• Orthopedic Elbow Exam Tests

    by Dr. J. Michael Bennett
    on Mar 16th, 2015

Call 281-633-8600 for an appointment.  In this video, Dr. J. Michael Bennett demonstrates and describes typical elbow examination tests that he uses in evaluating patient injuries.  Dr. Bennett is a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports Medicine Specialist with offices in Sugar Land, TX, and in Houston, near the Houston Galleria.

This is a transcript of Dr. Bennett’s elbow examination video.

– Hello. This next video here is just a little bit of a demystification of the orthopedic elbow exam. We’re going to go over some basic tests and what we look for as orthopedic surgeons in regards to evaluating an elbow exam.

So first off when you evaluate a patient for an elbow injury, you’re going to inspect the patient, just watch the patient, see what they’re doing when they’re sitting in your office. Sometimes they’re sitting there holding their elbow, sometimes they’re in a sling, sometimes they’re in a splint. So it’s very important number one, just to look at the patient and see how they’re sitting, see if there’s any swelling, any bruising, any deformity.

Also, make sure you get a very good history, what’s their mechanism of injury? Did they land directly on their wrist and hand? Did they land on their elbow? This all plays a big role in regards to what we’re looking for and kind of helps narrow down our diagnosis.

So the next thing we do is we basically, we’ll look at the elbow, and I’ll have the patients compare, show me both they’re elbows out in full extension. So I’ll have them go ahead and extend their elbows both ways, and then we’ll see exactly what the difference is. If one elbow is like this, and one elbow is coming to full extension, then you obviously have a contracture, you have something here that’s impeding them from getting the full extension. So, you evaluate both elbows in full extension, then you have them bend their elbows, and then you evaluate their supination, which is the palms up, and then their pronation, which is the palms down.

This actually tells us a lot about what’s going on in the radiocapitellar joint up here. Because if they cannot fully pronate, or if they’re stuck, that means that something physically is in the joint and keeping them from rotating the wrist, or rotating their elbow, or they may have a radial head fracture, or broken bone, or some swelling, or inflammation that’s keeping them from rotating. So that’s first and foremost, is looking at the range of motion.

The next thing you want to do is palpation, you want to see exactly where they hurt. So, you’ll go ahead and just break down the elbow in different sections. So you’ll start by palpating on the outside area of the elbow, this is the lateral epicondyle, which is this little bone over here. Then you have the radial head over here right below it. And sometimes you can feel the radiocapitellar joint kind of rolling back and forth here. Next, we palpate the olecranon tip over here. Sometimes patients will have what we call an olecranon bursitis, which is almost like this little fluid filled balloon in the back of the elbow here, which is a very common thing that we see in the office, usually due to trauma.

And then, you palpate the medial epicondyle over here and see if there’s any abnormality in any of those bones, if you see any kind of crepitus, which means crunchiness, or a deformity, or swelling. Then we go to specific tests in regards to the elbow.

The first test that I like to do, just depending on where the patient’s complaining of the pain, if they’re complaining of pain laterally, on the outside of the elbow, we usually go ahead and look at their strength and have them lift the wrist up, hold their wrist up real strong. If they have pain with that motion then that usually isolates it to the lateral epicondyle, then that may mean that they have a tennis elbow or lateral epicondylitis. And then we have them flex the elbow and resist with a flexion. If they have pain with flexion, then sometimes they’ll have a tendonitis on the inside of the elbow which is known as medial epicondylitis. This is called tennis elbow, this is called golfer’s elbow. And that just means you have a tendonitis or an overuse injury of the tendon on either the outside or the inside of the elbow.

The next test we’ll do, if we’re leaning towards a lateral epicondylitis or a tendonitis on the outside of the elbow, have them spread their fingers out, and have them resist us as we push this middle finger down. This is called a piano key sign, and the reason it hurts out here in the elbow is because the tendon that inserts here, the ECRB, also inserts down here at the base of the metacarpal of this finger here. So when you hold that finger up and it hurts up here, then that means that you may have a tendonitis or a lateral epicondylitis.

The last test for tennis elbow that we usually do, is we’ll have the patient grip as they’re doing a handshake, they’ll flex their elbow and then they squeeze, and you bring their arm into full extension, and then they have pain at the lateral side, that’s also consistent with a tennis elbow or lateral epicondylitis.

