Elbow Examination (Lecture 1) Flashcards
Review pathways for Ulnar, median, radial nerve - and know impingement points
What are the 3 joints in the elbow complex?
Ulnohumeral
Radiohumeral
Radioulnar
What articulates to make the ulnohumeral joint?
What is right infront of the troachlea notch? (anterior w/ a point)
Trochlea of the humerus articulates w/ the trochlea notch
Coronoid process
What kind of joint is the raioulnar joint?
Disc joint that spins
What articulates in the radiohumeral joint?
Capitulum of the humerus w/ the radial head
What articulates in the radioulnar joint?
Medial edge of radial head w/ lateral edge of trochlear notch (ulna)
Know the elbow anatomy
What is the open packed position for the unlohumeral joint? What about close packed? Capsular pattern of resitrction? Surrounding ligaments? What kind of joint is it?
70 degrees of elbow flexion, 10 degrees of supination = open packed
Full extension and supination = close packed
Capsular pattern (where it gets most restircted) = Flexion –> Extension
Ligaments = Ulnar (medial) collatearl ligament (anterior, posterior, and oblique portions)
Hinge joint
NOTE: Pronation / Supination does not happen here (because it is a hinge joint). Easy question on test here probaly
If someone has issues w/ supination / pronation what joints am I thinking might be the problem? Why?
Radiohumeral / Radioulnar
Because these two joints capsular pattern include pronation / supination while ulnohumerals does not
Open packed position for radiohumeral joint? Close packed position? Capsular pattern? Ligamentou structures?
Open packed = Full extension and supination
Close packed = 90 degrees elbow flexion 5 degrees supination
Capsular pattern fo ristriction = Flexion –> Extension –> supination –> pronation
Ligamentous = lateral collateral ligament (radial, latearl portions)
Open packed position for proximal radioulnar joint? Close packed? Capsular pattern? Ligamentous structure?
Open packed =70 elbow flexion, 35 degrees supination
Close packed = 5 degrees supination
Capsular pattern = Equal limiation of supination and pronation
Ligaments = Annular ligament
NOTE: Supination is measured from neutral
KNOW: lots of ligaments!!!!!
Probs important
NOTE: for the ligamentous structures the ligament portion is showing us which ligaments would be affected w/ a sprain or tear of that specific joint
KNOW: MOI for elbow:
* FOOSH (biggest one for elbow)
* Overuse
* CHange in load of elbow
* Fracture
* Dislcoation
KNOW: In the shoulder it was hard to figure out what was going on when the pointed to a certain spot (one spot could mean multiple things) however, in the elbow when they point to a certain spot its easy to know whats going on
KNOW: we can have neural issues w/o numbness and tingling (could present as weakness)
KNOW: functional outcomes for the elbow
* Disabilities of the Arm, Shoulder, And Hand ( quick DASH)
* Focus on therapudic outcomes (FOTO) –> has algrithum to it
* Patient rated elbow elvaulation
* liverpool elbow score
* Oxford elbow score
Where should we screen first for elbow problems?
Screen out shoulder and Wrist
KNOW: Used dutton text for dermatome / myotome
Wainer test item cluser for radiculopathy?
1) ULTT1 - Median (most specificity)
2) Cervical distraction helps
3) ROM >60 cervical rot to ipsilateral side
4) Spurling A positive
An absent reflex is rated?
0
A hypo reflex is rated (was on test)
1+
Normal reflex is rated
2+
Hyper reflex is rated
3+
Where are C5/C6/C7 reflexes tested?
C5 = bicep = elbow flexion
C6 = bracioradialis (arm goes back)
C7 = tricep = elbow extension
What is carrying angle? What are norms (male vs female)
Valgus angle of elbow in extension
Males: 5-10
Females: 10-15
What is gunstock deformity at the elbow? What causes it normally?
Excessive varus
Normally caused by an epiphyseal injury to distal humerus / fractures to the humerus (in adolesence)
What kind of biceps rupture is this?
Popped up so its a distal bicep rupture
What kind of biceps rupture is this?
Went down = proximal bicep rupture (top ligment isnt intact)
What normally causes distal bicep rupture (pops up)
Lifting something super heavy
KNOW: They may reattach is younger individual (older individuals might not have enough tissue quality to reattach)
What is this?
