Elbow

Question 1

Elbow AROM

Answer 1

• Flexion of the Elbow: – 140° to 150°
• Extension of the Elbow: – 0° to 10° hyperextension
• Supination of the Forearm: – 90°
• Pronation of the Forearm: – 80° to 90°

Question 2

Elbow PROM

Answer 2

• End Feel:
  
  • Elbow flexion – Tissue approximation
  • Elbow extension – Bone to bone
  • Forearm supination – Tissue stretch
  • Forearm pronation – Tissue stretch or bony end feel
• Capsular Patterns
  
  • Consider muscle length and tone:
    
    • Shoulder extension (Extended elbow)
    • Shoulder flexion (Flexed elbow)
    • Wrist flexion
    • Wrist extension

Question 3

Cozen’s Test

Answer 3

• Purpose:
  
  • To assess the integrity of the wrist extensors/common extensor tendon at the lateral epicondyle
• Procedure:
  
  • The patient is seated
  • The practitioner stands adjacent to the patient’s affected elbow
  • The practitioner stabilizes the elbow while palpating the lateral epicondyle
  • The patient is asked to pronate their forearm and extend the wrist
  • The patient then actively extends the wrist against the practitioner’s resistance (isometric contraction)
• Positive:
  
  • Pain over the lateral condyle is positive for lateral epicondylopathy
• Indication of Positive:
  
  • Lateral epicondylopathy

Question 4

Mill’s Test

Answer 4

• Purpose:
  
  • To assess the integrity of the wrist extensors/common extensor tendon at the lateral epicondyle
• Procedure:
  
  • Patient sitting with elbow fully extended
  • Practitioner stands adjacent to the patient’s affected elbow
  • The examiner extends the patient’s arm, passively pronates the forearm, and passively flexes the patient’s wrist
• Positive Test:
  
  • Pain along the lateral epicondyle region of the humerus
• Indication of Positive:
  
  • Lateral epicondylopathy

Question 5

Middle Finger Sign

Answer 5

• Purpose:
  
  • Assess the integrity of the wrist extensors at the elbow insertion
  • Assess the integrity of the radial nerve at the Arcade of Frohse and the radial tunnel
• Procedure:
  
  • The patient is seated with the forearm pronated and fingers extended
  • The practitioner stands facing the patient
  • The examiner resists extension of the third digit of the hand distal to the proximal inter-phalangeal joint (extensor digitorum)
• Positive:
  
  • Pain located over the lateral epicondyle
  • Pain may be located distal to the lateral epicondyle in the case of Radial Tunnel Syndrome (RTS)
• Indication of Positive:
  
  • Lateral epicondylopathy if pain is located about lateral epicondyle
  • Radial neuropathy is suspected if neuropathic pain or paraesthesia are present in addition to the normal symptoms associated with lateral epicondylopathy

Question 6

Test for Medial Epicondylopathy

Answer 6

• Purpose:
  
  • To assess the integrity of the wrist flexors/common flexor tendon at the medial epicondyle insertion
• Procedure:
  
  • Patient is sitting or standing and makes a fist with the involved side
  • The examiner stands facing the patient
  • The examiner palpates along the medial epicondyle with one hand and grasps the patient’s wrist with the other hand
  • The examiner passively supinates the forearm and extends the elbow, wrist and fingers
• Positive Test:
  
  • Complaints of discomfort along the medial aspect of the elbow
• Indication of Positive:
  
  • Medial epicondylopathy

Question 7

Tinel’s Sign: Elbow

Answer 7

• Purpose:
  
  • To assess the integrity of the ulnar nerve about the elbow
• Procedure:
  
  • The patient is seated, standing or supine
  • The practitioner stands adjacent to the patient’s affected arm
  • The practitioner taps/percusses over the cubital tunnelfor approximately 10 seconds
• Positive:
  
  • A tingling sensation in the ulnar distribution of the forearm and the hand distal to the point of compression of the nerve
• Indication of Positive:
  
  • Ulnar neuropathy about the elbow (refer to locations of entrapment)

Question 8

Elbow Flexion Test

Answer 8

• Purpose:
  
  • To assess the integrity of the ulnar nerve at the cubital tunnel
• Procedure:
  
  • The patient is sitting or standing with the elbows maximally flexed and the wrists extended
  • The patient holds this position for 3-5 minutes
  • The practitioner can also apply shoulder depression and contralateral cervical lateral flexion to sensitize the procedure
• Positive Test:
  
