ELBOW

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CHAPTER 5

ELBOW
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Précis of the Elbow Assessment*

History

Observation

Examination

Active movements

Passive movements (as in active movements, if necessary)

Resisted isometric movements

Reflexes and cutaneous distribution

Special tests

Joint play movements

Palpation

Diagnostic imaging

*The entire assessment may be done with the patient in the sitting position. After any examination, the patient should be warned that symptoms may be exacerbated as a result of the assessment.

SELECTED MOVEMENTS

ACTIVE MOVEMENTS1 image

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Figure 5-1 Range of motion at the elbow.

Supination

PASSIVE MOVEMENTS1,2 image

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Figure 5-2 Testing passive movements of the elbow complex. A, Flexion. B, Extension. C, Supination D, Pronation.

RESISTED ISOMETRIC MOVEMENTS3,4 image

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Figure 5-3 Positioning for resisted isometric movements. A, Elbow extension. B, Elbow flexion. C, Forearm supination. D, Forearm pronation. E, Wrist flexion. F, Wrist extension.

TEST PROCEDURE

The muscles of the elbow are tested isometrically, with the examiner positioning the patient and saying, “Don’t let me move you.” From this position, the examiner tests elbow flexion, extension, supination, and pronation. Wrist extension and flexion also must be tested, because a large number of muscles act over the wrist as well as the elbow. The examiner should slowly and steadily build up resistance when testing isometric muscle strength.

CLINICAL NOTES

• If the patient has complained that combined movements under load, repetitive movements under load, or sustained positions under load cause pain, the examiner should carefully examine these resisted isometric movements and positions as well, but only after the basic movements have been tested isometrically.

• Muscle flexion power around the elbow is greatest in the range of 90° to 110° with the forearm supinated. At 45° and 135°, flexion power is only 75% of maximum.

• Research shows that men isometrically are two times stronger than women when testing elbow strength. In both men and women, extension is 60% of flexion and pronation is about 85% of supination.

• If the history indicates that concentric, eccentric, or econcentric movements have caused symptoms, these movements should also be tested with load or no load as required.

SPECIAL TESTS FOR LIGAMENTOUS INSTABILITY

Relevant Special Tests

Epidemiology and Demographics5–12

The elbow is the second most commonly dislocated joint in adults and the most commonly dislocated joint in children. Six in 100,000 people dislocate an elbow over a lifetime. Dislocations account for 10% to 25% of all injuries of the elbow.

The mean age for dislocation of the elbow is 30 years. About 40% of elbow dislocations occur during a sports activity, most often gymnastics, wrestling, basketball, or football. Dislocations occur 2 to 2.5 times more often in males than in females.

Medial collateral ligament injury is common with activities that require repetitive overuse. Young athletes who play overhead sports (e.g., baseball pitchers) often experience pain and injury to this ligament. The cause frequently is a combination of overuse and poor mechanics.

Relevant History

Patients may or may not have a prior history of damage to the elbow. Lateral instability occurs after elbow dislocation in 75% of cases.13 Athletes who participate in overhead sports may have a history of lower extremity or back pain that does not allow normal throwing mechanics. This can lead to excessive stress in the elbow, especially on the medial collateral ligament.

Relevant Signs and Symptoms

Dislocation/Subluxation

With dislocation, the elbow is very painful and increased swelling is noted at the joint. The elbow is held in 90º of flexion, and the patient appears to closely guard the upper extremity. The forearm appears shorter than the upper extremity or contralateral side. All movements of the elbow are painful and limited. Even with reduction, ROM is limited, the joints are swollen, and muscle spasm and (at end range) pain are present.

