Introduction Steps to physical exam Inspection Palpation Range of Motion Stability Motor Sensory Vascular Provocative tests Inspection Skin Swelling patients with elbow effusion will generally hold elbow flexed at 70-80 degrees flexion at rest position of maximal elbow capsular distension fullness of the elbow soft spot (confluence of the radial head, lateral epicondyle and olecranon) Hypertrophy Elbow carrying angle in full extension, normal carrying angle is ~11 degrees in men and ~13 degrees in women will be higher in the throwing athlete Olecranon bursitis Clinical pearls cubital tunnel syndrome 1st dorsal interossei/1st webspace atrophy clawing of small and ring finger more commonly seen with Guyon's canal compression due to unopposed FDP flexion distal biceps tendon rupture medial ecchymosis and swelling change in contour of muscle, proximally varying degree of proximal retraction of the muscle belly “reverse Popeye sign” Palpation Bony prominences olecranon medial epicondyle lateral epicondyle radial head best palpated while rotating forearm from pronation to supination Muscles and soft tissues including flexor-pronator mass extensor mass origin olecranon bursa MCL insertion palpated just distal to medial epicondyle with elbow in 50-70 degree flexion to move flexor-pronator mass anterior LCL insertion Clinical pearls MCL injuries tenderness over MCL origin (just inferior to medial epicondyle) best assessed with elbow at 50-70 degrees in flexion to move the flexor pronator mass anterior to MCL Valgus extension overload tender to palpation over posteromedial olecranon Cubital tunnel syndrome subluxation of ulnar nerve over medial epicondyle with elbow coming from extension to flexion this hypermobility occurs in 33% of adults and is not necessarily associated with cubital tunnel syndrome important to differentiate from snapping medial head of triceps over medial epicondyle (which occurs in resisted elbow extension from a fully flexed elbow) Radial tunnel syndrome maximal tenderness is 3-5cm distal to lateral epicondyle more distal than lateral epicondylitis Lateral epicondylitis point tenderness at ECRB insertion into lateral epicondyle few mm distal to tip of lateral epicondyle unlike radial tunnel syndrome which exhibits tenderness 3-5 cm distal to epicondyle Medial epicondylitis tenderness 5-10 mm distal and anterior to medial epicondyle soft tissue swelling and warmth if inflammation present Range of Motion Check passive and active motion of both sides Check for crepitus and mechanical blocks Flexion-extension normal: 0-140 loss of full extension can be seen in professional throwers even in absence of pathology functional: 30-130 soft end point indicates effusion or capsular tightness firm end point indicates mechanical block (loose body, fracture, osteophyte) Pronation-supination check with shoulders fully adducted and elbow at 90 degrees normal pronation: 75 normal supination 85 functional: 50 pronation, 50 supination Stability Varus Stability Valgus Stability flex elbow to 20 to 30 degrees (unlocks the olecranon), externally rotate the humerus, and apply valgus stress tests integrity of MCL Motor Strength Elbow Flexion in full supination primary brachialis and biceps (C5 and C6) in neutral rotation (thumb pointing to ceiling) primarily brachioradialis (C6) Elbow Extension triceps (C7) Wrist Pronation flexor-pronator mass (C7, C8) Wrist Supination primarily biceps (C6) Wrist Extension ECRL, ECRB, ECU (C6-C8) Wrist Flexion FCR, FCU (C6-C8) Finger and thumb extension EDC, EPL (C7, C8) Finger and thumb flexion FDS, FDP, FPL (C7, C8) All small intrinsic movements of hand Lumbricals, interossei (T1) Clinical pearls cubital tunnel syndrome weak pinch from loss of thumb adduction (as much as 70% of pinch strength is lost) Froment sign compensatory thumb IP flexion by FPL (AIN) during key pinch compensates for the loss of MCP flexion by adductor pollicis (ulna n.) PIN syndrome finger metacarpal extension weakness wrist extension weakness inability to extend wrist in neutral or ulnar deviation the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent ECU (PIN) AIN syndrome postive OK sign (test FDP and FPL) patient unable to make OK sign pronator quadratus weakness shown with weak resisted pronation with elbow maximally flexed Sensory Sensation medial antebrachial cutaneous lateral antebrachial cutaneous posterior antebrachial cutaneous ulnar median superficial radial Clinical pearls cubital tunnel syndrome decreased 2-point discrimination over small finger and ulnar half of ring finger decreased 2-point discrimination over ulnar aspect of dorsal hand may discriminate cubital tunnel from more distal entrapment (dorsal branch of ulnar nerve branches 5 cm proximal to wrist) pronator syndrome sensory disturbances over the distribution of palmar cutaneous branch of the median nerve which arises 4 to 5 cm proximal to carpal tunnel unlike in carpal tunnel syndrome which does not exhibit sensory disturbances over palmar cutaneous nerve distribution Vascular Brachial artery palpable on the anterior aspect of the elbow, medial to the tendon of the biceps Radial artery Ulnar artery Provocative Tests - Stability MCL injuries milking maneuver creates valgus stress by pulling on the patient's thumb with the forearm supinated and elbow flexed at 90 degrees patient may be supine or seated/standing positive test is a subjective apprehension, instability, or pain at the MCL origin 87.5% sensitive with a negative predictive value of 100% moving valgus stress test place elbow in same position as the "milking maneuver" and apply a valgus stress while the elbow is ranged through the full arc of flexion and extension shoulder should be fully externally rotated during entire test positive test is a subjective apprehension, instability, or pain at the MCL origin between 70 and 120 degrees correlates in throwers to location of early acceleration (70 degrees flexion), and location of late cocking (120 degrees flexion) 100% sensitive and 75% specific LCL injuries lateral pivot-shift test patient lies supine with affected arm overhead; with shoulder fully externally rotated, forearm is supinated and valgus stress is applied while bringing the elbow from full extension to flexion at 40 degrees flexion, patient may feel pain and apprehension clunk appreciated at 40 degrees represents dislocated radiocapitellar