Elbow Examination: Difference between revisions

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'''Original Editor '''- [[User:Jason Brandi|Jason Brandi]] and [[User:Krista Dayton|Krista Dayton]] as part of the [[Temple University Evidence-Based Practice Project|Temple University EBP Project]]  
'''Original Editor '''- [[User:Jason Brandi|Jason Brandi]] and [[User:Krista Dayton|Krista Dayton]] as part of the [[Temple University Evidence-Based Practice Project|Temple University EBP Project]]  


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page. 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
</div>  
== Subjective  ==


==== '''Clinical Presentation'''<br>  ====
==Clinical Presentation ==


[[Image:Bone ElbowAnatomy.jpg|right|200px]]  
[[Image:Bone ElbowAnatomy.jpg|right|200px]]  


Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.
Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.  


==== '''Subjective History'''  ====
==Subjective History==
* Exact location of pain
* Timeline-When are the patients reported symptoms at their worst?
* Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis.<ref name="number 1">MacDermid JC, Michlovitz SL. Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther. 2006; 19(2):82-97.</ref>&nbsp;For a traumatic injuries, specific symptoms can be highly useful in determining a diagnosis. For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.<ref name="number 1" />
* Presence of numbness or tingling?
* Medications?
* Past Medical History
* Diagnostic Testing/Imaging?<br>


<br>• Exact location of pain<br>• Timeline-When are the patients reported symptoms at their worst?<br>• Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis.<ref name="number 1">MacDermid JC, Michlovitz SL. Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther. 2006; 19(2):82-97.</ref>&nbsp;For atraumatic injuries, specific symptoms can be highly useful in determining a diagnosis.<br>&nbsp;&nbsp;&nbsp;&nbsp; For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.<ref name="number 1" /><br>• Presence of numbness or tingling?<br>• Medications?<br>• Past Medical History<br>• Diagnostic Testing/Imaging?<br>
=== Region Specific Historical Question ===
 
These questions will help guide the examination. For example<ref>Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion, 2008.</ref>:
• '''Region Specific Historical Question: These questions will help guide the examination. For example<ref>Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion, 2008.</ref>:'''
# Do your symptoms change (better or worse) with any movements of the neck or shoulder?<br>&nbsp;&nbsp;&nbsp;&nbsp;  
 
# Does your elbow ever “slip out” or feel unstable?<br>&nbsp;&nbsp;&nbsp;&nbsp;  
Please refer to the User's Guide to the Musculoskeletal Examination for further information.<sup>2</sup><br>1. ''Do your symptoms change (better or worse) with any movements of the neck or shoulder?''<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>''2. Does your elbow ever “slip out” or feel unstable?''<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>''3. Does the pain change with gripping activities?''<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>''4. Do you ever experience numbness of tingling in the hand?''<br>&nbsp;&nbsp;&nbsp; <br>''5. Was the elbow hyper extended during the time of injury?''<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>''6. Do you relate the symptoms to a throwing activity?''<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>
# Does the pain change with gripping activities?<br>&nbsp;&nbsp;&nbsp;&nbsp;  
 
# Do you ever experience numbness of tingling in the hand?<br>&nbsp;&nbsp;&nbsp;  
'''• Environmental and Personal Factors'''<br>During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury.&nbsp;Table 1 outlines these issues.<ref name="number 1" />  
# Was the elbow hyper extended during the time of injury?<br>&nbsp;&nbsp;&nbsp;&nbsp;  
# Do you relate the symptoms to a throwing activity?<br>&nbsp;&nbsp;&nbsp;&nbsp; <br>


=== Environmental and Personal Factors ===
<br>During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury.&nbsp;Table 1 outlines these issues.<ref name="number 1" />
{| cellspacing="1" cellpadding="1" border="1" style="width: 562px; height: 121px;"
{| cellspacing="1" cellpadding="1" border="1" style="width: 562px; height: 121px;"
|-
|-
| ''Table 1. Patient Factors that can affect healing and return of function after elbow injury<br>''
| ''Table 1. Patient Factors that can affect healing and return of function after elbow injury<br>''
|-
|-
| Diabetes • Immunosuppression • Infection • Multiple site injuries • Tobacco use • Excessive alcohol intake • Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability)<br>
| Diabetes * Immunosuppression * Infection * Multiple site injuries * Tobacco use * Excessive alcohol intake * Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability)<br>
|}
|}  