Mechanism of Injury

Dislocation/Subluxation

The definition of elbow dislocation implies a complete discontinuity of the ulnohumeral articulation with associated radiocapitellar disruption. This can occur with or without proximal radioulnar disruption, associated neurovascular injury, and/or residual elbow instability. Ligament damage can occur with or without a concomitant elbow dislocation, as in the case of elbow subluxation. A posterior elbow dislocation is caused by a fall on an outstretched arm with the elbow forced into hyperextension. Mechanically, the hand is supinated as the body rotates in a pronated direction in relation to the elbow; this produces a valgus force on the elbow. As the body continues in a forward motion, the elbow hyperextends and a posterior dislocation of the ulna in relation to the humerus occurs.

Repetitive Stress Injuries

The stability of the elbow relies on the stability and integrity of the ligaments. Ligaments are designed to resist primarily tensile loading. Activities that repetitively overstress the affected ligaments can lead to injury and eventual laxity. Damage to the medial collateral ligament occurs when a valgus force is applied to the elbow joint; damage to the lateral collateral ligament occurs when a varus force is applied. Such damage can be due to either trauma or repetitive overuse.

LIGAMENTOUS VALGUS INSTABILITY TEST14,15 image

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Figure 5-4 Testing the medial collateral ligament of the elbow.

LIGAMENTOUS VARUS INSTABILITY TEST16 image

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Figure 5-5 Testing the lateral collateral ligament of the elbow.

MILKING MANEUVER14,17 image

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Figure 5-6 Milking maneuver to test the medial collateral ligament.

MOVING VALGUS STRESS TEST14,17 image

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Figure 5-7 A, The moving valgus stress test. B, Schematic representation of the moving valgus stress test. The shear range refers to the range of motion that causes pain while the elbow is extended with valgus stress. The shear angle is the point that causes maximum pain.

LATERAL PIVOT-SHIFT TEST14,16 image

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Figure 5-8 Posterolateral pivot-shift apprehension test of the elbow. A, The patient lies supine with the arm overhead. A mild supination force is applied to the forearm at the wrist. The elbow then is flexed while valgus stress and compression are applied to the elbow. B, If the examiner continues flexing the elbow at about 40° to 70°, subluxation and a clunk on reduction when the elbow is extended may occur, but usually only in an unconscious patient. C, Actual test with the elbow positioned to resemble the knee.

POSTEROLATERAL ROTARY DRAWER TEST14 image

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Figure 5-9 Posterolateral rotary drawer test.

POSTEROLATERAL ROTARY APPREHENSION TEST7,10,14,16,18,19 image

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Figure 5-10 Posterolateral rotary apprehension test.

SPECIAL TEST FOR EPICONDYLITIS

Relevant Special Test

Lateral epicondylitis test (tennis elbow or Cozen’s test)

Relevant Signs and Symptoms

Medial Epicondylitis/Epicondylosis

Mechanism of Injury

The mechanism of injury for epicondylitis/epicondylosis generally is insidious and involves repetitive microtrauma caused by eccentric and concentric overloading of the extensor carpi radialis brevis and other wrist extensors (lateral epicondylitis/epicondylosis) or wrist flexors (medial epicondylitis/epicondylosis). Acute trauma to the lateral or medial epicondyle can cause epicondylitis.

Generally, overload of the muscle-tendon unit results in the initial inflammatory process, and continued use results in the tendon breakdown seen in epicondylosis.

The term epicondylitis suggests an inflammatory process. However, acute inflammation occurs only in the early stages of the disease. Scientists and physicians have accepted the fact that the term tendonitis refers to the clinical syndrome and not the actual histopathology of the disorder. The actual histopathology of the disorder is called tendinopathy. With tendinopathy, collagen becomes disorganized, with a loss of parallel orientation, asymmetrical crimping and loosening, and microtears. Because of the hypovascularity of the tendons, the collagen fibers tend to break down during attempts to repair them after excessive load and trauma.

Specificity/Sensitivity Comparison

Unknown

LATERAL EPICONDYLITIS TEST (TENNIS ELBOW OR COZEN’S TEST)26 image

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Figure 5-11 Test for tennis elbow.

