INSPECTION

With the elbows in full extension, observe the carrying angle, noting any valgus or varus angulation. Inspect the elbow for erythema (acute inflammation or infection) or any vesicular rash, such as Herpes zoster. Check the extensor surface of the elbow for any subcutaneous nodules (rheumatoid nodules or gouty tophi) or cutaneous psoriasis (psoriatic arthritis). Inspect the olecranon for any visible swelling (olecranon bursitis; Table 3-2).

TABLE 3-2 EXAMINATION OF THE ELBOW

PALPATION

Slide your other hand along the forearm to the olecranon surface. Note any palpable subcutaneous nodules or swelling of the olecranon bursa. Swelling of the olecranon bursa presents itself as visible and/or palpable distension directly overlying the olecranon, often looking like the comic character Popeye (Figure 3-4).

FIGURE 3-4 SWOLLEN OLECRANON BURSA IN FLEXION AND EXTENSION.

Next, identify the small depression normally present between the olecranon and the lateral epicondyle, which is especially visible during full extension (Figure 3-5). This depression is the first area to be obliterated by an elbow effusion. Now, use your examining thumb to identify and palpate the lateral epicondyle. Slide your thumb slightly distally while you gently pronate and supinate the forearm with your other hand still in the “handshake” position. You can now feel the patient’s radial head, moving under your palpating thumb. The joint space between the lateral epicondyle and radial head should now be readily appreciable with only skin and subcutaneous tissue between your thumb and the joint line itself. Next, continue palpating the joint line while you bring the elbow into full extension. Note whether there is any pain or resistance to full extension, frequently seen with elbow joint synovitis (Figure 3-6).

FIGURE 3-5 INSPECTION OF THE LATERAL JOINT LINE.

A, Normal sulcus visible in extension. B, Bony anatomy present beneath the sulcus.

FIGURE 3-6 PALPATION OF THE LATERAL JOINT LINE.

Swelling of the elbow joint results in progressive obliteration of the normal small lateral sulcus and a “boggy” or thickened feel to the usually well-defined depression (joint line) between the lateral epicondyle and radial head. Furthermore, synovial distension may produce a visible or palpable bulge when the elbow is moved into full extension, as intraarticular pressure increases.

If your examining thumb strays laterally, sliding off the lateral epicondyle toward the olecranon, you may find a soft swelling in normal individuals that may feel very much like synovitis, but it is not: you have just discovered the belly of the anconeus muscle. (Keeping your examining thumb in contact with the lateral epicondyle at all times when palpating the lateral joint line will prevent this error.)

Palpable swelling, most frequently combined with the patient’s hesitation to permit full elbow extension due to pain, confirms the presence of synovial swelling and/or fluid within the elbow joint.

RANGE OF MOTION

Next, flex and extend each elbow. Full elbow flexion places the proximal forearm against the distal biceps (~150° to 160°). Elbow extension returns the joint to the outstretched anatomical position (0°). Place your hand under the olecranon to assist you in detecting any deficit in full extension (flexion contracture). Return the elbow to 90° of flexion and assess forearm pronation and supination.

SPECIAL TESTING

Next, if appropriate, assess for the presence of lateral epicondylitis (“tennis elbow”). Bring the elbow into partial flexion and identify the lateral epicondyle with your thumb. Palpate the lateral epicondyle and apply progressively increasing pressure to the epicondyle itself. Then, move ~1 cm distally and again apply pressure. Note any focal tenderness. Next, place the elbow in full extension and support the forearm with your arm. Ask the patient to make a fist and “cock it back” (fingers flexed and wrist extended). Supply downward force against the dorsum of the hand against the patient’s resistance. Note any lateral elbow pain (Figure 3-7).

FIGURE 3-7 LATERAL EPICONDYLITIS: RESISTED WRIST EXTENSION TEST.