<br>
==Self-Report Outcome Measures==


==== '''Self-Report Outcome Measures'''  ====
*[[DASH Outcome Measure|DASH]] (Quick Dash)
*[https://www.physio-pedia.com/Patient_Specific_Functional_Scale?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal#share Patient-Specific Functional Scale]
*PREE and ASES: Patient-rated elbow evaluation (PREE)<ref name="number 1" />and American Shoulder and Elbow Society evaluation(ASES)<ref>King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Commitee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999; 8:351–4.</ref>are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.<ref name="number 1" />
*P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.<ref name="number 1" />


*[http://www.physio-pedia.com/index.php5?title=DASH_Outcome_Measure DASH (Quick Dash)]  
*[[36-Item Short Form Survey (SF-36)|SF-36]]: [[36-Item Short Form Survey (SF-36)|SF-36]] is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the [[36-Item Short Form Survey (SF-36)|SF-36]] is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.<ref name="number 1" />
*[http://www.physio-pedia.com/index.php5?title=Patient_Specific_Functional_Scale Patient-Specific Functional Scale]  
*PREE and ASES: Patient-rated elbow evaluation (PREE)<ref name="number 1" />&nbsp;and American Shoulder and Elbow Society evaluation(ASES)<ref>King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Commitee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999; 8:351–4.</ref>&nbsp;are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.<ref name="number 1" />
*P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.<ref name="number 1" /><br>


*SF-36: SF-36 is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the SF-36 is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.<ref name="number 1" />
==Special Questions ==


==== '''Special Questions'''<br>  ====
*Red and Yellow Flags- Conditions that may require referral to appropriate health care provider.&nbsp;
*


• Red and Yellow Flags- Conditions that may require referral to appropriate health care provider.&nbsp;
*


{| cellspacing="1" cellpadding="1" border="1" style="width: 364px; height: 181px;"
{| cellspacing="1" cellpadding="1" border="1" style="width: 364px; height: 181px;"
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| '''Red Flags'''<br>
| '''Red Flags'''<br>
|-
|-
| •Infection/Inflammation<br>•Malignancy<br>•Fracture/Dislocation (Positive Elbow Extension Test)<br>• Inflammatory Arthritides<br>•Abnormal Vitals<br>•Abnormal Vascular/Neurological Exam<br>•Heterotopic Ossification (Post-Surgical Consideration)<br>•Inappropriate progress from treatment made after surgery<br>
|
|}
* Infection/Inflammation
 
* Malignancy
<br>
* Fracture/Dislocation (Positive Elbow Extension Test)
* Inflammatory Arthritides
* Abnormal Vitals
* Abnormal Vascular/Neurological Exam
* Heterotopic Ossification (Post-Surgical Consideration)
* Inappropriate progress from treatment made after surgery
|}  


{| cellspacing="1" cellpadding="1" border="1" style="width: 368px; height: 74px;"
{| cellspacing="1" cellpadding="1" border="1" style="width: 368px; height: 74px;"
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| '''Yellow Flags'''<br>
| '''Yellow Flags'''<br>
|-
|-
|  
|
-Psychosocial factors<br>-Passive coping<br>-Fear Avoidance Beliefs  
* Psychosocial factors  
 
* Passive coping  
|}
* Fear Avoidance Beliefs  


<br>
|}


==== '''Investigations'''<br>  ====
==Investigations ==


[[Image:Elbow x-ray.PNG|thumb|right|300px|Normal articulations of the elbow from lateral and antero-posterior views]]
[[Image:Elbow x-ray.PNG|thumb|right|300px|Normal articulations of the elbow from lateral and antero-posterior views]]  


• Radiological Considerations<br>
* Radiological Considerations
- The information from the history should be correlated with imaging findings of the elbow when available.<ref name="number 1" />
** The information from the history should be correlated with imaging findings of the elbow when available.<ref name="number 1" />  


== Objective  ==
== Objective  ==
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*General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms.  
*General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms.  
*Thoracic and cervical spine including kyphosis and forward head  
*Thoracic and cervical spine including kyphosis and forward head  
*Scapula  
*[[Scapula]]
*Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.<ref name="number 5">Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. 1999; 30(1):15-20.</ref>  
*Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.<ref name="number 5">Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. 1999; 30(1):15-20.</ref> variability occurs till age of 14 -15
*Swelling/ecchymosis/deformities/muscle wasting  
*Swelling/ecchymosis/deformities/muscle wasting  
*Triangle Sign
*Triangle Sign


