Assessment of the Elbow

Assessment of the Elbow for Physiotherapy students

1. Assessment of the Elbow Dr Sreeraj S R, Ph.D.

2. About Elbow Hinge joint Humero ulnar, Radiohumeral Sup. Radioulnar) Common - childhood injuries Easily prone for stiffness Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.

3. Ulnohumeral (Trochlear) Joint Resting position: 70° elbow flexion, 10° supination Close packed position: Extension with supination Capsular pattern: Flexion, extension Radiohumeral Joint Resting position: Full extension and full supination Close packed position: Elbow flexed to 90°, forearm supinated to 5° Capsular pattern: Flexion, extension, supination, pronation Superior Radioulnar Joint Resting position: 35° supination, 70° elbow flexion Close packed position: 5° supination Capsular pattern: Equal limitation of supination and pronation 3

4. Common Complaints Pain Swelling Stiffness Deformity Instability Paraesthaesias / neuro. manifestations 4

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8. Osteokinematics of the Elbow 8

9. Arthrokinematics for Elbow 9

10. 10 Elbow pain management algorithm. Javed M et al, 2015

11. Assessment of the Elbow Introduce yourself Consent for history taking and physical examinations Patient history and pain history Observation Palpation Special tests Reflexes and cutaneous distribution Diagnostic imaging 11

12. Subjective Assessment 12

13. Get Ready Introduction (name, grade) Explain assessment procedure Verbal consent Chaperone as appropriate Wash hands with alcohol/gel Patient to be sitting and adequately exposed. Listen to chief complaint from patient/go through case file “Chaperone” a person who acts as a witness during a medical examination or procedure.

14. Patient History Name, Age, Occupation What was the mechanism of injury? How long had the problem? Does the static or intermittent? Are there any activities that increase or decrease the pain? Does pulling (traction), twisting (torque), or pushing (compression) alter the pain? Are there any positions that relieve the pain? Is there any deformity, bruising, wasting, or muscle spasm? Are any movements impaired? What is the patient unable to do functionally? What is the patient’s usual activity or pastime? Have any of these activities been altered or increased in the past month? Does the patient complain of any abnormal nerve distribution pain? Does the patient have a history of previous overuse injury or trauma? 14

15. Pain History Location Type Onset AF/RF Diurnal variations Timeline Mechanism of the injury- In the case of a traumatic event Presence of numbness or tingling? 15

16. Muscle Pain Referral Patterns 16 Brachioradialis Biceps brachii Flexor carpi radialis Flexor carpi ulnaris Extensor carpi ulnaris Extensor carpi radialis longus Extensor carpi radialis brevis Gulick D. 2009

17. Observation 17

18. Posture Carrying angle Fixed flexion deformity Swellings Ecchymosis Deformities Muscle wasting Rheumatic nodules Gouty tophi Bursitis Skin changes Psoriatic plaques Scars Symmetry. Observe

19. Carrying Angle Expose the area and Look for; Normal carrying angle. In males, a normal angle is 5 to 10 degrees; In females, a normal angle is 10 to 15 degrees If the carrying angle is; > 15°, it is cubitus valgus; < 5° to 10°, it is cubitus varus 19 Axis of forearm Carrying angle Gulick D. 2009

20. Carrying Angle 20 Gunstock deformity Cubitus varus Cubitus valgus

21. 21 Olecranon Bursitis Tuberculosis of Elbow

22. Triangle sign 22 Isosceles triangle in 900 elbow flexion Elbow fully extended; the three points normally form a straight line. If there is a disruption of bone or cartilage, the distance between the apex and the base decreases and the isosceles triangle no longer exists.

23. Deformities 23

24. Palpation 24

25. Temperature changes Bony tenderness at; Lateral and Medial Epicondyles Olecranon Process Radial Head Joint line tenderness Nodules Boggy swelling.

26. Palpation Wrist Extensor Muscles 26 Gulick D. 2009 ECRL & B ED ECU

27. Palpation Wrist Flexor Muscles 27 Gulick D. 2009 Pronator teres FCR PL FCU

28. EXAMINATION 28

29. Active Movements Flexion of the elbow (140° to 150°) Extension of the elbow (0° to 10°) Supination of the forearm (90°) Pronation of the forearm (80° to 90°) If, in the history, the patient has complained that combined movements, repetitive movements, or sustained positions cause pain, these specific movements should be included in the active movement assessment.

