Physical Exam of the Elbow Whats The Evidence

Physical Exam of the Elbow: What’s The Evidence? Marc Safran, MD Ian Gao, MD Department of Orthopaedic Surgery Stanford University 2019 Advanced Team Physician Course December 12, 2019 - Las Vegas, NV

Outline § Inspection and Palpation § § § Axial alignment Anterior evaluation Medial evaluation Lateral evaluation Posterior evaluation § Range of Motion § Strength and Resistive Testing § Instability Testing § Posterolateral Rotatory Instability § Medial Instability

Inspection / Palpation Axial Alignment § Malalignment fm Prior Trauma or Skeletal Growth Disturbance § Normal Carrying Angle § 11°-14° valgus in men § 13°-16° valgus in women § Cubitus Valgus § Cubitus Varus Beals CORR 1976

Anterior Evaluation Hook Test § DBT Most Easily Palpable w/ Forearm Supin & Elbow Flex 90° § “Hook” Finger Under Tendon When Intact Hook test O'Driscoll et al AJSM 2007

Am J Sports Med, 2007 § 45 pts Surgery DBT § 33 pts w/ Complete Avulsion; 12 pts w/ Partial Tear § Hook Test § Abnormal in All Pts w/ Complete DBT Avulsion § Intact in All w/ Partial Tears § Sensitivity 100%, Specificity 100% § MRI § Partial Tear in 11/12 (92%) pts w/ Partial Tears § Complete Tear in 85% of pts w/ Complete Tears § Sensitivity 92%, Specificity 85%

Anterior Evaluation § DBT in Cubital Fossa § Intact DBT Often Visible § DBT Ruptures – Popeye Deformity

Medial Evaluation § Palpate Medial Epicondyle § Tender from Medial Epicondylosis (Golfer’s Elbow) or Injury to UCL. § Also Palpate Flexor. Pronator Muscles – § Medial Epicondylosis May Be TTP At MTJ of F-P Mass

Medial Evaluation Palpate Course of UCL § With Elbow in 50°-70° of Flexion § Tenderness Along Course of UCL Can Be Sign of Injury To UCL tear § Medial Epicondyle

Medial Evaluation Palpate Course of UCL § With Elbow in 50°-70° of Flexion § Tenderness Along Course of UCL Can Be Sign of Injury To UCL tear § Medial Epicondyle § Sublime Tubercle § 2 cm Distal & Posterior to Medial Epicondyle

Medial Evaluation Cubital Tunnel § Active F-E Elbow - See / Palpate Subluxing Ulnar Nn § Tinel Test

Medial Evaluation Cubital Tunnel § Ulnar Nerve Flexion-Compression Test § Scratch Collapse Test Ulnar nerve flexion-compression test Scratch collapse test Cheng et al J Hand Surg Am 2008

§ Prospective Study: 169 pts & 109 Controls § 70 Dx’d w/ Cubital Tunnel by Hx, PE, & + EMG/NCS § Compare Exam Findings § Scratch Collapse Test: 69% sensitivity, 99% specificity § Tinel Test: 54% sensitivity, 99% specificity § Flexion-Compression Test: 46% sensitivity, 99% specificity J Hand Surg Am, 2008

Lateral Evaluation Soft Spot § Between LE, Olecranon Tip, & Radial Head § Prominent From Joint Effusion § Non-inflammatory / Inflammatory Conditions § Acute Fx Hemarthrosis

Lateral Evaluation Lateral Epicondylosis (Tennis Elbow) § TTP At / Just Distal to LE § ECRB Origin

Lateral Evaluation Radial Tunnel Syndrome aka Resistant TE § TTP Even More Distal fm LE, Along Mobile Wad § 2 cm Anterior & 3 cm Distal to LE § Arcade of Frohse: Most Common Site of PIN Compression

OCD – RC Compression Active Radiocapitellar Compression Test • Forearm Pronation – Supination • Elbow in Extension 2. Pronate-supinate 1. Extend elbow

OCD – RC Compression

Posterior Evaluation Olecranon § Bony Prominence & TTP from Osteophyte Formation § Arthritis § Throwing Athlete

Posterior Evaluation Olecranon § Bursitis: Fluctuant Soft Tissue Prominence Olecranon bursitis

Posterior Evaluation Triceps § Palpable Defect w/ Retracted Muscle in Distal Triceps Rupture § TTP Along Tendon in Tendinitis § Occ Ulnar Nerve