Similarly, if appropriate, assess for the presence of medial epicondylitis (“golfer’s elbow”). Bring the elbow into partial flexion and identify the medial epicondyle with your thumb. Palpate the medial epicondyle and apply progressively increasing pressure to the epicondyle itself. Then, move ~1 cm distally and again apply pressure. Note any focal tenderness. Next, ask the patient to extend the elbow with the palm down, forearm in pronation. Then, ask them to flex the wrist (fingers extended and wrist flexed). Supply force against the palmar surface, attempting to move the wrist back to neutral while they resist. Note any medial elbow pain.

If indicated, assess for ulnar nerve irritation or compression in the cubital tunnel. Palpate the ulnar nerve at the medial aspect of the elbow, in the ulnar groove. Tap lightly over the ulnar nerve (Tinel sign, Figure 3-8) and note any pain or tingling radiating to the forearm and lateral hand (fourth and fifth digits). Next, palpate the ulnar groove during elbow flexion and extension. Note whether the nerve slips in and out of the ulnar groove. Finally, move the elbow into full flexion for ~60 seconds. Note any tingling or numbness in the ulnar aspect of the hand. Complete your assessment by checking for interosseous wasting and abduction strength of the fifth finger. Check sensory function over the fourth and fifth fingers. Note any deficits.

FIGURE 3-8 CUBITAL TUNNEL SYNDROME: TINEL SIGN.

In patients with suspected ligamentous instability, assess ulnar and radial ligamentous integrity with the elbow in 10° to 20° of flexion to unlock the olecranon process from its fossa. With the humerus stabilized with one hand, apply an abduction (valgus) force to the distal forearm to assess the medial (ulnar) collateral ligament, and apply an adduction (varus) force to the distal forearm to assess the lateral (radial) collateral ligament.

SKIN AND SUBCUTANEOUS ABNORMALITIES

The extensor surface of the elbow is one of the most common sites for rheumatoid nodules. They may be firm to hard subperiosteal swellings on the olecranon extensor surface or several centimeter-sized rubbery, moveable nodules in the olecranon bursa. The bursa itself is the most common site of tophi in patients with gout. Early tophi may be barely noticeable to your examining fingers but later may be present as rubbery, moveable nodules indistinguishable from rheumatoid nodules.

The extensor surface of the elbow is one of the most common sites of cutaneous psoriasis. Musculoskeletal complaints in patients with psoriasis raise the question of whether the patient might have psoriatic arthritis.

OLECRANON BURSITIS

The olecranon bursa is one of the few bursae where irritation and inflammation present as clinically visible and palpable swelling (Figure 3-4). Acute trauma may lead to hemorrhagic swelling within the bursa. Repetitive pressure on the olecranon may cause chronic swelling. The two most common inflammatory conditions affecting the olecranon bursa are rheumatoid arthritis and gout. The bursa may swell suddenly and painfully in acute gout; may swell gradually with minimal pain, warmth, or erythema in rheumatoid arthritis; or may swell imperceptibly over time with the development of rheumatoid nodules or gouty, tophaceous deposits.

The most clinically urgent problem involving the bursa is septic olecranon bursitis. Signs of significant acute inflammation usually develop over hours to days. It is very important to check for abrasions, scabs, or broken skin anywhere from the fingers to the elbow in all patients with olecranon bursitis, as these findings may be the only clue that leads you to appropriately suspect septic bursitis. Septic bursitis typically occurs in otherwise healthy adult men engaged in physical work involving frequent trauma to the forearms and elbows (e.g., plumbers, gardeners, and construction workers). Staphylococcus aureus is the most common pathogen.

Septic olecranon bursitis frequently has significant accompanying features of cellulitis with widespread erythema, subcutaneous swelling, and edema. Rapid bursal swelling due to bacterial infection may lead to bursal disruption with obliteration of normal anatomic landmarks around the entire elbow, leading to concern over the more serious possibility of septic arthritis.

Several historical and physical examination features are very helpful in differentiating septic bursitis from arthritis. First, carefully assess the time course and progression of swelling. Frequently the patient will recall Popeye-like swelling initially, indicating olecranon bursitis as the underlying problem. Second, patients with septic arthritis will usually have severe pain with limited elbow flexion and extension. Range of motion is surprisingly preserved in patients with septic-cellulitic olecranon bursitis. Gentle, passive elbow extension is perhaps the most useful discriminating maneuver to help differentiate between these two possibilities. Finding intense inflammation with intact elbow extension focuses attention on the olecranon bursa. Intense inflammation with incomplete, painful elbow extension directs attention to the joint itself.