=== Functional Tests<br>  ===
=== Functional Tests   ===


The goal in performing functional test is to obtain and quantify an asterisk sign to assess and reassess after intervention is performed.  
The goal in performing functional test is to obtain and quantify an asterisk sign to assess and reassess after intervention is performed.  
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[[Image:Anterior elbow.jpg|Illustration adapted from [Colman WW & Strauch RJ].]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; [[Image:Lateral elbow.jpg|Image:Lateral_elbow.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; [[Image:Medial elbow.jpg|Image:Medial_elbow.jpg]]<br>  
[[Image:Anterior elbow.jpg|Illustration adapted from [Colman WW & Strauch RJ].]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; [[Image:Lateral elbow.jpg|Image:Lateral_elbow.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; [[Image:Medial elbow.jpg|Image:Medial_elbow.jpg]]<br>  


Image 2: Anterior Elbow<ref name="number 5">Colman WW, Strauch RJ. Physical examination of the elbow. Orthopedic Clinics of North America, 1999:30(1):15-20.</ref>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 3'':''&nbsp;Lateral Elbow<ref name="number 5" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp; Image 4:&nbsp;Medial Epicondyle<ref name="number 5" />
Image 2: Anterior Elbow<ref name="number 5" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 3'':''&nbsp;Lateral Elbow<ref name="number 5" />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp; Image 4:&nbsp;Medial Epicondyle<ref name="number 5" />  
 
Bicep tendon Marked&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; Circle represents lateral epicondyle&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dot represents medial epicondyle<br>  


=== Neurologic Assessment <br> ===
Bicep tendon Marked&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; Circle represents lateral epicondyle&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dot represents medial epicondyle<br>
 
*Reflexes: C5-C7
*Myotomes: C5-T1
*Dermatomes: C5-T1


=== Neurologic Assessment    ===
*[[Reflexes]]: C5-C7
*[[Myotomes]]: C5-T1
*[[Dermatomes]]: C5-T1
=== Movement Testing  ===
=== Movement Testing  ===


• Active Range Of Motion(AROM)/Passive Range Of Motion(PROM) with or without overpressure<br>&nbsp;&nbsp;&nbsp;&nbsp; o Elbow<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Flexion <br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Extension<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Positive [http://www.physio-pedia.com/index.php5?title=Elbow_extension_sign Elbow Extension Test] may indicate fracture and referral.<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Forearm pronation/supination<br>&nbsp;&nbsp;&nbsp;&nbsp; o Wrist<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Flexion<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Extension<br>&nbsp;&nbsp;&nbsp;&nbsp; o Cervical, Shoulder and Elbow Range of Motion with or without overpressure<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Posterior-anterior glide assessment on cervical/thoracic spine for distal symptoms reproduction as well.<br>  
*Active Range Of Motion(AROM)/Passive Range Of Motion(PROM) with or without overpressure
**Elbow<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Flexion <br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Extension<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Positive [http://www.physio-pedia.com/index.php5?title=Elbow_extension_sign Elbow Extension Test] may indicate fracture and referral.<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Forearm pronation/supination  
**Wrist<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Flexion<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Extension  
**Cervical, Shoulder and Elbow Range of Motion with or without overpressure<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Posterior-anterior glide assessment on cervical/thoracic spine for distal symptoms reproduction as well.<br>  


• Resistive testing<br>&nbsp;&nbsp;&nbsp;&nbsp; o Elbow flexion/extension<br>&nbsp;&nbsp;&nbsp;&nbsp; o Forearm pronation/supination<br>&nbsp;&nbsp;&nbsp;&nbsp; o Wrist flexion/extension<br>&nbsp;&nbsp;&nbsp;&nbsp; o Pain-free grip strength<br>&nbsp;&nbsp;&nbsp;&nbsp; o Thumb <br>&nbsp;&nbsp;&nbsp;&nbsp; o Fingers  
*Resistive Testing
**Elbow flexion/extension  
**Forearm pronation/supination  
**Wrist flexion/extension  
**Pain-free grip strength  
**Thumb
**Fingers  


<br>• Accessory motion testing<br>&nbsp;&nbsp;&nbsp;&nbsp; o Humeroulnar traction<br>&nbsp;&nbsp;&nbsp;&nbsp; o Humeroradial traction<br>&nbsp;&nbsp;&nbsp;&nbsp; o Proximal/distal radioulnar Anterior/Posterior and Posterior/Anterior glides<br>  
* Accessory motion testing
** Humeroulnar traction
** Humeroradial traction
** Proximal/distal radioulnar Anterior/Posterior and Posterior/Anterior glides<br>


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=== Special Tests (broken up by possible diagnosis)<br>  ===


[http://www.physio-pedia.com/index.php5?title=Cubital_Tunnel_Syndrome Cubital Tunnel Syndrome]:  
[http://www.physio-pedia.com/index.php5?title=Cubital_Tunnel_Syndrome Cubital Tunnel Syndrome]:  


