Elbow Evaluation Module

Subjective/History
Determine : activity, MOI, location of pain, type of pain, severity of pain, onset of pain, unusual sounds/ sensations, actions that increase & decrease pain, S/S, change in S/S over time, prior injury/ surgery, family history & general medical health
6

Objective
Inspection
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General: swelling, discoloration, deformity, muscle symmetry/atrophy, symmetry of head and arm while standing & walking Skin: discoloration, open wounds, scars & skin infections Anterior View: carrying angle & cubital fossa Lateral View: lateral epicondyle, alignment, cubital recurvatum, extension lag & extensor muscle mass Medial View: medial epicondyle & flexor muscle mass Posterior View: bony alignment, olecranon process & olecranon bursa Elbow Palpation Rollover: using internet explorer rollover the images to trace some anatomy of the elbow Bony Palpation : medial epicondyle, medial supracondylar line of humerus, olecranon, ulnar border, olecranon fossa, lateral epicondyle, lateral supracondylar line of humerus & radial head Soft Tissue Palpation : Zone 1 (Medial Aspect): ulnar nerve, wrist flexorpronator muscle group (pronator teres, flexor carpi radialis, palmaris longus & flexor carpi ulnaris), medial collateral ligament, supracondylar lymph nodes Zone 2 (Posterior Aspect): olecranon bursa, triceps Zone 3 (Lateral Aspect): wrist extensors "mobile wad of three" (brachioradialis, extensor carpi radialis longus & extensor carpi radialis brevis), lateral collateral ligament & annular ligament Zone 4 (Anterior Aspect): cubital fossa ( biceps tendon, brachial artery, median nerve & musculocutaneous nerve) Range of Motion
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AROM: extension (05), flexion (135+), supination (90) & pronation (90) PROM: extension, flexion, supination & pronation RROM: extension, flexion, supination & pronation Upper Extrstrongity Neurologic & Circulatory Examination
1,5

Dermatomes: test sensation over the sensory distribution of each nerve root, this is done by having the patient close their eyes & distinguish a sharp stimulus from a dull stimilus Myotomes:

Reflex Testing: Peripheral Nerve Distributions: Circulation: Manual Muscle Testing : Biceps Brachii, Brachialis, Triceps Brachii, Anconeus, Palmaris Longus, Extensor Digitorum, Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Flexor Carpi Radialis, Flexor Capri Ulnaris, Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis,Extensor Carpi Ulnaris, Pronator Teres, Pronator Quadratus, Supinator, Brachioradialis Special Tests
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Lateral Epicondylitis/Resistive Tennis Elbow/Cozen's, Lateral Epicondylitis/Resistive Tennis Elbow, Lateral Epicondylitis/Passive Tennis Elbow , Medial Epicondylitis/Golfer's Elbow, Elbow Flexion, Varus Stress, Valgus Stress, Tinel's Sign, Pinch Grip, Pronator Teres Syndrome

Assessment
Identifies examiner's impression of injury & potientally complicating factors based on subjective & objective information

Plan
Explains examiner's goals as well as how the examiner intends on meeting these goals through initial managstrongent, treatment, rehabilitation

Manual Muscle Testing

Biceps Brachii
Origin of Short Head Apex of coracoid process of scapula Origin of Long Head Supraglenoid tubercle of scapula Insertion Tuberosity of radius & aponeurosis of biceps brachii Action Flexes the shoulder joint & the long head may assist with abduction if the humerus is laterally rotated Nerve Musculocutaneous, C56

Patient Supine or sitting Fixation Examiner places one hand under elbow to cushion it from table pressure Test Elbow flexion slightly less than or at right angle, with forearm in supination See Test

Brachialis
Origin Distal half of anterior surface of humerus & medial & latera intermuscular septa Insertion Tuberosity & coranoid process of ulna Action With origin fixed, flexes the elbow joint moving the forearm toward the humerus With the insertion fixed, flexes the elbow joint moving the humerus toward the forearm Nerve Musculocutaneous & small branch from radial, C5 6 Patient (see above) Fixation (see above) Test (see above) See Test