Olecrannon bursitits
What normally causes olecranon bursitis?
Excessive/reptitive compressive force on bursa
* sometimes called students elbow - think having elbow on desk for long period of time
* Can also happen to people in wheelchairs because they put that repetitive compressive force
NOTE: Not much we do about this
Elbow flexion AROM?
140-150
Elbow extension AROM
0 - 10
Elbow pronation AROM
80-90
Supination
90
What causes the boney block during elbow extension?
Olecranon of ulna hitting olecranon fossa of humerus
KNOW: End feel for elbow flexion = tissue approximation (tissue closes down on tissue) (soft end feel)
Elbow extension = boney block
Pronation/supination = tissue stretch/firm end feel
Whats in the cubital fossa? (nerves?)
On the anterior side of the arm
* Radial / Median
Braichal artery / v
* Biceps tendin
Cubital tunnel has what
Ulnar n
If a pt has pain w/ resisted elbow flexion what 4 things are we thinking it could be?
Liesion (something is going on w/) of:
* Biceps brachii
* Brachialis
* Brachioradlis
* Wrist extensions
If a pt has pain w/ resisted elbow extension what 4 things are we thinking it could be?
Lesion of:
* Triceps
* Anconeus
If a pt has pain w/ resisted supination what 4 things are we thinking it could be?
Lesion of:
* Biceps brachii
* Wrist extensors
* Radial nerve
* Supinator
If a pt has pain w/ resisted pronation what 4 things are we thinking it could be?
Lesion of:
* Wrist flexors
* Median nerve
* Pronator teres
* Pronator quadratus
If a pt has pain w/ resisted wrist extension what 4 things are we thinking it could be?
Lesion of:
* Wrist extensors
* Radial n
If a pt has pain w/ resisted wrist flexion what 4 things are we thinking it could be?
Lesion of:
* wrist extensors
What nerve innervates wrist extensors?
Radial n
What 3 positions can you test grip strength in?
Elbows extended or flexed
Pronation
Supination
Neutral
(all the positions basically)
KNOW: You can asses grip strength side to side to assess medial eipcondylagia, lateral epicondyalgia
KNOW: Pain free grip is a really good outcome measure
Gross grip strength relates to all cause mortality
Which side realtes to all cause mortality w/ grip stregnth. Affected or unaffected?
Unaffected (wouldnt make sense to relate a gripping problem because of some pathology of ligaments / muscles w/ all cause mortality)
What should the delta be dominant vs non-dominant grip strength
5-10% (dominant is slightly stronger)
* Note: someone who uses that dominant side way more (think baseball palyer) will be closer to that 10% delta than a normal person
Algia =
Pain
These are some major diagnoses leading to elbow PAIN
* Medial epicondylagia
* Ulnar collateral ligament injury
* Lateral epicondyalgia
* Elbow fracture/dislocation
* Olecranon Bursitis
* Bicipital tendinopathy
* Triceps tendinopathy
* Ulnar nerve entrapment (cubital tunnel syndrome)
* Radial nerve entrapment
* Medial n entrapment
Special Tests of the elbow (reference back to this)
Is common flexor tendin pain (medial forearm pain) typically inflammatory? - NOTE: This is medial epicondylalgia
No, normally beyond that inflammatory process
Normally theres increased collagen disorganization, fibrosis and neurovascular growth
more consisten w/ the -osis pathology
NOTE: the reason we say medial eipcondyalgia is because we can’t really tell if its an itis or osis so we just say “pain”
Fibrosis means
Thinking or scaring of connective tissue (usually from an injury)
-osis means
condition, disease, or abnormal process
Increased collagen disorganization, fibrosis and neurovascular growth
* basically a mal adaptation to a chronic disease
What kind of movement would someone proably be doing if they have medial epicondylagia (like something their job would be)
Repetitive wrist and finger flexion
* Occupations/sports/hobbies
NOTE: A change in load might have caused it
Crossfiters could have this due to the chronic wrist flexion
* especially crossfitters training at a new volume of new crossfitters (deviation in load / volume from the norm)
KNOW: a chronic load being added over time allows the tissue to adapt, while an acute load suddenly put on a person does not allow time for that tissue to adapt
Where does medial epicondyalgia normally happen (anatomcially)
At or anterior or distally to the medial epicondyle of the humerus (makes sense that it might be distal because those tendins run distally)
KNOW: medial / latearl epicondalgia = tendinopathy
* NOTE: Anytime you stretch that tendin or resist that tendins muscle activity you are going to create pain (which is great for creating those special tests)
KNOW: Special tests (know these arent validiated tests) (probs dont worry about these)
* Golfers elbow test
*
Passive elbow extension and wrist extension at 90 degrees of shoulder flexion, full supination = golfers elbow test
Resisted wrist and finger flexion w/ pronation (were doing this one becuase of proantor teres being at common flexor tendin)
What two muscles are most involved in medial epicondylalgia?
