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Elbow Examination: Difference between revisions

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==Introduction==
{{partial}}
Reliability and Utility of  Examination of the Elbow
 
A search of MEDLINE 1966-1998 using the MESH terms “diagnosis” and “elbow” failed to detect any studies concerning the characteristics of any clinical examination features around the elbow. Therefore, any recommendations that might be offered concerning examination of the elbow are based on tradition and concept validity.
 
==Inspection==
==Inspection==
 
*Skin changes such as psoriatic plaques
In contrast to the examination of deep axial structures such as the spine, the inspection of a superficial joint like the elbow is likely to be highly rewarding. It should be systematic, carefully addressing each of the structures and tissues around every aspect of the joint, for shape and contour. The key findings at issue are the presence of any fixed or reducible deformities, any bony, articular or olecranon bursal swelling and any signs of inflammation. The features of complex regional pain syndrome type 1, such as oedema, excessive or impaired sweating , skin discolouration and trophic skin changes can also be readily determined on simple inspection.
*Fixed or reducible deformity / soft tissue swelling
**Masses, nodules or tophi
** Carrying angle of the elbow
* Articular or olecranon bursal swelling
* Signs of inflammation
* [[CRPS|CRPS]] signs


==Palpation  ==
==Palpation  ==
Determine the exact sight of tenderness. Undertake a systematic approach
*start with palpating bony prominences: medial epicondyle, olecranon, lateral epicondyle, radial head
*Palpate elbow joint line:  olecranon fossa, olecranon-humeral joint line
*Palpate ligaments and tendons:  medial and lateral collateral ligaments, common flexor, extensor proximal tendons, and distal biceps tendon.
*Cubital tunnel / ulnar nerve
Also assess for [[:Category:Heritable Connective Tissue Disorders|hypermobility and skin hyperextensibility]].


Other than further evaluating any observed swelling, the true value of palpation is in determining the site of any tenderness around the elbow. This should be undertaken systematically, carefully addressing each of the structures and tissues around the joint. Any tenderness should be defined in terms of its anatomical location in relation to the joint – lateral, medial, anterior, posterior, and in terms of the structure or tissue involved, if possible – bony tenderness, joint margin, ligament, tendon, or skin.  
==Range of movement==
Assess active and passive range of motion of the elbow joint. Normal flexion is 135-145 degrees, and normal extension is 0-5 degrees <ref>Morrey BF, Askew LJ, An KN, et al. A biomechanical study of normal functional elbow motion. J Bone Joint Surg. 1981;63A: 872–6.</ref> Compare to the opposite side and assess for end feel of movement.


However, in this context it should be recognised that when several structures overlie one another tenderness  evoked by pressing over a region cannot be validly ascribed to any one of these structures. Under those circumstances, the most honest description of the tenderness is on in terms of its general anatomical location. For tenderness to be ascribed selectively to a particular tendon or like structure, that structure should be palpable from at least three directions, such that it is tender not only upon pressing the structure but also upon selectively squeezing it. Only in this manner can it be shown that the tenderness is not located in an underlying or overlying structure.
The forearm range of motion is 85 degrees of supination, and 75 degrees of pronation. The hand should move medially as the forearm pronates <ref>Weinberg AM, Pietsch IT, Helm MB, et al. A new kinematic model of pro- and supination of the human forearm. J Biomech. 2000;33:487–91</ref>


==Range of movement==
Also assess varus and valgus stress testing.


The range of movement in the elbow is readily determined. However, no explicit data have been published on the diagnostic value of such assessments. It is generally accepted that patients with medial or lateral epicondylitis will have no significant restriction on flexion or extension of the elbow1, but may have pain with the combination of pronation, wrist flexion and elbow extension (Mill’s manoeuvre)2.
==Special Tests==
There are few special tests of the elbow<ref>Chumbley EM et al. Evaluation of overuse elbow injuries. Am Fam Physician. 2000; 61: 691 – 700.</ref>
# The tennis elbow test
# Pain on resisted third finger extension
# Varus and valgus aligned stress testing
# Posterolateral rotary instability test


==Other Manoeuvres ==
== Paediatric Examination ==
A consensus approach to the MSK examination in children was developed by Foster et al in 2011.<ref>{{#pmid:21954040}}</ref> The <u>underlined</u> components are those that are additional to the adult examination The ''italicised'' components are those that the doctor should be aware of but not necessarily competent in.