  • Radiating pain into the ulnar nerve distribution in the patient’s arm and/or hand
• Indication of Positive:
  
  • Cubital tunnel syndrome

Question 9

Froment’s Sign

Answer 9

• Purpose:
  
  • To assess the integrity of the ulnar nerve
• Procedure:
  
  • The patient attempts to grasp a piece of paper between the thumb and index finger
  • The examiner attempts to pull the paper away and observes the patient’s thumb positioning
• Positive:
  
  • IP joint flexion of the thumb is a positive Froment’s Sign (1915)
  • Additional:
    
    • Hyperextension of the 1st MCP joint is noted as a positive Jeanne’s Sign (1915)
    • Pollock’s Sign (1919): Inability to flex the distal phalanx of the fifth finger
    • Wartenberg’s Sign (1939): Inability to adduct the extended little finger to the ring finger
• Indication of Positive:
  
  • Ulnar nerve palsy
• Clinical Note:
  
  • Normal nerve supply (Ulnar n.) to adductor policis is required to properly perform this test
  • Patient’s will cheat using flexor policis (Median n.) if there is an ulnar nerve palsy

Question 10

Test for Pronator Teres Syndrome

Answer 10

• Purpose:
  
  • To assess the integrity of the median nerve at the level of the pronator teres muscle
• Procedure:
  
  • Part A:
    
    • The patient sits with the elbow flexed to 90°
    • The patient strongly resists attempts by the practitioner to supinate the forearm
    • While trying to supinate the patient’s forearm, the practitioner passively extends the patient’s arm
    • This position is held for 30 seconds
  • Part B:
    
    • The patient is asked to relax and the practitioner then applies firm pressure over the belly of pronator teres for approximately 1 minute
• Positive:
  
  • Tingling or paresthesia in the median nerve distribution •
• Indication of Positive:
  
  • Pronator Teres Syndrome
• Note:
  
  • Part A of the test is designed to enhance blood flow to the deep and superficial muscle bellies of pronator teres to minimise space available for the median nerve that passes between these two heads of the muscle
  • Part B is performed directly after Part A and is designed to directly compress the median nerve

Question 11

Pinch Grip Test (OK Sign)

Answer 11

• Purpose:
  
  • To assess the integrity of the anterior interosseous nerve (AIN)
• Background:
  
  • The anterior interosseous nerve is a primarily motor branch of the median nerve which innervates flexor pollicis longus, flexor digitorum profundus of the index/middle finger and pronator quadratus
• Procedure:
  
  • The patient is sitting or standing
  • The examiner instructs the patient to pinch the tips of the thumb and index finger together making an ‘OK’ sign
• Positive:
  
  • Inability to touch the tips of the thumb and index finger together or touching the pads of the thumb and index finger together
• Indication of Positive:
  
  • Neuropathy of the anterior interosseous nerve (AIN)
  • Commonly due to a neuritis as opposed to a specific entrapment

Question 12

Valgus Stress Test

Answer 12

• Purpose:
  
  • To assess the integrity of the structures which stabilise the elbow against valgus stress
• Background:
  
  • The Medial (Ulnar) Collateral Ligament is the primary passive restraint for elbow valgus forces, of which the antero-oblique bundle is of greatest importance
• Procedure:
  
  • The patient is sitting or standing
  • The patient’s elbow is flexed 20-30°, with the forearm pronated
  • The patient’s arm is stabilised with the practitioner’s primary contact over the lateral elbow, and the secondary contact holds the patient’s wrist
  • The practitioner creates a valgus force through the patient’s elbow using the primary and secondary contacts
  • The practitioner assesses the end-feel of the ulnar collateral ligament and the degree of opening at the medial elbow joint
• Positive:
  
  • Pain
  • Laxity
• Indication of Positive:
  
  • MCL ligament sprain with or without joint instability

Question 13

Moving Valgus Stress Test

Answer 13

• Purpose:
  
  • To assess the integrity of the structures which stabilise the elbow against valgus stress during movement
• Background:
  
  • The Medial Collateral Ligaments are the primary passive restraint to valgus forces
• Procedure:
  
  • The patient is standing or sitting
  • The practitioner stands adjacent to the patient’s affected elbow
  • The patient’s arm is abducted to approximately 90° and externally rotated
  • The patient’s elbow is then flexed to approximately 130°
  • The patients arm is stabilised with the practitioner’s secondary hand at the lateral distal humerus (elbow) while palpating the MCL with the fingers of that hand
  • The examiner’s primary hand contacts the patient’s wrist
  • Abduction and external rotation are maintained while a valgus force is applied at the elbow by the examiner’s secondary hand
  • The patient’s elbow is then moved into extension
• Positive:
  