SPECIAL TESTS FOR NEUROLOGICAL SYMPTOMS

Relevant Special Tests

Epidemiology and Demographics27–34

Cubital Tunnel Syndrome

Cubital tunnel syndrome is the second most common nerve compression injury in the upper extremity (the most common one is carpal tunnel syndrome). Historically, cubital tunnel syndrome has been more common in men and manifests between the ages of 13 and 20 years. The incidence is higher in men largely because more men than women participate in repetitive and high velocity throwing activities, which have a high reported incidence compared with other sports-related activities. However, the incidence of ulnar neuritis in the workplace is on the rise, especially in occupations requiring repetitive and prolonged compressive forces on the elbow. Examples of this are truck drivers who place their arm on the truck window still while driving or computer programmers who rest upon their elbows while using the computer. This type of neuritis is not age determined, but rather activity and time correlated.

Relevant Signs and Symptoms

Cubital Tunnel Syndrome

Initially the patient complains of pain, point tenderness, and swelling of the medial aspect of the elbow, primarily in the cubital tunnel. This progresses to numbness, tingling, and a cold feeling in the medial distal third of the forearm and the little and ring fingers. The numbness increases over time, and the individual often complains of waking up at night with numbness and tingling in the same area (especially those who habitually sleep with the elbows fully flexed) or increased symptoms during work or an aggravating activity. As the symptoms worsen, the muscles supplied by the ulnar nerve begin to atrophy, but more significantly, the patient complains of having difficulty gripping, clumsiness, and frequently dropping objects because of hand weakness.

Mechanism of Injury

Cubital Tunnel Syndrome

Several different mechanisms of injury have been identified for cubital tunnel syndrome. It can be caused by trauma (e.g., hitting the “funny bone”), prolonged compressive or stretching forces, secondary trauma, or joint disfigurement or dysfunction. Joint disfigurement occurs secondary to osteophyte formation or changes in bony composition from previous fractures or trauma. Prolonged compression or stretching forces are seen in patients with a history of sleeping in a position of prolonged elbow flexion, occupational positions requiring prolonged elbow flexion, or students or workers who spend a prolonged time working at a computer or desk while leaning on the elbows or the proximal forearms.

Pronator Teres Syndrome

Pronator teres syndrome may occur when the nerve is compressed at the tendinous origin of the deep head of pronator teres (the most common presentation) or as it passes between the two heads of pronator teres. The term “pronator syndrome” refers to median nerve compression between the two pronator teres heads before it branches to form the anterior interosseous nerve. Entrapment also can occur under the bicipital aponeurosis at the elbow or under the flexor digitorum superficialis tendon. The pain is aggravated by activities that require repetitive pronation and supination. Examples of such activities are assembly workers who are required to repetitively pronate and supinate their hands, construction workers who use screwdrivers or wrenches, or grocery clerks as they scan products for purchase. The syndrome also has been associated with repetitive exertional grasping activities, such as are performed by carpenters or tennis players.

ELBOW FLEXION TEST35,36 image

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Figure 5-12 Elbow flexion test for a pathological condition of the ulnar nerve.

PINCH GRIP TEST37 image

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Figure 5-13 Normal tip-to-tip pinch compared with the abnormal pulp-to-pulp pinch seen in anterior interosseous nerve syndrome.

JOINT PLAY MOVEMENTS

RADIAL DEVIATION OF THE ULNA AND RADIUS ON THE HUMERUS image

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Figure 5-14 Radial deviation of the ulna on the humerus.

ULNAR DEVIATION OF THE ULNA AND RADIUS ON THE HUMERUS image

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Figure 5-15 Ulnar deviation of the ulna on the humerus.

ELBOW DISTRACTION image

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Figure 5-16 Distraction of the olecranon process from the humerus.

ANTERIOR-POSTERIOR GLIDE OF THE RADIUS ON THE HUMERUS image

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Figure 5-17 Anterior-posterior glide of the radius.

POSTERIOR-ANTERIOR GLIDE OF THE RADIUS ON THE HUMERUS image

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Figure 5-18 Posterior-anterior glide of the radius.

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