Updated: 4/13/2020

Elbow Physical Exam

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https://upload.orthobullets.com/topic/322131/images/arm_sensory_map..jpg
https://upload.orthobullets.com/topic/322131/images/mcl_and_medial_epicondyle_..jpg
https://upload.orthobullets.com/topic/322131/images/milking_maneuver..jpg
https://upload.orthobullets.com/topic/322131/images/right_1st_dorsal_interossei_atrophy..jpg
https://upload.orthobullets.com/topic/322131/images/modified_thompson_sign..jpg
https://upload.orthobullets.com/topic/322131/images/biceps_crease_test..jpg
Introduction
  • Steps to physical exam
    • Inspection
    • Palpation
    • Range of Motion
    • Stability
    • Motor
    • Sensory
    • Vascular
    • Provocative tests
1. 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” 
2. 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
3. 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
4. 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
5. Motor Strength
  • Elbow Flexion
    • in full supination
      • primary brachialis and biceps (C5 and C6)
    • in 90 degrees supination (thumb pointing to celing)
      • 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, FPL, 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
6. 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
7. Vascular
  • Brachial artery
    •  palpable on the anterior aspect of the elbow, medial to the tendon of the biceps
  • Radial artery
  • Ulnar artery
8. 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 post 
      • 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
9. 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
10. 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 post
    • no instability or apprehension with valgus stress or milking maneuver
      • used to differentiate from MCL injuries. 
 

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