Range of Motion § Flexion-Extension § Normal: 0°-140° ± 10° § Pronation-Supination § Normal: 80° pronation to 85° supination § Functional ROM for Most ADLs (Morrey et al, 1981) § F-E: 30°-130° § P-S: 50° to 50° § Some Sports Need Full Extension

Range of Motion Painful Mid-Arc § Suggests Articular Pathology § Also Assess for Mechanical Catching Or Locking § Loose Body § Cartilage Flap § Plica

Range of Motion Painful Hyperextension § Posterior Olecranon Osteophyte in Arthritic Elbow or Spur In Thrower § Impingement of PM Olecranon Spur § Often in Throwing Athlete) § Increase with Valgus In Extension = VEOS Test

Strength & Resistive Testing § F-E & P-S Strength Test w/ Neutral Forearm Rotation & Elbow @ 90° § Extension Strength 60%-70% of Flexion Strength § Pronation Strength 85% of supination strength § Weakness Due to Pain, Atrophy, Dysfunction, Tendon Rupture, or Nerve injury § Distal Triceps Rupture: Weakness or Loss of Active Elbow Extension § Distal Biceps Rupture: § § Flexion Strength Reduced by 15%-30% Supination Strength Reduced by 40%-50% Nesterenko et al JSES 2010

Strength & Resistive Testing Lateral Epicondylosis § Pain Over LE w/ Resisted Wrist Extension and/or Resisted Supination

Strength & Resistive Testing Medial Epicondylosis § Pain over ME w/ Resisted Wrist Flexion and/or Pronation

Strength & Resistive Testing Radial Tunnel Syndrome § Pain over Mobile Wad w/ Resisted Long Finger MCP Extension

Instability Testing § Gapping of Joint Not Always Easily Appreciated on PE § Objective Joint Widening &/or Patient Apprehension & Pain Can Suggest Instability § Fluoroscopy Can Be Used With Stress Testing To Confirm Widening

Instability Testing Varus Instability § Varus Stress § Arm Positioned in 15° Elbow Flexion § Full IR Of Humerus § Pronation of Forearm Varus testing

Valgus Stress Test Forearm in Neutral Rotation or Pronation

UCL Injury Detect Clinical Laxity § 26% (24/91) - Andrews ‘ 00 § 82% (68/83) – Thompson & Jobe ‘ 01

UCL Injury Other Signs § Tenderness § 81% - Thompson & Jobe ‘ 01 § Pain With Laxity Test § 26% - Andrews ‘ 00 § 53% –Thompson & Jobe ‘ 01

Modified Milking Maneuver Elbow at 70 Degrees

Moving Valgus Stress Test

Medial Instability Moving Valgus Stress Test § 100% Sensitive § 75% Specific § UCL Insufficiency O’Driscoll et al, AJSM 2005

PLRI – Pivot Shift § Supine, Arm Overhead, Shoulder ER § Forearm Supinated, Valgus, Axial Load § Full Ext Flexion

PLRI – Pivot Shift § Clunk of Reduction at 40 Deg § The More Lax the Patient or Ligament, The More Flexion Before the Reduction / Clunk

PLRI – Pivot Shift § Apprehension Awake § Clunk of Reduction Under GA or Local Anesthetic Into Joint § Posterior Prominence (of RH Dislocation) § Dimple in Skin Proximal to RH

PLRI: Chair Sign § Arise From Seated Position § Elbows @ 900 Flexion § Forearms Supinated § Arms ABducted > Shoulder Width § Apprehension As Extend Elbow / Arise

PLRI: Push Up Test § Elbow @ 900 Flexion § Forearm Supinated § Arms ABducted More Than Shoulder Width § Apprehension As Extend

PLRI § 8 Pts w/ PLRI § Compared Pivot-Shift § w/ & w/o Sedation § § Push-up Sign Chair Sign 38% Awake Pts w/ + Pivot Shift Positive Apprehension Test 87. 5% (7/8) § Chair Sign & Push Up § 100% Had One or Other Apprehension Regan, et al JSES 2006

PLRI: Table Top Relocation Test § Part I § § § Press Up w/ Elbow Pointed Laterally Elbows Flexed 900 Forearms Supinated Push Up vs Table Apprehension As Extend Elbow / Arise § Part II § Re-do w/ Thumb on Radial Head § Symptoms Eliminated § Part III § Remove Thumb, Symptoms Return

Table Top Relocation Test

PLRI Table Top Reduction Test § 8 Pts w/ PLRI by Pivot Shift § All 8 With Positive Table Top Reduction Test Arvind, Hargreaves JSES 2006

Other Causes Referred Pain § Neck § Shoulder § Wrist / Forearm

Thank You