physical Exam of the Elbow
Biceps
• Palpate biceps
• Hook test
Physical Exam of the Elbow
Biceps Hook Test
Physical Exam of the Elbow
Hook TestPhysical Exam of the Elbow Lateral Elbow
• Lateral epicondylitis
• Capitellar OCD
• Radiocapitellar arthritis
• Synovial plica
• Contusion – hit by pitch
Physical Exam of the Elbow
SymptomsSymptoms
• Lateral elbow pain
• Painful wrist flexion
• Painful resistedextension
• Decrease grip strength
Physical Exam of the Elbow
Lateral Epicondylitis
• Tender ECRB
• Pain with resisted wrist and long finger extension
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Physical Exam of the Elbow
Lateral Epicondylitis
Physical Exam of the Elbow
Radiocapitellar
Physical Exam of the Elbow
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
Physical Exam of the Elbow
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Physical Exam of the Elbow
Bounce Test
Physical Exam of the Elbow
Arm Bar Test
Physical Exam of the Elbow
Ulnohumeral ChondromalaciaPhysical Exam of the Elbow Medial elbow
• UCL tear
• Stress reaction
• Flexor Strain
• Medial epicondylitis
• Ulnar nerve
• Snapping triceps
Physical Exam of the Elbow
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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Physical Exam of the Elbow Physical Examination
• UCL tenderness to palpation
• Pain / apprehension / instability valgus stress
• Moving valgus stress test
UCL InjuriesPresentation
Physical Exam of the Elbow Physical Examination
• UCL tenderness to palpation
• Pain / apprehension / instability valgus stress
• Moving valgus stress test
UCL InjuriesPresentation
O’Driscoll et al AJSM 2005
Physical Exam of the Elbow
Physical Exam of the Elbow
Physical Exam of the Elbow
Milking Maneuver
Physical Exam of the Elbow
Milking Maneuver
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Physical Exam of the Elbow
Moving Valgus Stress Test
Physical Exam of the Elbow
Moving Valgus Stress Test
Physical Exam of the Elbow
Ulnar NerveCompression
Hypertrophy of the medial head of tricepsGlousman RE, et al, 1990
Physical Exam of the Elbow
Ulnar Nerve
Subluxation
• 16% of pop ulnar nerve instability
• Repetitive throwing causes repetitive nerve instability -neuritis
Physical Exam of the Elbow
Ulnar Nerve
Snapping TricepsUnder-diagnosed
• Unrecognized dislocation of med head of triceps cause of failed ulnar nerve transposition
Spoinner et al J Neurosurg
Physical Exam of the Elbow
CASE
CASE: Snapping triceps
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Physical Exam of the Elbow
Physical Exam of the Elbow
Ulnar NervePhysical Examination
• Palpate
• Assess subluxation
• Tinel’s sign
• Flex, abd, pron
Physical Exam of the Elbow
Ulnar NervePhysical Examination
• 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
Physical Exam of the Elbow
Ulnar Nerve
Physical Exam of the Elbow
Physical Exam of the Elbow
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Physical Exam of the Elbow
8 months s/p TJ surgery
Physical Exam of the Elbow Post UCL Reconstruction
Physical Exam of the Elbow
Post UCLPhysical Exam of the Elbow
Physical Exam of the Elbow
Physical 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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Physical Exam of the Elbow
American Journal or Orthopedics, 2015
Physical Exam of the Elbow Physical Examination
• UCL tenderness to palpation
• Pain / apprehension / instability valgus stress
• Moving valgus stress test
UCL InjuriesPresentation
Physical Exam of the Elbow Physical Examination
• UCL tenderness to palpation
• Pain / apprehension / instability valgus stress
• Moving valgus stress test
UCL InjuriesPresentation
Physical Exam of the Elbow
Physical Examination
• UCL tenderness to palpation
• Pain / apprehension / instability valgus stress
• Moving valgus stress test
UCL InjuriesPresentation
O’Driscoll et al AJSM 2005
Physical Exam of the Elbow
Physical Exam of the Elbow
Ulnar NerveCompression
Hypertrophy of the medial head of tricepsGlousman RE, et al, 1990
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Physical Exam of the Elbow
Ulnar Nerve Subluxation Test
Physical Exam of the Elbow
Ulnar Nerve
Subluxation
• 16% of pop ulnar nerve instability
• Repetitive throwing causes repetitive nerve instability -neuritis
Physical Exam of the Elbow
Ulnar Nerve
Snapping TricepsUnder-diagnosed
• Unrecognized dislocation of med head of triceps cause of failed ulnar nerve transposition
Spoinner et al J Neurosurg
Physical Exam of the Elbow
CASE
CASE: Snapping triceps
Physical Exam of the Elbow
Physical Exam of the Elbow
Ulnar NervePhysical Examination
• Palpate
• Assess subluxation
• Tinel’s sign
• Flex, abd, pron
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Physical Exam of the Elbow
Ulnar NervePhysical Examination
• 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
Physical Exam of the Elbow
Ulnar Nerve
Physical Exam of the Elbow
Physical Exam of the Elbow
Physical Exam of the Elbow
8 months s/p TJ surgery
Physical Exam of the Elbow Post UCL Reconstruction
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Physical Exam of the Elbow
Post UCL
Physical Exam of the Elbow
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 of the Elbow
Physical Exam: Palpation
• Posterior– triceps
– olecranon tip
• Anterior– biceps
– common flexor muscle group
– median nerve
Physical Exam of the Elbow
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,
76
Physical Exam of the Elbow
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 of the Elbow
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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Physical Exam of the Elbow
Jupiter et al. The Assessment and Management of the Stiff Elbow. AAOS Instructional Course Lectures, Volume 52, 2003
79
Physical Exam of the Elbow
Physical Exam of the Elbow
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 of the Elbow
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
Physical Exam of the Elbow
Elbow Specific Maneuvers
1. Elbow ROM and Ulnar Nerve Subluxation Test
2. Valgus Stress test
3. Milking Maneuver
4. Moving Valgus Stress Test
Physical Exam of the Elbow
Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006.
84
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Physical Exam of the Elbow
Elbow ROM & Ulnar Nerve Subluxation
Physical Exam of the Elbow
Valgus Stress Test
Physical Exam of the Elbow
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