ELBOW JOINT SWELLING

Elbow joint swelling in the context of acute injury or major trauma should prompt a comprehensive orthopedic evaluation for fracture or dislocation, which is beyond the scope of this discussion. The elbow joint is not often a site of primary osteoarthritis but is a site of secondary osteoarthritis related to prior significant injury or repetitive trauma. Inflammatory processes involving the elbow include crystalline arthritis (gout or pseudogout), rheumatoid arthritis, psoriatic arthritis, or infection (bacterial and rarely tuberculous or fungal infections).

Elbow joint swelling is usually experienced by the patient as a deep, poorly localized ache aggravated by motion, especially at the extremes of flexion and extension. The greater the acuteness of inflammation, the more likely the patient is to hold the elbow at ~70° of flexion, the position of lowest intraarticular pressure. Chronic elbow synovitis, as in rheumatoid arthritis, may be minimally tender or not tender at all, with no accompanying warmth or visible erythema; acute inflammatory synovitis, as in acute crystalline arthritis, may exhibit all the cardinal features of inflammation. If the elbow joint is the site of an acute inflammatory monoarthritis, it is imperative, as with all acute monoarthritides, to aspirate the joint to check for crystals or infection.

LATERAL EPICONDYLITIS

Patients with lateral epicondylitis, also called tennis elbow, usually complain of localized pain and tenderness at the lateral epicondyle, often accompanied by a mild aching discomfort in the proximal forearm. Contrary to its common name, “tennis elbow” it is usually vocational, recreational, or idiopathic in origin and rarely due to playing tennis. Understanding that lateral epicondylitis is not primarily an elbow problem, but related to use of the wrist and hand, helps greatly in understanding the problem. The extensor carpi radialis is a powerful extensor of the wrist and is essential to an important hand function, the power grip. To firmly grasp objects with the hand, the finger flexor tendons must be stretched to allow the flexor muscles in the forearm to exert maximal force. It is “setting the wrist up” (in extension) in preparation for a power grip that results in the generation of significant force at the proximal tendon and its insertion site.

Patients with lateral epicondylitis usually have an insidious onset of pain over weeks to months. On careful questioning, most will associate lifting heavy objects (milk cartons, hammers, suitcases) with increased pain. On occasion, actions as simple as shaking hands will provoke symptoms. Some patients will be concerned that they are “losing hand strength.”

Localized tenderness is present just distal, medial, and slightly anterior to the lateral epicondyle, over the common extensor tendon, particularly that part derived from the extensor carpi radialis brevis muscle. The pain is increased by resisted dorsiflexion of the wrist with the elbow in extension.

MEDIAL EPICONDYLITIS

Medial epicondylitis, or so-called golfer’s elbow, is far less common than lateral epicondylitis. Like tennis elbow, it also is not primarily an elbow problem; it relates instead to an overuse syndrome from repetitive strain of the common flexor tendon involved in both forearm pronation and wrist flexion. Insertional tendinitis at the medial epicondyle may result from swimming, baseball pitching, or golfing. It is often associated with aching discomfort in the medial epicondyle and flexor aspect of the proximal forearm. It is increased by lifting, grasping, and other activities that require frequent wrist flexion and forearm pronation. There is tenderness at and just distal to the medial epicondyle over the origin of the common flexor tendon, particularly that portion derived from the pronator teres and flexor carpi radialis muscles. Resisted pronation of the forearm and resisted flexion of the wrist with the elbow in full extension are clinically helpful provocative maneuvers. Flexion of the fingers, rather than of the wrists, may sometimes elicit pain at the medial epicondyle. In addition, it is important to examine the ulnar nerve in the cubital tunnel, as ulnar neuropathy may also cause medial elbow pain.