Triceps Brachii
Origin of Long Head Infraglenoid tubercle of scapula Origin of Lateral Head Lateral & posterior surfaces of proximalone half of body of humerus & lateral intermuscular septum Origin of Medial Head

Distal two thirds of media & posterior surfaces of humerus below the radial groove & from medial intermuscular septum Insertion Posterior surface of olecranon process of ulna and antebrachial fascia Action Extends the elbow joint, with the long head assisting in adduction and extension of the shoulder joint Nerve Radial, C68, T1 Patient Supine or prone Fixation Shoulder abducted to 90, nuetral with regard to rotation, & supported between the shoulder & elbow by the table Test Extension of the elbow joint (to just short of full extension) Pressure Against the forearm in the direction of flexion See Test

Anconeus
Origin Lateral epicondyle of humerus on the posterior surface Insertion Lateral side of olecranon process and upper one fourth of posterior surface of body of ulna Action Extends elbow joint & may stabilize the ulna during pronation & supination Nerve Radial, C78 Patient (see above)

Fixation (see above) Test (see above) Pressure (see above) See Test

Palmaris Longus
Origin Common flexor tendon from medial epicondyle of humerus & deep antebrachial fascia Insertion Flexor retinaculum & palmar aponeurosis Action Tenses the palmar fascia, flexes the wrist & may assist elbow flexion Nerve Median, C68 & T1 Patient Sitting or supine Fixation Provided by table Test Tensing the palmar fascia by strongly cupping the palm pf the hand & flexion of the wrist Pressure Against the thenar & hypothenar eminences in the direction of flattening the hand & against the hand in the direction of wrist extension

Extensor Digitorum
Origin Common flexor tendon from lateral epicondyle of humerus & deep antebrachial fascia Insertion By four tendons of the second to fifth digits which divide over the proximal phalanx into one middle and two lateral bands, the middle band inserts to the base of the middle

phalanx while the lateral bands reunite over the middle phalanx & insert at the base of the distal phalanx Action Extends the metacarpophalangeal (MCP) joints, assists with interphalaneal (IP) joint extension of second to fifth digits & also assists wrist extension Nerve Radial & C68 Patient Sitting or supine Fixation Examiner stabilizes wrist avoiding full extension Test Extension of the MCP joints of second to fifth digits with IP joints relaxed Pressure Against the dorsal surface of the proximal phalanges in the direction of flexion

Flexor Digitorum Superficialis

Origin Humeral Head: common flexor tendon from medial epicondyle of humerus, ulnar collateral ligament & deep antebracial fascia Ulnar Head: medial side of coronoid process Radial Head: oblique line of radius Insertion By four tendons of the second to fifth digits to side of middle phalanges Action Flexes proximal interphalangeal (PIP) joints of digits two to five & assists flexion of wrist & metacarpophalaneal (MCP) joints Nerve Median, C78 & T1 Patient Sitting or supine Fixation

Examiner stabilizes MCP joint with wrist in neutral position or slight extension Test Flexion of PIP joints with distal interphalangeal (DIP) joints extended on digits two to five Pressure Against the palmar surface of the middle phalange in the direction of extension

Flexor Digitorum Profundus

Origin Anterior & medial surfaces of the proximal three fourths of the ulna, interosseous membrane, & deep antebrachial fascia Insertion By four tendons into base of distal phalanges of second to fifth digits Action Flexes distal interphalangeal (DIP) joints of digits two to five & assists flexion of the metacarpophalaneal (MCP) joints, proximal interphalangeal (PIP) joints & wrist Nerve Profundus I: median, C78 & T1 Profundus II: radial, C78 & T1 Patient Sitting or supine Fixation With the wrist in slight extension the examiner stabilizes the proximal & middle phalandes Test Flexion of the DIP joints two to five Pressure Against the palmar surface of the distal phalange in the direction of extension

Flexor Carpi Radialis

Origin Common flexor tendon from medial epicondyle of humerus & deep antebrachial fascia Insertion Base of second & third metacarpal Action

