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L15: Examination Elbow 2 Flashcards

1
Q

What are the common conditions of the elbow?

A
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2
Q

What is the most common overuse injury of the elbow?

A

Lateral epicondylalgia / lateral epicondylitis / ‘tennis elbow’

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3
Q

What are the 3 characteristics of prevalence of laterla lebow tendinopathy?

A
  1. Common in those aged 35-54 years
  2. Dominant arm in both men and women
  3. Increased incidence
    • Tennis players
    • Occupations involving repetitive forearm and wrist movements
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4
Q

What are the 5 pathophysiologies for lateral elbow tendinopathy?

A
  1. Non-inflammatory
  2. Degenerative changes
    1. Collagen disorganisation
    2. Increase in cell numbers
    3. Neovessel ingrowth
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5
Q

What are the 5 degenerative changes in pathophysiology for lateral elbow tendinopathy?

A
  1. Collagen disorganisation
  2. Increase in cell numbers
  3. Neovessel ingrowth
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6
Q

What are the 2 pain system changes (peripheral and central NS) in pathophysiology for lateral elbow tendinopathy?

A
  1. Increased local neural transmitters
  2. Mechanical hyperalgesia - local and widespread
    • Sensitive to painful mechanical sensatiion
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7
Q

What are the 3 motor system changes in pathophysiology for lateral elbow tendinopathy?

A
  1. Diminished strength / strength imbalance
    • ↓ F and E strength in wrist and hand, but not MCP E
    • Global UL weakness
  2. Morphological abnormalities (eg. ECRB)
  3. Sensori-motor changes
    • Flexed wrist posture during grip
    • ↓ UL reaction time, speed of movement
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8
Q

What are the 3 MOI in the presentation for lateral elbow tendinopathy?

A
  1. Acute – consider tendon tear
  2. Repetitive activity
  3. Alternating periods of activity & inactivity may lead to degenerative changes (may precede onset of symptoms)
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9
Q

What are the 3 presentations for lateral elbow tendinopathy?

A
  1. Pain over the lateral elbow, possibly radiating into forearm
  2. Pain and loss of strength with gripping/ lifting or tasks involving manipulation of hand/fingers
  3. Possible co-existing neck or shoulder pain
    • Quite prevalent in people with tennis elbow
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10
Q

What is the palpation presentation for lateral elbow tendinopathy in the physical examination?

A

Pain over the lateral epicondyle or common extensor tendon origin

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11
Q

What are 3 presentations in the muscle exam for lateral elbow tendinopathy in the physical examination?

A
  1. Pain with passive wrist flexion
  2. Pain with resisted wrist extension
  3. Pain with resisted 2nd / 3rd finger extension
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12
Q

What are 3 gripping presentations in the muscle exam for lateral elbow tendinopathy in the physical examination?

A
  1. Pain with gripping
  2. Decreased pain-free grip strength
  3. Wrist deviated or more flexed
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13
Q

What are 4 characteristics in the muscle exam for lateral elbow tendinopathy in the physical examination?

A
  1. Gripping
    1. Pain with gripping
    2. Decreased pain-free grip strength
    3. Wrist deviated or more flexed
  2. Decreased strength or endurance at elbow, wrist and shoulder
  3. Difficulty dissociating wrist and finger extension
  4. Altered muscle control during functional tasks i.e. lifting, tennis, golf
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14
Q

What are treatment direction tests for lateral elbow tendinopathy in the physical examination?

A

Used to determine effect of MWM on symptoms

Example

  1. Ax of functional movement- pain-free grip / wrist or finger extension
  2. Lateral elbow glide / PA glide radial head/ cervical lateral glide (C5/6)
  3. ReAx of functional movement- Significant increase in grip strength i.e. by 50%

Eg. Lateral glide –> grip (for MWM)= decrease pain (don’t push painful structure rather than medial glide)

Eg. PA glide of radial head)

Purpose of glides:

  • Biomechanical effect
  • Neurophysiological effect (afferent input –> decrease pain)
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15
Q

What are investigations of lateral elbow tendinopathy in the physical examination?