ULNAR ENTRAPMENT NEUROPATHY

Cubital tunnel syndrome is due to entrapment of the ulnar nerve in its groove behind the medial epicondyle. It is characterized by medial elbow pain, paresthesia along the ulnar aspect of the forearm into the ring and little fingers, and sometimes a weak hand grip with fatigue and clumsiness. Tenderness is often present over the ulnar nerve, and the Tinel sign is usually positive. Atrophy of the hypothenar muscles may be present.

Causative mechanisms include sudden direct trauma to the ulnar nerve in the ulnar groove, repetitive injury to the nerve from chronic pressure on hard surfaces, such as desks and countertops, and repetitive stretching injury of the nerve in its groove due to occupational or sport activities involving prolonged elbow flexion such as skiing, throwing, and racquet sports. Chronic progressive entrapment of the nerve may also be due to scarring or bony osteophyte formation as a result of remote major trauma to the elbow (fracture or dislocation).

OLECRANON BURSA

Using a retracted ballpoint pen, mark the skin on the ulnar surface ~1 cm distal to the olecranon bursa. Prep the skin with iodine solution and allow to air dry, then prep with alcohol. Using a 22 gauge needle, inject 1% or 2% lidocaine subcutaneously at the site of your skin mark and advance proximally into the bursa. Use an 18 gauge needle on a 10 mL syringe for aspiration. While you advance the needle with your dominant hand, use your nondominant hand to squeeze the bursa between your gloved thumb and index fingers to help guide the needle into the bursa. Occasionally, the bursal fluid is loculated, and you will need to make a series of passes with the needle to aspirate fluid (your nondominant hand is invaluable here in helping stabilize and center the bursa). Aspirate the bursal fluid. If clinically appropriate, inject corticosteroid (Figure 3-9). This subcutaneous “tunnel” technique avoids puncturing the bursa on its exposed extensor surface and decreases the likelihood of fluid leakage with elbow flexion subsequent to aspiration.

FIGURE 3-9 ASPIRATION AND INJECTION OF THE OLECRANON BURSA.

Elbow Joint

With the elbow in ~45° of flexion, identify the lateral epicondyle, the radial head, and the tip of the olecranon. These three points form a triangle, the center of which is the entry point for the lateral approach to the elbow joint. Palpate at the center of this imaginary triangle, and use a retracted ballpoint pen to make a mark at this site. Prep the skin with iodine and allow to air dry, then prep with alcohol. Use a 22 gauge needle and 1% or 2% lidocaine to create a skin wheel. Now, direct the needle along a plane parallel to an imaginary line connecting the lateral and medial epicondyles. (Using this angle of needle entry, rather than perpendicular to the skin surface, may make successful aspiration much easier; Figure 3-10A). As you advance the needle, inject lidocaine until you enter the joint space. Once in the joint space, change syringes and aspirate with a 10 mL syringe. Occasionally, the synovial fluid is loculated and may be difficult to aspirate initially. You may need to rotate the needle or make several small changes in needle depth to obtain fluid (gentle, rather than forceful, suction is often the most effective). Aspirate the joint completely if possible. If clinically appropriate, inject corticosteroid.

FIGURE 3-10 A, Approach to elbow joint aspiration and injection. B, Rheumatoid patient with joint effusion being aspirated at lateral joint line (plus nodules in the anatomically separate olecranon bursa).

Lateral Epicondyle

Using a retracted ballpoint pen, mark the skin at the point of maximum tenderness, usually ~1 cm distal to the lateral epicondyle (Figure 3-11). Prep the skin with iodine and allow to air-dry, then prep with alcohol. Using a 25 gauge needle, inject 1% or 2% lidocaine into the skin. Advance into and through the extensor tendon and inject additional lidocaine. Leave the needle in place, exchange syringes, and inject a corticosteroid preparation. After completing the procedure, it is useful to repeat resisted elbow extension. If the injection has been appropriately placed, there should be a dramatic decrease in pain with this provocative maneuver, frequently surprising the patient.

FIGURE 3-11 INJECTION TECHNIQUE FOR LATERAL EPICONDYLITIS.

The technique is similar for injecting the medial epicondyle. Inject directly on or just distal to the epicondyle. Avoid injecting posterior to the epicondyle in the region of the ulnar groove and ulnar nerve.