The next test we’ll do is, we’ll look at the elbow stability. And the best way to do that is basically stressing the elbow back and forth in full extension and then a little bit at 30 degrees flexion, and then we can test the ligaments stability on the outside and on the inside of the elbow. Some patients are naturally lax and have a little bit of looseness, so it’s important to do a comparative evaluation on the other elbow. Other patients, if they have significant pain or if you feel a large pop or snap when you stress the elbow, then obviously that means that they have a recurrent instability at the elbow.

The next test that we’ll do is, we’ll look at the inside aspect of the elbow. We talked about the lateral epicondylitis, now we’ll look at the medial epicondylitis. If we press this bone here and it hurts, then it may be a tendonitis on that side as well. But we already showed you before, if it’s painful when they resist you at volar flexion here that maybe indicate medial epicondylitis.

Now some people may describe numbness and tingling going down the inside aspect of their forearm with medial pain and that may be indicative of a ulnar nerve compression. There’s a nerve that runs behind this bone here, that’s basically that funny bone, and innervates this whole inner aspect of the forearm and these two fingers. So they feel these tingling burning sensations going down the inside of the elbow, you can recreate that symptom by just tapping this little nerve over here, and if you start to feel that again usually that’s indicative of a cubital tunnel syndrome which is an irritation of the ulnar nerve.

If we have somebody like a pitcher that comes in and they’re throwing, and repetitively throwing and you feel a pop or snap in the inside of the elbow, sometimes they’ll come in and they’ll show us their elbow. They have some swelling on the inside of the elbow, some bruising of the elbow. That makes us worried for or looking for more of an ulnar collateral ligament injury or a ligament injury on the inside aspect of the elbow. So usually they start by palpating along the ulnar collateral ligament. If they have pain then we’ll stress it with the varus valgus stress.

The next thing we’ll do is something called the valgus extension stress test, where you have them lift their thumb up, we’ll have them fully abduct the shoulder, flex their elbow, and create a valgus stress where we pull on this thumb as they come into extension. That puts stress across the ulnar collateral ligament. If that’s creating pain to the patient, then that indicates possibly an ulnar collateral ligament injury and usually we’ll have to get something like an MRI arthrogram or an MRI to further evaluate the ligament to make sure that it’s okay. There are other symptoms such as a a synovitis or a plica band syndrome that you can have in patients where they have a recurrent snapping or clicking in the elbow, or even osteochondritis dissecans where you have a cartilage flap within the elbow. Often times you can palpate sometimes these snapping or popping usually in this lateral, posterior lateral area of the elbow with recreating range of motion. If your feel any kind of snapping or clicking in that area, usually an MRI is warranted to further evaluate that region.

Last but not least, we like to look at the anterior and the posterior aspects of the elbow. There are two major tendons on either side. The first one that we look at is the anterior aspect and this is the distal bicep. So you have the biceps muscle here, and you have the small biceps tendon here that inserts at the radial tuberosity deep into this forearm region. So if a patient comes in after they maybe caught something after it fell down or lifting something heavy, and they felt a snap or a pop in the front of their elbow, they see a little bit of swelling or bruising, they see a little bit of ecchymosis, and a deformity in their biceps and they come in complaining of weakness and pain.

What we’ll do is, we’ll first off, we’ll palpate the biceps, which will feel like this strong cord-like tendon here, we’ll rotate the wrist a little bit, and then we’ll have them what we call a supination stress test, where they rotate their hand against resistance. And we have them do that, and if they have severe pain here or weakness, then that usually will indicate a distal biceps injury. Especially if you can’t palpate that cord-like tendon in the front, okay. And we usually get an MRI to evaluate that further.

Next, we’ll look at the posterior aspect of the elbow. And if you see any swelling or bruising, or sometimes you can palpate a defect in this triceps region, you have the patients push out against you and feel this triceps, and see if there’s any defect or pain there. That would usually indicate maybe a triceps injury or calcification at the distal triceps. So we start with a plain x-ray of course, but usually an MRI would be helpful to see what the tendon looks like, or even an ultrasound. So this is basically a what we do for an elbow exam, just the nuts and bolts. If you have any questions or would like to get an evaluation, please call us at 281-633-8600. Thank you.

Author Dr. J. Michael Bennett

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