A
  1. Absence of ultrasound findings can effectively rule condition out and prompt for other pathology
  2. Presence of a large tendon tear or lateral collateral ligament tear indicates a poorer prognosis and may prompt early referral
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16
Q

What are prognosis of lateral elbow tendinopathy in the physical examination?

A

83-90% much improved or completely recovered within 1 year if wait and see

  • Except for A&E (no other treatments)
  • Self-limiting condition = get better with time even without treatment
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17
Q

What are 5 prognostic factors for poorer long-term outcome for lateral elbow tendinopathy?

A
  1. High baseline pain and disability- Eg use questionnaire score of >54 = high baseline pain and disability
  2. Concomitant neck pain
  3. Cold hyperalgesia
  4. Large tendon tear or ligament tear
  5. Work-related factors – manual tasks with high loads, low job control- Can’t switch between tasks (monotonous tasks)

Can still help with management but just need to change some techniques

  • Liaise with work
18
Q

What are 4 differential diagnoses for lateral elbow tendinopathy?

A
  1. Radiohumeral joint pathology
    • Eg. Joint stiffness, cartilage, OA
  2. PIN entrapment / radial tunnel syndrome
    • Weakness (might not have much pain (due to motor nerve)
    • Not much weakness but have pain and pins and needles
  3. Arthritis
  4. Referred pain (C5-6)
19
Q

What is the interview findings (6) and physical exam for a RHJ pathology (lateral)?

A

Interview

  1. Eg. throwers, gymnast- overload joints
  2. -> valgus and compresison on lateral side)
  3. Area of pain = more posterior to lateral epicondyle
  4. Pain = dull and diffused
  5. Clicking, locking and snapping
  6. Loading (increase compressive loads)

Physical exam

  1. Glides (radio-humeral joint stiffness)
  2. Elbow AROM
  3. Elbow PROM
  4. Palpation through joint line
20
Q

What is the interview findings (4) and physical exam (6) for a PIN entrapment/radial tunnel syndrome (lateral)?

A

Interview

  1. MOI: repetitive forearm supination and pronation
  2. Are of pain:: not at lateral elbow, over wrist extensors or wrist
  3. Symptoms: Neural (pins and needles, numbness, weakness)

Physical

  1. Not as much grip strength (rather for tennis elbow)
  2. Muscle strength (nerve function)
    • Extensors,
    • Finger extensors
    • Thumb Abductors
  3. Nerve palpation
  4. Neurodynamic tests (because PIN is a motor nerve so do not need to do neurological as much- sensory)
  5. Resisted supination (common compression site)
  6. Radial tunnel - no sensory loss (no numbness but will might get pins and needles due to hypersensitivity of nerve)
    • Splits before the radial tunnel so there for not sensory loss vs motor problems/loss
21
Q

What is the interview findings (4) and physical exam (3) for referred pain (lateral)?

A

Interview

  1. Activities that load the neck (sustained postures, repetitive movements of the neck, overhead lifting
  2. Pain is more widespread (possible dermatomal)
  3. Pain at elbow and neck
  4. Aggravating factors: neck movts, postures,

Physical exams

  1. Pain with neck mvts
  2. Cervical spine PAIVMS and PPVIMS
  3. Nerve root –> neurological deficits –> neurological exam
22
Q

What are the 3 characteristics of prevalence of lMCL injury?

A

Common in overhead athletes

  • Baseball - ‘pitcher’s elbow’
  • 24.1% of total injuries of major and minor league baseball
  • Javelin throwers
  • Volleyball players
  • Tennis players
23
Q

What is the traumatic and overuse MOI in MCL injury?

A
  1. Traumatic
    • May have felt a ‘pop’
  2. Overuse
    • Repetitive valgus force with throwing
24
Q

What are the 2 presentations of acute MCL injury?