Flexor Carpi radialis
Pronator teres (PFPF –> first two when you put it on arm)
* these are more lateral and are more involved
* NOTE: A lot of people don’t have a palmaris longus so it cant be this one
Lesser involved:
* Palmis longus (not all have this)
* Flexor carpi ulnaris
* Flexor digitorum superficialis
What is treatment like for medial epicondyalgia?
Consevative
*Do PT
No real surgery is really indicated
What are two differintial diagnosis for medial epicondylalgia? (what can it be mixed up w/) (2)
Cubital Tunnel Syndrome (ulnar n entrapment)
Ulnar (medial) collatearl ligament injury
These two things can also cause that pain on the medial elbow
We would do tests to rule in medial epicondyalgia and tests to rule out these 2
What kind of motion creates UCL issues? What kind of athletes get it?
External rotation stresses the UCL
Baseball players
* especially in younger players
* Practice the # of hrs that your age is
* NOTE: adaptations need to happen in the UE for this to happen over and over again. These kids don’t have that external rotation ability yet - so they’re putting lots of valgus stress through that elbow which puts lots of stress on that UCL
Where would a UCL injury cause there to be tenderness?
Medial elbow
What motion causes UCL issues? (2)
repettive Elbow valgus (think that external rotation w/ baseball)
* This could even be a frisbe - its jsut a repetitive valgus stress
NOTE: It could also be a traumatic valgus stress (one time causes all the damage)
Would a UCL issue cause inflammation?
Possible swelling, especially if its acute
Why would a FOOSH cause a UCL injury?
Because w/ FOOSH’s theres a traumatic valgus stress that happens
* similar to falling from a high place and landing on legs or lifting a heavy squat (knees go in). Same thing when you do a FOOSH - your elbow caves in and the UCL pathology happens
What is the singular special test for UCL pathology?
Moving valgus stress test
* Rules in
* Make sure partener doesnt have instability
* Key is externally rotate the shoulder which will put the elbow into that valgus force
What are the two differeintial diagnosis for UCL issues?
Medial Epicondylalgia
Cubital tunnel syndrome
The key is knowing if there was a traumatic valgus incident or if they were the kind of person that has been doing repetitive valgus activities (like a baseball player)
Is there inflammation w/ Lateral epicondyalgia?
Not typically
* normally more that osis = increased collagen disorganization, fibrosis and neurovascular growth
* more of a tendinopathy
Whats more common, medial epicondyalgia or lateral?
Lateral
KNOW: 1-2% of general pop experiences lateral epicondyalgia at some time
40-50% of tennis players get this at some point
What two issues cause lateral epicondyalgia to be more common (kind of people who are likely to have it)
Smokers = because if worse tissue healing
Manual laborers = overuse - not enough time for tissue to adapt - just have to show up and do it the next day. Normally the human body can withstand what they’re doing - the problem is that they don’t get enough time to adapt
If you grip as hard as you can is the wrist in more flexion or extension
Extension (do it)
KNOW: Repetitive and foreful grasping will cause lateral epicondyalgia (because wrist goes into that slight extension w/ gripping)
What muscle is affected w/ lateral epicondylalgia?
Extensor carpi radialis brevis
* Merges w/ lateral colatearl ligament and fuses w/ annular ligament
To a lesser degree externor carpi radialis longus
Where is pain located w/ lateral epicondylalgia?
