ELBOW

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ELBOW

Précis of the Elbow Assessment ^*

Observation

Examination

Active movements

Elbow extension

Combined movements (if necessary)

Repetitive movements (if necessary)

Sustained positions (if necessary)

Passive movements (as in active movements, if necessary)

Elbow extension

Resisted isometric movements

Elbow extension

Wrist extension

Reflexes and cutaneous distribution

Peripheral nerves

Median nerve and branches

Radial nerve and branches

Special tests

Ligamentous valgus instability test

Ligamentous varus instability test

Milking maneuver test

Moving valgus stress test

Lateral pivot-shift test

Posterolateral rotary drawer test

Posterolateral rotary apprehension test

Lateral epicondylitis (tennis elbow or Cozen’s) test

Elbow flexion test

Pinch grip test

Joint play movements

Radial deviation of ulna and radius on humerus

Ulnar deviation of ulna and radius on humerus

Distraction of olecranon process on humerus in 90° of flexion

Anterior-posterior glide of radius on humerus

Posterior-anterior glide of radius on humerus

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 MOVEMENTS ¹

Figure 5-1 Range of motion at the elbow.

GENERAL INFORMATION

If the patient has difficulty with or cannot complete a movement but the motion is pain free, the examiner must consider a severe injury to the contractile tissue (rupture) or a neurological injury. In such cases, further testing is necessary. It is important to remember that the most painful movements are done last. Structures outside the joint may affect range of motion (ROM). For example, with lateral epicondylitis, the long extensors of the forearm often are found to be tight or shortened. Therefore, the position of the wrist and fingers may affect the ROM at the elbow.

PATIENT POSITION

The patient is sitting.

EXAMINER POSITION

The examiner is positioned in front of the patient.

The patient is asked to actively flex the elbow.

INDICATIONS OF A POSITIVE TEST

Active elbow flexion is 140° to 150°. Movement usually is stopped by contact of the forearm with the muscles of the arm.

• The examiner should test active flexion in a neutral position as well as in the fully pronated and supinated positions. Differences in flexion ROM should be noted.

• Terminal flexion loss is more disabling than the same degree of terminal extension loss, because flexion is needed for so many activities of daily living. Loss of either motion affects the reach of the hand, which in turn affects function.

The patient is asked to actively extend the elbow.

INDICATIONS OF A POSITIVE TEST

Active elbow extension is 0°, although up to 10° of hyperextension may be seen, especially in women. This hyperextension is considered normal if it is equal on the two sides and the patient has no history of trauma.

• Normally, the extension movement is arrested by the locking of the olecranon process of the ulna into the olecranon fossa of the humerus. Loss of elbow extension is a sensitive indicator of an intra-articular pathological condition. It is the first movement lost after injury to the elbow and the first regained with healing.

The patient is asked to flex the elbow to 90° and then to actively pronate the elbow.

INDICATIONS OF A POSITIVE TEST

Active pronation should be approximately 80° to 90°, so that the palm faces down. If the patient is unable to fully pronate the forearm while maintaining the elbow at the side of the body, pronation is restricted.

• The examiner should make sure the patient does not abduct the shoulder in an attempt to increase the amount of pronation or to compensate for a lack of sufficient pronation.

• For both supination and pronation, only about 75° of movement occurs in the forearm articulations; the remaining 15° is the result of wrist action.

The patient is asked to flex the elbow to 90º and then to actively supinate the forearm.

INDICATIONS OF A POSITIVE TEST

Active supination should be 90°, so that the palm faces up. If the patient is unable to fully supinate the forearm while maintaining the elbow at the side of the body without adducting the shoulder, supination is restricted.

• The examiner should make sure the patient’s shoulder does not adduct further in an attempt to give the appearance of increased supination or to compensate for a lack of sufficient supination.

• Loss of ROM with supination often is the result of wrist injuries or fracture. Therefore, loss of motion or symptom reproduction with supination does not always imply a pathological condition of the elbow.

• If the patient history includes a complaint that combined movements, repetitive movements, or sustained positions cause pain, these specific movements should be included in the active movement assessment.

PASSIVE MOVEMENTS ^1,²

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

PATIENT POSITION

The patient is either sitting or supine.

EXAMINER POSITION

The examiner is positioned directly in front of the patient.

The examiner grasps the patient’s distal wrist with one hand and uses the other hand to cup and stabilize the posterior aspect of the elbow. The elbow is passively guided into flexion, extension, supination, and pronation. If the motions are pain free, the examiner may choose to place additional overpressure on the joint to test the end feel in each direction. If the motion produces pain without overpressure, no overpressure should be applied.

INDICATIONS OF A POSITIVE TEST

ROM deficits and symptom reproduction both indicate a positive test result. The motion of the injured elbow should be compared with that of the contralateral side.

• Passive movements should be carried out carefully to test the end feel and to test for a capsular pattern. Tissue approximation is the normal end feel of elbow flexion; in thin patients, the end feel may be bone to bone as a result of the coronoid process of the ulna hitting in the coronoid fossa of the humerus. Pronation also may be bone to bone in thin individuals. The examiner should note whether a capsular pattern is present.

• The capsular pattern for the elbow complex as a whole is more limitation of flexion than extension.

RESISTED ISOMETRIC MOVEMENTS ^3,⁴

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.

To assess the strength of the elbow musculature.

PATIENT POSITION

The patient is sitting.

EXAMINER POSITION

The examiner is positioned directly in front of the patient.

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.

Elbow flexion. The examiner places the palm of his or her hand on the superior aspect of the patient’s forearm to provide resistance.

Elbow extension. The examiner places the palm of his or her hand on the inferior aspect of the patient’s forearm to provide resistance.

Pronation. The examiner grasps the patient’s forearm to provide resistance.

Supination. The examiner grasps the patient’s forearm to provide resistance.

Wrist flexion. The examiner holds the patient’s palm with one hand to provide resistance while stabilizing the forearm with the other.

Wrist extension. The examiner holds the dorsum of the patient’s hand with one hand to provide resistance while stabilizing the forearm with the other.

INDICATIONS OF A POSITIVE TEST

A positive test result is indicated by weakness or symptom reproduction (or both) compared with the contralateral, uninvolved side. If the resisted isometric contraction is weak and pain free, the examiner must consider a major injury to the contractile tissue (third-degree strain) or neurological injury.

• 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

Ligamentous valgus instability test

Ligamentous varus instability test

Milking maneuver

Moving valgus stress test

Lateral pivot-shift test

Posterolateral rotary drawer test

Posterolateral rotary apprehension test

Definition

The term instability can be used to describe a wide spectrum of clinical disorders ranging from traumatic elbow dislocation to ligament laxity secondary to repetitive strain. In any case, laxity and pain often are associated with the tissue damage.

Suspected Injury

Elbow dislocation

Elbow subluxation

Posterolateral instability

Medial collateral ligament sprain or tear

Lateral collateral ligament sprain or tear

Epidemiology and Demographics 5–12

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.

Repetitive Stress Injuries

Patients with ligament laxity or overuse injuries complain of a vague pain and soreness with activity of the elbow. Intermittent episodes of snapping, popping, or clicking in the joint may be noted with activity. Episodes of apprehension or a feeling of slipping of the lateral structures, especially with loaded activities (i.e., weight on the arm), may be present with excessive joint laxity. The patient also may complain of episodes of the elbow giving way or the joint locking. The individual commonly has difficulty lifting with the forearm supinated, pushing, pulling, and pushing up out of a chair.

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.

Related

Orthopedic Physical Assessment Atlas and Video Selected Special