A
  1. sudden onset medial elbow pain, often with popping sensation
  2. Inability to throw after injury
25
What are the 2 presentations of overuse MCL injury?
1. gradual onset pain with i.e. throwing, often symptoms of giving way 2. Problems with throwing 3. Pain usually in late cocking or early acceleration phases 4. Decreased velocity, distance, accuracy of throw, early fatigability
26
What are 2 concomitant pathologies for Ulnar nerve irritation/compression for MCL injury?
1. Acute MCL injuries - irritation from swelling 2. Chronic MCL injuries – valgus instability placing tensile stress on ulnar nerve, irritation/compression from MCL scarring * Osteophytes formation
27
What are 2 observations of MCL injury in the physical examination?
1. Swelling of medial elbow 2. Arm held in slight flexion Accommodate for swelling for acute Contracture or tightness for chronic
28
What are 3 palpation of MCL injury in the physical examination?
1. Pain on palpation of MCL 2. Swelling 3. Possible hypersensitivity of ulnar nerve
29
What are 3 characteristics of movement exam for MCL injury in the physical examination?
1. Decreased elbow extension ROM 2. Decrease muscle length of elbow flexors 3. Decreased power specific to throwing
30
What are 2 characteristics of ligament stress test (positive valgus stress test) for MCL injury in the physical examination?
1. Increased laxity 2. Altered end-feel
31
What are 2 characteristics of muscle exam for MCL injury in the physical examination?
32
What are 5 other possible associated problems for MCL injury in the physical examination?
1. Ulnar nerve irritation / compression 2. RHJ problems 3. Medial elbow tendinopathy 4. Osteochondral defects- Due to increase compression 5. Loose bodies around olecranon
33
What are 3 conditions depending on patient's age (i.e young athletes)?
1. Medial epicondylar apophysitis (‘little league elbow’) * Inflammation of apophysis (due to weakness of the apophysis instead to getting a MCL sprain) 2. Avulsion fracture of medial epicondyle 3. Osteochondritis dissecans * Usually on radial head or capitulum * Separation of bone due to repetitive compression
34
What are 3 types of investigations in MCL injury?
1. X rays * Avulsion fractures * 2º changes of chronic MCL insufficiency- Eg. osteophyte changes, wearing of RHJ) 2. Ultrasound- Not common (while for sprains) 3. MRI * Gold standard for confirming diagnosis of MCL injury * Identify associated pathologies
35
What is the interview findings (5) and physical exam (3) for a medial elbow tendinopathy (Golfer's elbow) (medial)?
Interview 1. Repetitive valgus stress 2. Throwing 3. Repetitive gripping or use of the hand (muscles) 4. Tender over medial epicondyle and referral to forearm 5. Aggravating activity: valgus activity forces, gripping, use of hands and fingers, activation of pronators and writs flexors Physical 1. Palpation (common flexor tendon and medial epicondyle) 2. Resisted tests (writs and finger flexion, pronation, grip) 3. Length test (wrist extension)
36
What is the interview findings (2) and physical exam (3) for an ulnar nerve (medial)?
Interview 1. MOI: repetitive valgus stress, sustained compression on posterior elbow (eg. rest elbow when they are driving on the arm rest, or wheelchair), compression of ulnar nerve (repeated 2. Symptoms: pins and needles, numbness Physical 1. Neurodynamic 2. Palpation 3. Neurological test * Muscle strength * Sensation loss
37
What is the incidence for instabililty/dislocations for acute elbow injuries?
1. 2nd most commonly dislocated major joint, after the shoulder in adults. 2. Most frequently dislocated joint in children 3. Posterior dislocations most common
38
What is the MOI for instabililty/dislocations for acute elbow injuries?
Posterolateral rotatory force from FOOSH 1. Posterolateral rotatory subluxation * Radial head subluxes from ulnar and humerus 2. Posterior dislocation of elbow * Axial compression + valgus stress in supination = dislocation
39
What are the 4 stages in the specturm of elbow instability?
3 stages Rupture in UCL (subluxation of radial head that can relocated) Injury to lateral complex and anterior and posterior capsule (sublux radial head and ulnar) = partial Lateral complex, capsule + ulnar = full dislocation ???
40
What are the 3 MOI for fracture in acute elbow injuries?
1. Elbow dislocations 2. FOOSH 3. Direct blows
41
What is the protocol for X ray referral for fractures in aute elbow injuries?
Elbow extension test: Supinated, elbow F, shoulder F 90˚ \> Full both elbow E

PHTY3120 (29 decks)

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