Anterior to the lateral epicondyle
What motion aggravate lateral epicondyalgia?
Passive wrist flexion with elbow extension and pronation (putting the tendin on stretch)
* Note this is mills test (rules in = high specificity w/ positive test)
*
What two special tests do we have for lateral epicondyalgia?
* Which one rules out and which one rules in?
Cozens test (rules out)
* high sensitivity (negative test = rules out)
Mill’s Test (rules in)
* High specificity (positive test = rules in)
So if I get someone who says they have lateral epicondyalgia and I don’t really think its latearl epicondyalgia im going to perform a cozens test to rule it out. But if thats a positive - then I’ll perform a Mill’s test to rule it in (positive mills = rules in)
What is the terrible Triad for the elbow?
Radial head fracture
Ulna coronoid fracture
Posterior dislocation of the ulna (I think its posterior)
What kind of injury can cause an olecranon fracture? (3)
1) Backwards fall on elbow
2) FOOSH
3) Tricep eccentric contraction (avulsion fracture)
Tricep eccentric contraction could break what bone?
Olecranon of ulna (avulsion fracture = tendin tears away bone)
* Tricep force so strong that we pull that boney promince off
* Typically falling forward and activating tricep
What position are olecranon pts normally found in? Why?
90 degrees
They sit in this position because its the furthest the olecranon of ulna can be from the olecranon fossa (humerus) without eccentric tension from the tricep
They typically stay in this position for about 2 weeks then have a gradual restoration of movement
KNOW: Olecranon fractures can be opperative or non operative (normally non opperative are more that hairline fracture)
Varus or valgus force causes radial head fractures?
Valgus
Think about it - MCL is strained (coming apart) so the radial head must be in firm articulation w/ the capitulum of the humerus
What kind of injury normally causes a radial head fracture? Why?
FOOSH
because FOOSH’s normally cause valgus - and valgus force causes radial hd fractures
Why would you screen for wrist / hand injuries w/ radial hd fractures?
Because radial hd fractures come from FOOSH’s so they would’ve landed on that hand first
Does radial head fracture come from blunt force trauma? Why?
Because a hit to the radius won’t really get the radial head because its so deep in there
* normally injuried via compression force from a FOOSH
What kind of presentation would someone w/ a FOOSH have?
Localized pain, swelling / tenderness at the radial head
Reduced ROM
Why would we assess for nerve injuries w/ a FOOSH? Which n?
We would assess for radial n injuries w/ a FOOSH because the radial n wraps around the radial hd
What position would we want to avoid w/ radial head fractures (acute)
Full extension
Also - full elbow extension causes elbow valgus (the position that originally caused the radial hd fracture most likely)
KNOW: w/ full elbow extension you go into valgus
3 components of elbow terrible triad?
Posterior dislocation of ulnohumeral joint
Fracture of radial head
Fracture of coronoid
because when the dislocation happens its going to bump up against the coronoid process and fracture that - and then the capitulum will fracture the radial hd (makes sense w/ the posterior dislocation pulling the radial hd back into the capitulum)
What kind of injury normally causes elbow terrible triad?
FOOSH (makes sense as to the how the ulna posteriorly dislocates)
If someone has a radial head fracture what other injury should be assumed until ruled out w/ imaging?
Terrible triad (same MOI [FOOSH])
w/ a FOOSH which two aspects of ROM are the most limited?
Extension & Pronation
Pronation = radial head spinning
What two things cause olecranon bursitits
Trauma or repetitive pressure on the bursa that leads to inflammation and swelling
AKA students elbow
Whats the risk of not reating olecranon bursitits? How do they treat it?
Infection
Drain it then dont bare weight on the elbow for about a week
What are the 4 differntial diagnosis of olecranon bursitits?
Fracture - can cause swelling (typically olecranon fracture)
Synovial cyst
RA = joint swelling
GOUT
What tendinopathy happens on the anterior elbow?
Distal bicipital tendinopathy
What position causes distal bicipital tendinopathy?
Reptitive Extension w/ pronation
This is max flexing that bicep (does flexion / supination)
OR
Repetitive elbow flexion w/ pronation / supination (stressing tendin concentrically)
Think dribbiling a basketball (Does all this)
How would we stretch the bicep to rule in bicep tendinopathy?
