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Inspection Physical Examination of the Elbow • Inspection – elbow is a subcutaneous joint – deformity, effusion and atrophy easily detected Elbow • Carrying angle the – women 2-5 degrees > men of – changes with flexion / extension “ ”

Exam • Lateral dimple

– loss of lateral dimple indicative of effusion Anthony A. Romeo, MD Professor, Department of Orthopedics • Posterior mass Head, Section of Shoulder and Elbow Surgery

Rush University Physical President-Elect, American Shoulder Elbow Surgeons – olecranon bursitis Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics Today

Elbow Physical Exam

Exam Strategy Elbow Elbow • Divide elbow into 4 quadrants the the

– Anterior of of – Lateral – Posterior Exam Exam – Medial • Examine each quadrant sequentially Physical Physical

Anterior Elbow

Anterior Elbow • Often Vague Pain Elbow Elbow the the • Humeral Stress Reaction of of • Biceps tendinitis • Cervical Radiculopathy Exam Exam

• Thoracic Outlet • Median Nerve Compression Physical Physical

1 2/14/2017

Venous Effort Thrombosis TOS Elbow Elbow the the of of

Exam Exam

Physical Physical

Pronator Syndrome Humerus and Median Nerve Palpation Physical Exam • Forearm percussion test Elbow Elbow • NEGATIVE Phalen’s Test/ the the Cubital Tinel’s of of • Weak thenar muscles • Anterior interossei muscles Exam Exam (FPL, FDP) spared Physical Physical

Median Nerve

Palpate Median Nerve Elbow Elbow the the of of

Exam Exam

Physical Physical

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Biceps Biceps Hook Test

• Palpate biceps • Hook test Elbow Elbow the the of of

Exam Exam

Physical Physical

Hook Test Lateral Elbow Elbow Elbow

• Lateral epicondylitis the the

of of • Capitellar OCD

• Radiocapitellar arthritis Exam Exam • Synovial plica

Physical Physical • Contusion – hit by pitch

Symptoms Lateral Epicondylitis

• Tender ECRB • Pain with resisted wrist and long finger extension • Lateral elbow pain Elbow Elbow

• Painful wrist flexion the the of of • Painful resisted extension Exam Exam • Decrease grip strength Physical Physical

3 2/14/2017

Lateral Epicondylitis Radiocapitellar Elbow Elbow the the of of

Exam Exam

Physical Physical

Plica Plica Elbow Elbow the the of of

Exam Exam

Physical Physical

Posterior Elbow Elbow Elbow the the

• Triceps tendinitis of of • Posterior/posterior medial impingement • Loose body Exam Exam • Olecranon stress fracture/reaction Physical Physical

4 2/14/2017

Bounce Test Arm Bar Test Elbow Elbow

the the

of of

Exam Exam

Physical Physical

Ulnohumeral Chondromalacia Medial elbow Elbow Elbow • UCL tear the the • Stress reaction of of

• Flexor Strain Exam Exam

• Medial epicondylitis • Ulnar nerve • Snapping triceps Physical Physical

Flexor Pronator UCL Injuries Presentation

Physical Examination

Elbow Elbow • UCL tenderness to

palpation the the of of

• Pain / apprehension / instability valgus Exam Exam

stress • Moving valgus stress test Physical Physical

5 2/14/2017

UCL Injuries UCL Injuries Presentation Presentation

Physical Examination Physical Examination • UCL tenderness to

Elbow • UCL tenderness to Elbow

palpation palpation the the • Pain / apprehension / of of

• Pain / apprehension / instability valgus instability valgus stress Exam Exam

stress • Moving valgus stress • Moving valgus stress test test Physical Physical O’Driscoll et al AJSM 2005 Elbow Elbow the the of of

Exam Exam

Physical Physical

Milking Maneuver Milking Maneuver Elbow Elbow the the of of

Exam Exam

Physical Physical

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Moving Valgus Stress Test Moving Valgus Stress Test Elbow Elbow the the of of

Exam Exam

Physical Physical

Ulnar Nerve Ulnar Nerve Compression Hypertrophy of the medial head of triceps Subluxation Glousman RE, et al, 1990 • 16% of pop ulnar Elbow Elbow nerve instability the the • Repetitive throwing of of causes repetitive nerve instability - Exam Exam neuritis Physical Physical

Ulnar Nerve CASE Snapping Triceps CASE: Snapping triceps Under-diagnosed • Unrecognized Elbow Elbow dislocation of med

the head of triceps cause the of of

of failed ulnar nerve transposition Exam Exam

Spoinner et al J Neurosurg Physical Physical

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Ulnar Nerve Physical Examination

• Palpate Elbow Elbow • Assess the the of of

subluxation • Tinel’s sign Exam Exam

• Flex, abd, pron Physical Physical

Ulnar Nerve Ulnar Nerve Physical Examination • Elbow Flexion Test – With wrist extended, hyperflex elbow and Elbow Elbow maintain flexion for 30 the the seconds of of – Assess for pain, numbness, tingling Exam Exam