*[http://www.physio-pedia.com/index.php5?title=Elbow_Flexion_Test Elbow Flexion Test]  
*[http://www.physio-pedia.com/index.php5?title=Elbow_Flexion_Test Elbow Flexion Test]  
*[http://www.physio-pedia.com/index.php5?title=Tinel%27s_Sign_at_Elbow Tinnel's Sign]  
*[[Tinel's Sign at Elbow|Tinel's Sign]]  
*Ulnar Nerve Compression Test
*Ulnar Nerve Compression Test


<br> [http://www.physio-pedia.com/index.php5?title=Lateral_Epicondylitis Lateral Epicondylalgia]:  
<br> [http://www.physio-pedia.com/index.php5?title=Lateral_Epicondylitis Lateral Epicondylalgia]:  


*[http://www.physio-pedia.com/index.php5?title=Mill%E2%80%99s_Test Passive elbow extension, pronation, wrist flexion (Mill's Test)]  
*[[Mill’s Test|Passive elbow extension, pronation, wrist flexion (Mill's Test)]]  
*[http://www.physio-pedia.com/index.php5?title=Cozen%E2%80%99s_Test Resisted wrist extension with radial deviation (Cozen's Test)]  
*[[Cozen’s Test|Resisted wrist extension with radial deviation (Cozen's Test)]]  
*Resisted middle finger extension (Maudley's Test)
*[[Maudsley's test|Resisted middle finger extension (Maudley's Test)]]


<br> Ligamentous Tests:  
<br> Ligamentous Tests:  
Line 461: Line 164:
*[http://www.physio-pedia.com/index.php5?title=Moving_Valgus_Stress_Test Moving Valgus Stress Test]
*[http://www.physio-pedia.com/index.php5?title=Moving_Valgus_Stress_Test Moving Valgus Stress Test]


<br> Neurodynamic Tests  
<br> [[Neurodynamic Assessment|Neurodynamic Tests]]:


*Median nerve bias: Upper Limb Neurodynamic Test 1  
*Median nerve bias: Upper Limb Neurodynamic Test 1  
*Radial nerve bias:&nbsp; Upper Limb Neurodynamic Test 2b  
*Radial nerve bias:&nbsp; Upper Limb Neurodynamic Test 2b  
*Ulnar nerve bias:&nbsp; Upper Limb Neurodynamic Test 3<br>
*Ulnar nerve bias:&nbsp; Upper Limb Neurodynamic Test 3  
 
   
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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== References  ==
== References  ==
References will automatically be added here, see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Assessment]] [[Category:Elbow]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Temple_Student_Project]]
[[Category:Assessment]]  
[[Category:Elbow]]  
[[Category:Musculoskeletal/Orthopaedics]]  
[[Category:Temple_Student_Project]]
[[Category:Elbow - Assessment and Examination]]
[[Category:Sports Medicine]]
[[Category:Athlete Assessment]]

Latest revision as of 12:34, 25 July 2021

Original Editor - Jason Brandi and Krista Dayton as part of the Temple University EBP Project

Top Contributors - Jason Brandi, Krista Dayton, Laura Ritchie, Kim Jackson, Nikhil Benhur Abburi, Admin, Rachael Lowe, Kai A. Sigel, Scott A Burns, WikiSysop, Anas Mohamed, Tarina van der Stockt, Wanda van Niekerk, 127.0.0.1, Johnathan Fahrner and Naomi O'Reilly

Clinical Presentation[edit | edit source]

Bone ElbowAnatomy.jpg

Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.

Subjective History[edit | edit source]

  • Exact location of pain
  • Timeline-When are the patients reported symptoms at their worst?
  • Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis.[1] For a traumatic injuries, specific symptoms can be highly useful in determining a diagnosis. For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.[1]
  • Presence of numbness or tingling?
  • Medications?
  • Past Medical History
  • Diagnostic Testing/Imaging?

