LOOK FEEL SEADS Surface Anatomy Lateral and medial - - PowerPoint PPT Presentation

12/10/2016 1

Elbow Exam

Anthony Luke MD, MPH, CAQ (Sport Med) UCSF Sports Medicine ABC’s of MSK Care December 10, 2016

Disclosure

• Founder, RunSafe™, RaceSafe™
• Founder, SportZPeak Inc.
• Sanofi, Investigator initiated grant

LOOK

“ “ “ “SEADS” ” ” ”

• Swelling
• Erythema
• Atrophy
• Deformity
• Surgical Scars

FEEL

• Surface Anatomy

– Lateral and medial epicondyles – Olecranon – Ulnar Nerve

• Crepitus / Motion
• Swelling

12/10/2016 2 MOVE

• Average flexion

0° ° ° ° to 145° ° ° ° +/- 10° ° ° °

• Pronation ~ 80°

° ° ° and supination 85° ° ° °

Generalized Laxity

3 Basic P/E findings for tendinopathy

1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch

Epicondyles tender

12/10/2016 3 Special Tests

• Pain
• Instability
• Dysfunction
• Numbness
• Provocative Tests
• Stress Tests
• Functional Tests
• Neurological tests
• Radicular signs

Valgus stress test

• The patient’

’ ’ ’s wrist and hand are fixed and a valgus stress is applied with the patient’ ’ ’ ’s elbow at 30 degrees.

Milking Maneuver

• Arm at 70°

° ° °

• Apply valgus force

applied by supporting the elbow and tractioning the thumb

• Similar to milking a

cow

Moving Valgus Stress Test

• Shoulder abducted to 90°
• Apply valgus force to the

elbow until the shoulder is fully externally rotated

• While maintaining the valgus

torque, quickly extend the elbow to approximately 30°

• Positive test: reproduces

pain at the UCL, typically

• ccurring maximally

between 120° and 70° of flexion

12/10/2016 4 Nerves

• Ulnar Nerve
• Passes behind the

medial epicondyle and lies over the ulnar collateral ligament

• Then under the

bicipital aponeurosis and pronator teres

• Radial Nerve
• Passes posterior to

anterior at distal third

• f the humerus
• Posterior interosseous

nerve

• Supplies deep

muscles

• Passes under the

Arcade of Frohse near Supinator

Ulnar nerve – Cubital Tunnel

• Ulnar nerve

compression, traction

• r subluxation

Evaluation

• Repetive extension

to flexion

• Elbow Flexion test
• Tinel’s

Cubital Tunnel Syndrome

Physical Exam

• Positive Tinel’s

test

• Positive

Froment’s sign (weakness with thumb/index finger pinch)

• Decreased

sensation in 4th/5th digit

15

Cervical Spine

• Referred or

radicular pain

– C4 – C5 – C6 – C7

12/10/2016 5 Cervical Spine - Differentiation

• Location of Referral

– Neck pain – Scapular pain – Pain distal to elbow – Paresthesia

• Aggravating factors

– Ask about the neck – Spurling’s Test

Thoracic Spine

Thoracic Outlet Syndrome

– Repetitive upper extremity use

• shoulder, elbow, hand

– assembly line – computer with mouse and phone

– Poor posture – Reaching – Stress

Adson’s Test

• Seated patient extends and

turns head toward the tested shoulder,

• Shoulder is slightly abducted

and extended. The subject inhales while the examiner palpates the ipsilateral radial pulse.

• Positive findings: Diminution
• r elimination of the pulse

and reproduction of the paresthesias

• Studies have documented

the Adson’s maneuver to have poor to good specificity and good sensitivity.

Wright’s Hyperabduction Test

• With patient seated, the

clinician hyperabducts and externally rotates the patient’s arm while assessing the ipsilateral radial pulse

• Positive findings:

Diminution or elimination of the radial pulse and reproduction of the paresthesias

• No studies have examined

validity

12/10/2016 6 Roos Stress Test

• Patient holds shoulders in

abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes.

• Positive findings: Reproduction of

their symptoms or a sensation of heaviness and fatigue.

• No studies have examined validity
• f the Roos stress test as it

pertains to thoracic outlet syndrome.

Vascular Problems

• Complaints of

heaviness, fatigue, paresthesias, and effort-related pain