• Critical to discern UCL,

Physical VEO and flexor/pronator Physical issues Elbow Elbow the the of of

Exam Exam

Physical Physical

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8 months s/p TJ surgery

Post UCL Reconstruction Elbow Elbow the the of of

Exam Exam

Physical Physical

Post UCL Elbow Elbow the the of of

Exam Exam

Physical Physical Elbow Elbow the the of of

Exam Exam

Physical Physical

54 Cohen, MS. Elbow Instability: Surgeon’s Management. Rehabilitation of the hand and upper extremity. 6th edition. Elsevier. Philadelphia, PA. 2011

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UCL Injuries Presentation

Physical Examination Elbow Elbow • UCL tenderness to

palpation the the

of of

• Pain / apprehension / American Journal or Orthopedics, 2015 instability valgus Exam Exam

stress • Moving valgus stress test Physical Physical

UCL Injuries UCL Injuries Presentation Presentation Physical Examination Physical Examination • UCL tenderness to

Elbow • UCL tenderness to Elbow palpation palpation the the • Pain / apprehension / of of • Pain / apprehension / instability valgus stress instability valgus • Moving valgus stress Exam Exam stress test • Moving valgus stress test Physical Physical O’Driscoll et al AJSM 2005

Ulnar Nerve Compression Hypertrophy of the medial head of triceps Glousman RE, et al, 1990 Elbow Elbow the the of of

Exam Exam

Physical Physical

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Ulnar Nerve Subluxation Test Ulnar Nerve

Subluxation • 16% of pop ulnar Elbow Elbow nerve instability the the • Repetitive throwing of of causes repetitive nerve instability - Exam Exam neuritis Physical Physical

Ulnar Nerve CASE Snapping Triceps CASE: Snapping triceps Under-diagnosed • Unrecognized Elbow Elbow dislocation of med

the head of triceps cause the of of

of failed ulnar nerve transposition Exam Exam

Spoinner et al J Neurosurg Physical Physical

Ulnar Nerve Physical Examination

• Palpate Elbow Elbow • Assess the the of of

subluxation • Tinel’s sign Exam Exam

• Flex, abd, pron Physical Physical

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Ulnar Nerve Ulnar Nerve Physical Examination • Elbow Flexion Test – With wrist extended, hyperflex elbow and Elbow Elbow maintain flexion for 30 the the seconds of of – Assess for pain, numbness, tingling Exam Exam

• Critical to discern UCL,

Physical VEO and flexor/pronator Physical issues Elbow Elbow the the of of

Exam Exam

Physical Physical

8 months s/p TJ surgery

Post UCL Reconstruction Elbow Elbow the the of of

Exam Exam

Physical Physical

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Post UCL Physical Exam: Palpation

• Lateral – lateral epicondyle Elbow Elbow – radial head the the

• Medial of of – medial epicondyle – ulnar notch / ulnar nerve Exam Exam

Physical Physical American Journal or Orthopedics, 2015

Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006.

Physical Exam: Palpation

• Posterior – triceps – olecranon tip Elbow Elbow • Anterior the the – biceps of of – common flexor muscle group Exam Exam – median nerve Physical Physical

76 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,

Physical Exam: Motion Physical Exam: Motion

• Motion occurs in two axis • Flexion - extension – flexion - extension – Normal: 0 - 140 degrees ± 10 degrees – forearm supination, pronation – Functional: 30 - 130 degrees Elbow Elbow

• Check for: • Forearm Pronation – supination the the • Measured from neutral of – crepitus of

– end points: painful? – Control shoulder abduction ° ° Exam Exam – Normal: pro75 sup 85

• soft - suggests soft tissue • solid- suggests bony block – Functional: pro/ sup 50° – active versus passive motion Physical Physical

13 2/14/2017 Elbow Elbow

the the

of of

Exam Exam

Physical Physical

79 Jupiter et al. The Assessment and Management of the Stiff Elbow. AAOS Instructional Course Lectures, Volume 52, 2003

Physical Exam: Strength Physical Exam: Stability

• Flexion / extension & pronation/supination • Difficult to examine strength testing: – especially with painful elbow – conducted against resistance – Need relaxed patient Elbow Elbow

– forearm in neutral : key • Valgus instability assessed with: the the – humerus in full external rotation of – elbow flexed 90 degrees of

• Extension strength ~ 70% flexion strength – forearm in supination Exam Exam • Supination strength ~ 15% > pronation • Varus instability assessed with: • Dominant ~ 5 - 10% > nondominant – humerus in full internal rotation • Forces magnified ~ 10x from hand to elbow – forearm in pronation Physical Physical – Lever arm

Elbow Specific Maneuvers

1. Elbow ROM and Ulnar Nerve Subluxation Test

Elbow 2. Valgus Stress test Elbow

the the 3. Milking Maneuver of of

4. Moving Valgus Stress Test Exam Exam

Physical Physical

84 Netter FH. Atlas of Human Anatomy, 4th Edition. Elsevier, New York, NY. 2006.

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Valgus Stress Test Elbow ROM & Ulnar Nerve Subluxation Elbow Elbow

the the

of of

Exam Exam

Physical Physical Elbow

the

of

Exam

Physical

15