Extension at shoulder
Extension at elbow
Pronation at elbow
Can also do resisted bicep MMT
KNOW: Gradual loading of tendin helps tendinitis / tendinosis
What is this
Distal biceps tendin RUPTURE
* can tell its a rupture because the biceps actually moves
Who normally gets biceps tendin ruptures?
* gender
* age
* arm
* position
Males
~50
Dominant arm
Max load in 90 degrees of elbow flexion
After a distal biceps tendinopathy where is pain typically felt? what kind of pain?
Sharp pain in the antecubital fossa (progresses to a dull ache)
* This is anterior arm
What two motions at the elbow are lossed after biceps tendin rupture?
Flexion / Supination (duh)
Who normally gets surgery to fix biceps tendin if ruptured?
Active young (easy to reattach tendin)
Wont do it for older complciated cases where the tissue quality is poor
What two things cause triceps tendinpathies?
Repetitive extension / Heavy lifting
* wt lifting
* boxing
* gymnastics
* throwing/racket sports
Where is pain w/ triceps tendinopathy?
Localized pain at triceps insertion at olecranon
What motion is weakened and hurts w/ triceps tendinopathies?
Elbow extension
What are the 3 differeintial diagnosis for triceps tendinopathies?
Olecranon bursitits
Olecranon fracture
Olecranon avulsion
What motion typically causes triceps tendon ruptures?
Strong eccentric contraction of the triceps
What 3 places does the ulnar nerve get entrappted?
Arcade of Struthers (more superior)
Cubital retinaculum
Arcade of osborne - flexor carpi ulnaris muscle splits to create this
What muscle splits to create the arcade of osborne?
Flexor carpi ulnaris muscle
Where does cubital tunnel normally cause ulnar n intrapment
medial elbow
Ulnar n causes numbness where?
Down the medial aspect of forearm into 4th/5th digits
Weakness from medial n loss causes what 4 weakness things to happen
1) Ulnar deviation
2) 5th digit flexion
3) wrist flexion
4) Benediction sign w/ hand opening
happens when they open their hand
3 special tests for ulnar n entrapment
1) Tinel’s Sign - at cubitial tunnel - tapping to feel ulnar n symptoms - reproduction of their symptoms - hard taps
2) Elbow flexion test -
3) Pressure provocation test
3 Sites of entrapment for median n
1) Ligament of Struthers
2) Bicipital aponeurosis
3) Pronator teres (called pronator teres syndrome)
w/ median n entrapment where is the numbness / tingling
Palmar aspect of hand except fingers 4/5
Dorsal aspect of fingertips
What 5 weaknesses do we have w/ median n entrapment
1) Pronation
2) Wrist flexion
3) radial deivation
4) Grip ability is affected (because of prior 2)
5) Ape hand deformity - thumb is in extension / abduction at rest and MCP joints are extended
6) Thumb opposition / flexion
7) Benediction sign while attempting to make a fist (closing hand)
APE hand
Patient presents like this. What is it and what nerve is damaged
Apes hand
Median n damaged
Which nerve damage creates benedition sign when closing fist? (damaged n)
Median
Which n creates benedication sign while opening hand (damaged n)
Ulnar
Two places the radial n gets entrapped?
Supinator muscle belly
Acrade of Frohse
Where is the numbness / tingling? radial n
Lateral 2/3 dorsum of hand including thumb
What differenital diganosis can be mixed up w/ radial n entrapment
lateral epicondyalgia
Where are the 4 places of weakness w/ radial n entrapment?
1) wrist exnteion
2) supination
3) finger extension
4) Thumb abduction
What is the most commonly injured periperal n?
Radial n
What kind of fractures normally cause radial n entrapments?
Humeral
SMART Goals
Specific
Measureable
Attainable
Relevant
Time dependent
Must relate back to a functional WHY
EX: In 8 weeks, patient to carry 8lbs in R hand for 300 deet to allow pt to carry gallon of milk into house
EX: In 4 weeks, pt to present w/ at least 10 degrees increase in elbow extension AROM for improved ability to wt bear on UEs