The extensor carpi radialis brevis tendon (ECRB) inserts into the proximal part of the dorsum of the third metacarpal.3. It has been suggested that lateral epicondylar pain reproduced by wrist extension resisted by pressure over the distal third metacarpal is specific for pain arising from the origin of ECRB4.  No data has been advanced to support or refute this viewpoint.
* Look for carrying angle, scars, swellings or rashes, deformity
 
* Feel for skin temperature
In challenging restraints on the ulnar side of the elbow recommendations have been to test with the elbow at 30o of flexion, with examination for the end feel of the ligament.5. Again, no data have been found to verify that this is a reliable or valid test.
* Feel over head of radius, joint line, medial and lateral epicondyles
* Assess full flexion and extension, pronation and supination – actively and passively
* Assess function – e.g. hand to nose or mouth, hands behind head
* ''Option – hypermobility syndromes, muscle power, entheses'', ''instability tests''


==References==
==References==


1. Geoffroy P, Yaffe MJ, Rohan I.  Diagnosing and treating lateral epicondylitis.  Can Fam Physician 1994;  40:73-78.
[[Category:Elbow and Forearm]]
2. Sölveborn SA.  Radial Epicondylalgia ('tennis elbow') treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements.  Scand J Med Sci Sports 1997;  7:229-237.
[[Category:Examination]]
3. Briggs CA, Elliott BG.  Lateral epicondylitis. A review of structures associated with tennis elbow.  Anat Clin 1985;  7:149-153.
4. Wadsworth TG.  Tennis elbow: conservative, surgical and manipulative management.  BMJ 1987;  294:621-624.
5. Field LD, Altchek DW.  Elbow injuries.  Clin Sports Med. 1995;  14:59-78.
 
[[Category:Elbow & Forearm]]

Latest revision as of 14:17, 13 March 2022

This article is still missing information.

Inspection

  • Skin changes such as psoriatic plaques
  • Fixed or reducible deformity / soft tissue swelling
    • Masses, nodules or tophi
    • Carrying angle of the elbow
  • Articular or olecranon bursal swelling
  • Signs of inflammation
  • CRPS signs

Palpation

Determine the exact sight of tenderness. Undertake a systematic approach

  • start with palpating bony prominences: medial epicondyle, olecranon, lateral epicondyle, radial head
  • Palpate elbow joint line: olecranon fossa, olecranon-humeral joint line
  • Palpate ligaments and tendons: medial and lateral collateral ligaments, common flexor, extensor proximal tendons, and distal biceps tendon.
  • Cubital tunnel / ulnar nerve

Also assess for hypermobility and skin hyperextensibility.

Range of movement

Assess active and passive range of motion of the elbow joint. Normal flexion is 135-145 degrees, and normal extension is 0-5 degrees [1] Compare to the opposite side and assess for end feel of movement.

The forearm range of motion is 85 degrees of supination, and 75 degrees of pronation. The hand should move medially as the forearm pronates [2]

Also assess varus and valgus stress testing.

Special Tests

There are few special tests of the elbow[3]

  1. The tennis elbow test
  2. Pain on resisted third finger extension
  3. Varus and valgus aligned stress testing
  4. Posterolateral rotary instability test

Paediatric Examination

A consensus approach to the MSK examination in children was developed by Foster et al in 2011.[4] The underlined components are those that are additional to the adult examination The italicised components are those that the doctor should be aware of but not necessarily competent in.

  • Look for carrying angle, scars, swellings or rashes, deformity
  • Feel for skin temperature
  • Feel over head of radius, joint line, medial and lateral epicondyles
  • Assess full flexion and extension, pronation and supination – actively and passively
  • Assess function – e.g. hand to nose or mouth, hands behind head
  • Option – hypermobility syndromes, muscle power, entheses, instability tests

References

  1. ↑ Morrey BF, Askew LJ, An KN, et al. A biomechanical study of normal functional elbow motion. J Bone Joint Surg. 1981;63A: 872–6.
  2. ↑ Weinberg AM, Pietsch IT, Helm MB, et al. A new kinematic model of pro- and supination of the human forearm. J Biomech. 2000;33:487–91
  3. ↑ Chumbley EM et al. Evaluation of overuse elbow injuries. Am Fam Physician. 2000; 61: 691 – 700.
  4. ↑ Foster et al.. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis care & research 2011. 63:1503-10. PMID: 21954040. DOI.
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