Flexion & abduction (radial deviation) of the wrist, may assist flexion of the elbow & forearm pronation Nerve Median & C68 Patient Sitting or supine Fixation The forearm is in slightly less than full supination & rests on the table for support or is supported by the examiner Test Flexion of the wrist toward radial deviation Pressure Against the thenar eminence in the direction of extension toward ulnar deviation

Flexor Carpi Ulnaris

Origin Humeral Head: common flexor tendon from medial epicondyle of humerus Ulnar Head: by aponeurosis from the medial margin of olecranon, proximal two thirds of the posterior borser of the ulna & from the deep antebrachial fascia Insertion Pisiform bone, by ligaments to hamate & fifth metacarpal Action Flexion & adduction (ulnar deviation) of the wrist & may assist flexion of the elbow Nerve Ulnar, C78 & T1 Patient Sitting or supine Fixation The forearm is in slightly less than full supination & rests on the table for support or is supported by the examiner Test Flexion of the wrist toward ulnar deviation

Pressure Against the hypothenar eminence in the direction of extension toward radial deviation

Extensor Carpi Radialis Longus

Origin Distal one third of the lateral supracondylar ridge of the humerus & lateral intermuscular septum Insertion Dorsal surface of the second metacarpal on the radial side Action Extension & abduction (radial deviation) of the wrist & may assist flexion of the elbow Nerve Radial & C58 Patient Sitting with elbow resting on table in approximately 30 of flexion Fixation The forearm is in slightly less than full pronation & rests on the table for support Test Extension of the wrist toward radial deviation Pressure Against the dorsum of the hand along the second & third metacarpals in the direction of flexion toward ulnar deviation

Extensor Carpi Radialis Brevis

Origin Common extensor tendon from the lateral epicondyle of the humerus, radial collateral ligament & deep antebrachial fascia Insertion Dorsal surface of the third metacarpal Action Extension & assists abduction (radial deviation) of the wrist Nerve Radial & C68 Patient

Sitting with elbow completely flexed Fixation The forearm is in slightly less than full pronation & rests on the table for support Test Extensionion of the wrist toward radial deviation Pressure Against the dorsum of the hand along the second and third metacarpals in the direction of flexion toward ulnar deviation

Extensor Carpi Ulnaris

Origin Common extensor tendon from the lateral epicondyle of the humerus, by aponeurosis to the posterion border of the ulna & deep antebrachial fascia Insertion On the ulnar side of the base of the fifth metacarpal Action Extension & assists adduction (ulnar deviation) of the wrist Nerve Radial & C68 Patient Sitting or supine Fixation The forearm is in full pronation & rests on the table for support Test Extension of the wrist toward ulnar deviation Pressure Against the dorsum of the hand along the fifth metacarpal in the direction of flexion toward radial deviation

Pronator Teres
Origin Humeral Head: immediately above the medial epicondyle, common extensor tendon from the medial epicondyle of the humerus & deep antebrachial fascia Ulnar Head: medial side of the coronoid process of the ulna

Insertion Middle of lateral surface of ulna Action Pronates the forearm & assists with elbow flexion Nerve Median & C67 Patient Supine or sitting Fixation The elbow should be held against the patients side, or stabilized by the examiner to avoid any shoulder abduction Test Pronation of the forearm with the elbow flexed approximately 40 Pressure At lower forearm above the wrist in the direction of supination See Test

Pronator Quadratus
Origin Medial side, anterior surface of distal one fourth of ulna Insertion Lateral side, anterior surface of distal one fourth of radius Action Pronates the forearm Nerve Median, C78 & T1 Patient Supine or sitting Fixation The elbow should be held against the patients side, or stabilized by the examiner to avoid any shoulder abduction Test

Pronation of the forearm with the elbow completely flexed Pressure At lower forearm above the wrist in the direction of supination

Supinator
Origin Lateral epicondyle of the humerus, radial collateral ligament, annular ligament & supinator crest of ulna Insertion Lateral surface of upper one third of body of radius covering part of anterior & posterior surfaces Action Supinates the forearm Nerve Radial & C57 Patient Supine Fixation The examiner holds the shoulder in flexion with the elbow completely flexed, have patient close fist to avoid contact with the table Test Supination of the forearm Pressure At the distal end of the forearm above the wrist in the direction of pronation