joint with increased flexion, triceps tension reduces the radial head and another clunk may be appreciated often more reliable on anesthetized patient posterolateral rotatory drawer test with patient supine and elbow flexed to 40 degrees, forearm is supinated and the examiner's index finger is placed under the radial head and the thumb over it. application of an anterior-to-posterior force if performed over the lateral proximal forearm positive test is indicated by apprehension or presence of a skin dimple (indicating posterior subluxation of radial head) chair push-up test sitting on a chair, patient attempts to perform a pushup while holding on to handles with forearm supinated inability to do pushup or apprehension indicates a positive test. 87.5% sensitivity (100% when combined with prone push-up test) table-top relocation test 3-part test 1st part: patient places hand of symptomatic elbow around edge of table and is asked to perform press-up maneuver with elbow pointing laterally and forearm supinated pain and apprehension as elbow is gradually flexed indicates a positive test 2nd part: same maneuver as 1st part but examiner places thumb over patient's radial head during the maneuver relief of pain and apprehension indicates a positive test (as examiner's thumb should be preventing radial head subluxation) 3rd part: same as 1st part without examiner's thumb pain and apprehension during 1st and 3rd part with relief during 2nd part indicate posterolateral instability with an intra-articular radial head fracture, pain would be present in all 3 parts. prone push-up test patient unable to perform push-ups with forearm supinated 87.5% sensitivity (100% when combined with chair push-up test) Valgus extension overload pain with forced elbow extension valgus loading during terminal extension reproduces pain varus loading reduces pain Provocative Tests - Nerve Cubital tunnel syndrome Jeanne sign compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.) Wartenberg sign persistent small finger abduction and extension during attempted adduction secondary to weak intrinsics and unopposed action of EDM Masse sign palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion Tinel sign positive over cubital tunnel with elbow extended elbow flexion test positive when flexion of the elbow for > 60 seconds reproduces symptoms Radial tunnel syndrome resisted long finger extension test reproduces pain at radial tunnel (weakness because of pain) resisted supination test (with elbow and wrist in extension) reproduces pain at radial tunnel (weakness because of pain) passive pronation with wrist flexion reproduces pain at radial tunnel passive stretch of supinator muscle increases pressure inside radial tunnel to 250mmHg (normal 50mmHg) PIN syndrome resisted supination will increase pain symptoms normal tenodesis test tenodesis test is used to differentiate from extensor tendon rupture Pronator syndrome positive Tinel sign in the proximal anterior forearm but no Tinel sign at wrist provocative symptoms with wrist flexion as would be seen in CTS tests for specific sites of entrapment resisted elbow flexion with forearm supination (compression at bicipital aponeurosis) resisted forearm pronation with elbow extended (compression at two heads of pronator teres) resisted contraction of FDS to middle finger (compression at FDS fibrous arch) AIN syndrome distinguish from FPL attritional rupture (seen in rheumatoid) by passively flexing and extending wrist to confirm tenodesis effect in intact tendon if tendons intact, passive wrist extension brings thumb IP joint and index finger DIP joint into relatively flexed position Provocative Tests - Tendon Triceps tendon rupture modified Thompson squeeze test patient lies prone with the elbow at the end of the table and forearm hanging down triceps muscle is firmly squeezed inability to extend the elbow against gravity suggests complete disruption of triceps proper and lateral expansion Distal biceps tendon rupture Hook test performed by asking the patient to actively flex the elbow to 90° and to fully supinate the forearm examiner then uses index finger to hook the lateral edge of the biceps tendon. with an intact / partially torn tendon, finger can be inserted 1 cm beneath the tendon false positive partial tear intact lacertus fibrosis underlying brachialis tendon sensitivity and specificity 100% Ruland biceps squeeze test (akin to the Thompson/Simmonds test for Achilles rupture) elbow held in 60-80° of flexion with the forearm slightly pronated. one hand stabilizes the elbow while the other hand squeezes across the distal biceps muscle belly. a positive test is failure to observe supination of the patient’s forearm or wrist. sensitivity 96% biceps crease interval (BCI) measurement of the distance between palpable and anatomic biceps insertion patient elbow is brought from flexion to extension with forearm supinated and main crease in antecubital fossa is marked (crease) next, location of where distal biceps tendon turns most sharply toward antecubital fossa is marked (cusp) the distance between the crease and the cusp is the BCI values > 6 cm or 1.2x the value of contralateral arm are positive for biceps tendon rupture 92% sensitivity, 100% specificity passive forearm pronation test observation that the biceps muscle belly moves proximally with forearm supination and distally with forearm pronation (actively and passively) performing the hook test, passive forearm pronation test and BCI test in sequence results in 100% sensitivity and 100% specificity for complete biceps tendon rupture loss of more supination than flexion strength Lateral epicondylitis the following maneuvers exacerbate pain at lateral epicondyle resisted wrist extension with elbow fully extended and pronated resisted extension of the middle finger (Maudsley Test) selectively recruits fibers of the ECRB maximal flexion of the wrist passive wrist flexion in pronation causes pain at the elbow chair Test with elbow fully extended, forearm pronated and shoulder forward flexed, patient is asked to lift a chair lateral elbow pain is positive for lateral epicondylitis. Medial epicondylitis pain with resisted forearm pronation and wrist flexion no instability or apprehension with valgus stress or milking maneuver used to differentiate from MCL injuries.
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