Region Specific Historical Question[edit | edit source]

These questions will help guide the examination. For example[2]:

  1. Do your symptoms change (better or worse) with any movements of the neck or shoulder?
        
  2. Does your elbow ever “slip out” or feel unstable?
        
  3. Does the pain change with gripping activities?
        
  4. Do you ever experience numbness of tingling in the hand?
       
  5. Was the elbow hyper extended during the time of injury?
        
  6. Do you relate the symptoms to a throwing activity?
        

Environmental and Personal Factors[edit | edit source]


During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury. Table 1 outlines these issues.[1]

Table 1. Patient Factors that can affect healing and return of function after elbow injury
Diabetes * Immunosuppression * Infection * Multiple site injuries * Tobacco use * Excessive alcohol intake * Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability)

Self-Report Outcome Measures[edit | edit source]

  • DASH (Quick Dash)
  • Patient-Specific Functional Scale
  • PREE and ASES: Patient-rated elbow evaluation (PREE)[1]and American Shoulder and Elbow Society evaluation(ASES)[3]are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.[1]
  • P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.[1]
  • SF-36: SF-36 is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the SF-36 is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.[1]

Special Questions[edit | edit source]

  • Red and Yellow Flags- Conditions that may require referral to appropriate health care provider. 
Red Flags
  • Infection/Inflammation
  • Malignancy
  • Fracture/Dislocation (Positive Elbow Extension Test)
  • Inflammatory Arthritides
  • Abnormal Vitals
  • Abnormal Vascular/Neurological Exam
  • Heterotopic Ossification (Post-Surgical Consideration)
  • Inappropriate progress from treatment made after surgery
Yellow Flags
  • Psychosocial factors
  • Passive coping
  • Fear Avoidance Beliefs

Investigations[edit | edit source]

Normal articulations of the elbow from lateral and antero-posterior views
  • Radiological Considerations
    • The information from the history should be correlated with imaging findings of the elbow when available.[1]

Objective[edit | edit source]

Observation[edit | edit source]

  • General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms.
  • Thoracic and cervical spine including kyphosis and forward head
  • Scapula
  • Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.[4] variability occurs till age of 14 -15
  • Swelling/ecchymosis/deformities/muscle wasting
  • Triangle Sign

Functional Tests[edit | edit source]

The goal in performing functional test is to obtain and quantify an asterisk sign to assess and reassess after intervention is performed.

  1.  Determination of an asterisk sign-(What activity increases symptoms?)
  2.  Pain-Free Grip Strength
  3.  Push-off Test: The push off test can be used to quantify a person’s ability to bear weight through the upper           extremity. This can help identify functional/occupational limitations. (ICC=0.31-0.97).[1]
  4. Functional Impairment Test-Hand, Neck, Shoulder Arm (FIT-HaNSA): Standardized physical test. Assesses gross activities of the upper extremity. Validation in elbow conditions has not yet been completed. [1]

Palpation[edit | edit source]

  • Medial/lateral epicondyle
  • Olecranon and olecranon fossa
  • Radial head
  • Ulnar Collateral Ligament (UCL) of the elbow
  • Soft tissue in upper arm and forearm/wrist for pain provocation, heat, swelling

Illustration adapted from [Colman WW & Strauch RJ].                                       Image:Lateral_elbow.jpg                                       Image:Medial_elbow.jpg

Image 2: Anterior Elbow[4]                Image 3: Lateral Elbow[4]                             Image 4: Medial Epicondyle[4]

Bicep tendon Marked                        Circle represents lateral epicondyle             Dot represents medial epicondyle

Neurologic Assessment[edit | edit source]

Movement Testing[edit | edit source]

  • Active Range Of Motion(AROM)/Passive Range Of Motion(PROM) with or without overpressure
    • Elbow
                Flexion
                Extension
                     - Positive Elbow Extension Test may indicate fracture and referral.
                Forearm pronation/supination
    • Wrist
                Flexion
                Extension
    • Cervical, Shoulder and Elbow Range of Motion with or without overpressure
                Posterior-anterior glide assessment on cervical/thoracic spine for distal symptoms reproduction as well.
  • Resistive Testing
    • Elbow flexion/extension
    • Forearm pronation/supination
    • Wrist flexion/extension
    • Pain-free grip strength
    • Thumb
    • Fingers
  • Accessory motion testing
    • Humeroulnar traction
    • Humeroradial traction
    • Proximal/distal radioulnar Anterior/Posterior and Posterior/Anterior glides

Special Tests[edit | edit source]

Cubital Tunnel Syndrome:


Lateral Epicondylalgia:


Ligamentous Tests:


Neurodynamic Tests:

  • Median nerve bias: Upper Limb Neurodynamic Test 1
  • Radial nerve bias:  Upper Limb Neurodynamic Test 2b
  • Ulnar nerve bias:  Upper Limb Neurodynamic Test 3

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 MacDermid JC, Michlovitz SL. Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther. 2006; 19(2):82-97.
  2. ↑ Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion, 2008.
  3. ↑ King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Commitee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999; 8:351–4.
  4. ↑ 4.0 4.1 4.2 4.3 Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. 1999; 30(1):15-20.
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