Brachioradialis
Origin Proximal two thirds of the lateral supracondylar ridge & lateral intermuscular septum Insertion Base of the styloid process on the lateral side Action Flexes the elbow, assists with pronation when supinated & supination when pronated Nerve Radial & C56

Patient Supine or sitting Fixation The examiner places one hand under the elbow to cushion it from table pressure Test Flexion of the elbow with the forearm in neutral with respect to pronation & supination Pressure Against the lower forearm in the direction of extension

Special Tests
Lateral Epicondylitis Test/Resistive Tennis Elbow Test/Cozen's Test
Steps Athlete is sitting Examiner stabilizes the involved elbow while palpating along the lateral epicondyle With closed fist, the athlete pronates and radially deviates the forearm and extends the wrist against the examiner's resistance Positive Test Pain along the lateral epicondyle region of the humerus or objective muscle weakness as a result of complaints of discomfort Positive Test Implications Lateral epicondylitis See Test

Lateral Epicondylitis Test/Passive Tennis Elbow Test

Steps Athlete is sitting with elbow in relaxed position supported by table Examiner stabilizes involved elbow with one hand and places the palm of the other hand on the dorsal espect of the patients hand just distal to the proximal interphalangeal joint of the third digit Positive Test Pain along the lateral epicondyle region of the humerus or objective muscle weakness

Positive Test Implications Lateral epicondylitis See Test

Lateral Epicondylitis Test/Passive Tennis Elbow Test (Cozen's Test)

Steps Athlete is sitting with elbow fully extended Examiner passively pronates the forearm and flexes the athlete's wrist Positive Test Pain along the lateral epicondyle region of the humerus Positive Test Implications Lateral epicondylitis See Test

Medial Epicondylitis Test/Golfer's Elbow Test

Steps Athlete is sitting or standing and makes a fist with the involved side Examiner faces the athlete and palpates along the medial epicondyle with one hand and grasps the athlete's wrist with the other hand Examiner passively supinates the forearm and extends the elbow, wrist and fingers Positive Test Complaints of discomfort along the medial aspect of the elbow Positive Test Implications Medial epicondylitis See Test

Elbow Flexion Test

Steps Athlete is sitting or standing Athlete maximally flexes the elbow and holds the position for 3 to 5 minutes Positive Test Radiating pain into the median nerve distribution in the athlete's arm and/or hand

Positive Test Implications Cubital fossa syndrome

Varus Stress Test

Steps Athlete is sitting with elbow flexed to 20 to 30 degrees Examiner stands with the distal hand around the athlete's wrist (laterally) and the proximal hand over the athlete's elbow joint (medially) Examiner stabilizes the wrist and applies a varus stress to the elbow with the proximal hand Positive Test Lateral elbow pain and/or increased varus movement with diminished or absent endpoint Positive Test Implications Radial (lateral) collateral ligament sprain See Test

Valgus Stress Test

Steps Athlete is sitting with the elbow flexed to 20 to 30 degrees Examiner stands with distal hand around the athlete's wrist (medially) and the proximal hand over the athlete's elbow joint (laterally) Examiner stabilizes the wrist and applies a valgus stress to the elbow with the proximal hand Positive Test Medial elbow pain and/or increased valgus movement with a diminished or absent endpoint Positive Test Implications Ulnar (medial) collateral ligament sprain See Test

Tinel's Sign Test

Steps Athlete is sitting with the elbow in slight flexion Examiner grasps athlete's wrist (laterally) with distal hand

Examiner stabilizes the wrist and taps on the ulnar nerve in the ulnar notch with the index finger Positive Test Tingling along the ulnar distribution of the forearm, hand and fingers Positive Test Implications Ulnar nerve compromise See Test

Pinch Grip Test

Steps Athlete is sitting or standing Examiner instructs athlete to pinch the tips of the thumb and index finger together Positive Test Inability to touch the tips of the thumb and index finger together or touching the pads of the thumb and index finger together Positive Test Implications Pathology of the anterior interosseous nerve between the two heads of the pronator muscle See Test