30. Passive Movements Passive Movements and Normal End Feel Elbow flexion (tissue approximation) Elbow extension (bone-to-bone) Forearm supination (tissue stretch) Forearm pronation (tissue stretch) 30

31. Resisted Isometric Movements Elbow flexion Elbow extension Supination Pronation Wrist flexion Wrist extension 31

32. Resisted Isometric Movements Stresses contractile tissues Isometric contraction of specific muscles "Neutral" joint position - don't allow joint motion Possible Responses & Reasons 32 Type of response Possible tissues involved Strong and pain free : No lesion of the contractile unit Strong and painful : First- or second-degree local lesion Weak and painful : Major lesion of a muscle, tendon OR a fracture Weak and pain free : A third-degree strain, complete avulsion #, peripheral nerve or nerve root involvement.

33. Functional Assessment Liverpool elbow score American Shoulder and Elbow Surgeons-E (ASES-E) The Disability of Arm, Shoulder and Hand (DASH) & Quick-DASH Mayo elbow performance index Oxford elbow score Patient-Rated Tennis elbow evaluation Barthel Index Lawton - Brody Instrumental Activities of Daily Living Scale (I.A.D.L.) 33

34. Special Tests 34

35. TENNIS ELBOW Commonly known as tennis elbow Occurs in mostly 30-50 years age group Due to degeneration of the tendon fibres over the lateral epicondyle which are involved in wrist extension severe burning pain on outside of elbow Pain worse on gripping or lifting objects and with direct pressure over lateral epicondyle Pain may radiate down forearm

36. Cozen’s test The patient’s elbow is stabilized by the examiner’s thumb, which rests on the patient’s lat. epicondyle. The patient is then asked to make a fist, pronate the forearm, and radially deviate and extent the wrist while the examiner apply resistance. A positive sign is sudden severe pain in the area. Tests ECRL & ECRB

37. Mill’s test While palpating lat. epicondyle, the examiner passively pronate the patient’s forearm, flexes the wrist fully and extends the elbow. A positive test is indicated by pain over the area. Tests ECRL & ECRB

38. Tennis Elbow test/ Maudsley's Lateral Epicondylitis Test Patient sitting with forearm rested on a plinth. Forearm pronated. The examiner resists extension of the third digit of the hand distal to the proximal IP joint, stressing the ED muscle and tendon. A positive test indicated by pain over the area

39. The Chair Test Ask the patient to attempt to lift a chair with elbow straight and shoulders flexed to 60° Difficulty to perform and complain of pain over lat. aspect is a positive sign

40. Thomson’s test Ask the patient to clench the fist, dorsiflex the wrist and extend the elbow. Tester does a forceful palmar flexion against patient’s resistance Pain over the area is a positive sign

41. Golfer’s Elbow Also known as Medial epicondylitis Similar to Tennis elbow Most common in men 20-50 years Pain over medial elbow, may radiate down inner forearm Pain worse when make fist/shake hands

42. Golfer’s elbow test Flex the elbow, supinate the hand, and then extend the elbow. Pain over the med. epicondyle is a positive sign.

43. Olecranon Bursitis Infection/inflammation of bursa Causes- Trauma Prolonged pressure Infection Medical conditions e.g. rheumatoid arthritis/gout

44. Medial Ligamentous Injuries MCL/ UCL/ ”Little Leaguer’s Elbow” Usually injured due to valgus trauma (acute) or repetitive overhead throwing activities (chronic) Valgus stress test Elbow flexed 25-30 degrees. Abduction or valgus force is applied to the distal forearm while the ligament is palpated The examiner feels the ligament tense when stress is applied

45. Lateral Ligamentous Injuries If LCL damaged, varus opening present with stress Varus laxity increases with annular ligament injury due to separation of head of radius from ulna Varus stress test – Elbow flexed 25-30° and stabilized with the examiner’s hand. An adduction force is applied by the examiner to the distal forearm. The examiner feels the ligament tense when stress is applied

46. Posterolateral Instability Posterolateral Rotatory Instability (PLRI) of the elbow instability is common in cases of ulna/radius displacement. Posterolateral Rotary Apprehension Test/ The Lateral Pivot-Shift Patient lies supine with arm to be tested overhead. Grasp patient’s wrist & extend elbow. A mild supination force applied to forearm at wrist. Patient's elbow is then flexed while a valgus stress and compression applied to elbow. If there is PL instability a look of apprehension will become evident as the elbow moved to flexion.