  • Pain, usually between 70° and 130° of flexion
  • Laxity
  • Crepitus
  • Replication of ulnar nerve symptoms
• Indication of Positive:
  
  • MCL ligament sprain with or without joint instability
  • Ulnar neuropathy

Question 14

Valgus Extension Overload Test

Answer 14

• Purpose:
  
  • To detect the presence of a posteromedial olecranon osteophyte or olecranon fossa overgrowth
• Background:
  
  • These disorders result from repetitive abutment of the olecranon into the olecranon fossa combined with valgus torques, resulting in impaction and shear along the posteromedial olecranon
• Procedure:
  
  • The patient is standing or sitting
  • The practitioner stands adjacent to the patient’s affected elbow
  • The patient’s arm is abducted to approximately 50° and flexed to approximately 30°
  • The examiner stabilises the humerus with the primary contact and pronates the patient’s forearm
  • The practitioner creates a valgus force at the patient’s elbow using the primary and secondary contacts
  • While maintaining the pronation and the valgus force at the elbow, the practitioner quickly takes the patient’s elbow into full extension
• Positive:
  
  • Pain posteromedially as any olecranon tip osteophytes engage the posteromedial olecranon fossa
• Indication of Positive:
  
  • Posteromedial elbow impingement
  • Stress fracture of the olecranon

Question 15

Radiocapitellar Compression Test

Answer 15

• Purpose:
  
  • To assess the integrity of the radiocapetallar joint
• Background:
  
  • An axial load applied with passive supination and pronation often provokes pain and can be helpful in differentiating radiocapitellar chondromalacia from lateral tennis elbow. Radiographs may show a loss of joint space, marginal osteophytes and, possibly loose bodies
• Procedure:
  
  • Patient is seated or standing
  • The practitioner sits or stands facing the patient
  • With the secondary hand the practitioner cups the posterior elbow with either a thumb or index finger palpating the radial head
  • The practitioner holds the patient’s wrist in slight extension and radial deviation
  • The practitioners primary contact exerts an axial load through the forearm to the radiocapitellar joint via the patients hand and wrist
  • Active or passive pronation and supination of the forearm are preformed during midrange elbow extension/flexion motion
• Positive:
  
  • Pain and crepitus in the radiocapitellar joint
• Indication of Positive:
  
  • Radiocapitellar joint degeneration or anomaly
  • OCD of the radiocapitular joint
  • Panner’s Disease
  • Radial head/neck fracture

Question 16

Varus Stress Test

Answer 16

• Purpose:
  
  • To assess the integrity of the structures which stabilise the elbow against varus stress
• Background:
  
  • The lateral (radial) collateral ligaments are the primary passive restraints of the elbow varus. The LCL complex consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament
• Procedure:
  
  • The patient is sitting or standing
  • The practitioner stands adjacent to the affected elbow
  • The patient’s elbow is flexed to 20-30° with the forearm supinated
  • Patients arm is stabilised with the practitioner’s secondary contact at the medial elbow
  • The primary contact is placed at the patient’s wrist
  • A varus force is applied at the elbow by the primary and secondary contacts
  • The practitioner assesses the end feel of the lateral ulnar collateral ligament, and the degree of opening at the lateral elbow joint
• Positive:
  
  • Pain
  • Laxity
• Indication of Positive:
  
  • LUCL ligament sprain with or without joint instability

Question 17

Posterolateral Pivot-Shift Apprehension Test

Answer 17

• Purpose:
  
  • To assess for elbow posterolateral rotatory instability
  • Posterolateral instability= LUCL laxity
• Procedure:
  
  • Patient is supine with arm to be tested held overhead and externally rotated
  • The examiner grasps the patient’s wrist and extended elbow
  • A mild supination force is applied to the forearm at the wrist
  • The patient’s elbow is then flexed while valgus stress and compression are applied to the elbow
  • The practitioner MUST contact the humerus to create valgus, not the radius otherwise displacement will not be permitted
• Positive:
  
  • Apprehension as the elbow is flexed 20-30 degrees
  • Reduction (cluck) of the radial head (or ulnar sometimes) around 40-70 degrees of flexion
• Indication of Positive:
  
  • Posterolateral rotary instability
• Notes:
  
  • The setup phase is designed to luxate the humeroulnar/radiohumeral joint
  • As the joint is moved into flexion the ulnar and/or radius will relocate