Updated: 1/6/2023

Elbow Physical Exam

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  • 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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