47. Cubital Tunnel Syndrome Tinel Sign: The area of ulnar nerve in the groove between olecranon process and med. epicondyle is tapped. A + ve sign is indicated by tingling sensation in ulnar distribution distal to the point of compression. This indicates point of regeneration of sensory fibers. The most distal point at which abnormal sensation felt represents the limit of nerve regeneration.

48. Scratch Collapse Test For evaluation of carpal and cubital tunnel syndrome The patient faces the examiner in sitting position with arms adducted, elbows flexed, and hands outstretched with wrists at neutral. The examiner asks the patient to externally rotate both the shoulders. The examiner resist the external rotation movement by placing the hands over the lateral aspect of the forearm and give an inward force. The patient is instructed to resist the force applied by the examiner. Next, the examiner “scratches” or swipes with fingertips over the area of nerve compression. The procedure mentioned above is immediately repeated. Brief temporary loss of the patient’s external resistance tone is considered a positive scratch collapse test 48

49. Scratch Collapse Test Basis of the Test Painful cutaneous stimulus has been noted to cause a period of inhibition in tonic voluntary muscle activity. It is generally thought to be an inhibitory spinal reflex that may play a protective role in facilitating withdrawal of a limb from potentially harmful stimuli 49

50. Wartenberg’s Sign Sitting with hands on table. The examiner passively spreads fingers apart and asks patient to bring them together. Inability to bring little finger close indicates Ulnar neuropathy.

51. Elbow Flexion Test Patient is asked to fully flex elbow with extension of the wrist and shoulder girdle abduction and depression and hold it for 3 to 5 minutes. A positive test is indicated by tingling or parasthesia in ulnar nerve distribution The test is confirmatory for cubital tunnel syndrome

52. Ulnar nerve injuries Loss of sensation as shown Motor supply to small muscles of hand except thenar muscle and 1st two lumbricals Produces decreased grip strength

53. Median Nerve Injury Occasionally damaged in supracondylar fractures More commonly in wrist lacerations Produces loss of sensation as shown High injuries produce decreased strength in wrist flexion, loss of ulna deviation and thumb opposition

54. Median Nerve Injury Test For Pronator Teres Syndrome : Patient sits with elbow flexed to 90°. Examiner strongly resists pronation as the elbow is extended. A positive test is indicated by tingling or parasthesia in median nerve distribution. Also called humerus supracondylar process syndrome

55. Pinch Grip Test Patient is asked to pinch the tips of index and thumb together. If patient is unable to pinch tip to tip and have a pulp to pulp pinch it is indicative of injury to ant. interosseous nerve, branch of median nerve.

56. Ant. Intr. Nerve Can be entrapped as it passes between the two heads of pronator teres muscle known as ant. intr. nerve syndrome or Kilho -Nevin syndrome Pinch deformity

57. Radial Nerve Injury can be due to trauma or compression in between the two heads of supinator in the arcade or canal of Frohse Can also be a radial tunnel syndrome Compression of superficial branch of radial nerve as it passes under the tendon of brachioradialis. Only sensory changes and patient complaints of nocturnal pain along the dorsum of wrist, thumb and web space Known as Cheiralgia parasthetica or Wartenberg’s disease

58. Dermatomes C5 – lateral arm C6 – lateral forearm, thumb and index finger C7 – posterior forearm and middle finger C8 – medial forearm, ring and little fingers T1 – medial arm Except T2 all other dermatomes extend distally to forearm and hand

59. Myotomes C5 – shoulder abduction C6 – elbow flexion, wrist extension C7 – elbow extension, wrist flexion C8 – finger flexion/grip strength T1 – finger abduction/adduction

60. Cutaneous distribution Pain may be referred to the elbow and surrounding tissues from neck, often mimicking Tennis Elbow, shoulder or wrist.

61. REFLEXES Biceps (C5,C6) Brachioradialis (C5-C6) Triceps (C7- C8)

62. Cervical radiculopathy Affecting C6 will involve biceps, brachioradialis, supinator and part of triceps. The triceps reflex is the one usually most affected. Any sensory loss affects the thumb and index finger. 62

63. References Gulick D. Ortho Notes : Clinical Examination Pocket Guide. 2nd ed. F.A. Davis; 2009:84-98. Magee DJ. Orthopedic Physical Assessment. 6th ed. Saunders; 2014: 388-428. Buckup K, Buckup J. Clinical Tests for the Musculoskeletal System: Examinations, Signs, Phenomena. 2008. 3rd ed., Stuttgart, Thieme , 2016, pp. 138–154. Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to assessment and management in primary care. Br J Gen Pract . 2015;65(640):610-612. doi:10.3399/bjgp15X687625 63