Keywords: Subjective Ax, objective Ax, Elbow assessment, Active ROM, Elbow pain, Strength Tests, Special tests, Differential Diagnosis, Red flags elbow.
- Mechanism of injury
- Recent elbow trauma? (R/O myositis dissecans)
- Dominant hand
- Pins and needles? (suggests neural involvement)
- Numbness?(suggests neural involvement) Is this in a particular dermatomal pattern? This may be referred from neck?
What does this tell you?
When examining the elbow you must consider places that can refer to this area to rule out whether the source of the pain is truely coming from structures within or around the elbow. Neck, shoulder, trigger points and neural tightness can all present with elbow pain. Key details in aiding differential diagnosis include the presents of pins and needles (usually representative of neural involvement), mechanism of injury (Did the patient receive trauma to the head/neck? Do they have poor posture- could this be compressing on neural structures? Do they have a manual job which requires heavy/repetitive movements?) and nature of pain (is it purely one sided?).
These are the special questions which may indicate that something more sinister may be going on. Patients should be referred immediately back to the GP with your concerns noted. The GP will appreciate a thorough assessment including a neurological examination ( Dermatomes, Myotomes, Reflexes) and this report will allow you to easily reflect on your decision and provide evidence of suspected underlying pathology.
Click here to see exemplar reports to the GP.
Ask a seniors advice on the severity of these symptoms and whether and A and E referral is more appropriate. Mechanism of Injury is important here, if they fell from a height, lost conciousness or have neck pain this may indicate a cervical fracture. If they have bilateral pins and needles with associated elbow pain this could also indicate neural compression or underlying neck pathology particularly if bilateral.
- Pins and needles in both hands
- Un relenting pain not easing with rest or movement.
- Unexplained weight lost.
- Loss in appetite
The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. For example documenting that a lady has – 10 degrees elbow extension will allow you to re-assess at her next treatment session and monitor improvement or deterioration. This should help guide you on whether a treatment has been effective and can help confirm a diagnosis.
Observation in standing
Posture – normal carrying angles 5-10 degrees valgus (males) and 15 degree valgus (females).
Observation in sitting
R/O cervical or shoulder involvement or referred pain.
- Posture, guarding, willingness to move arm, atrophy, oedema.
- AROM of the elbow: Flex(140-150 deg), Ext (0 deg), Pronation (70-80 deg), Supination (80-90 deg)
- Myotomes: Shoulder Elevation(C3-4), Shoulder Abd (C5), Shoulder flex (C5-7), Elbow flex wrist ext (C6),Elbow ext wrist flex (C7), Thumb IP joint ext (C8) and finger adduction (T1).
- Muscle strength: Elbow Flexion, Elbow Extension, Supination, Pronation, Wrist Extension, Wrist Flexion
- Reflexes (Biceps(C5), Brachioradialis(C6) and triceps (C7))
- Sensation (Dermatomes – light touch and pin prick differentiation).
- Palpation (Soft tissue, bone landmarks, pain apprehension, guarding, spam).
What does this tell you?
“As a student I wanted everything to fit into a box, unfortunately it doesn’t. Take an anatomy book, pick a joint and list the structures that may be affected if it were to have a force through it in any direction. As you learn your anatomy you will discover the list becomes longer and longer. As a physiotherapist anatomy is your bread and butter which enables so you to rule out structure that may be causing the issue. It is rare that only one structure is affected with no damage to surrounding structures so bear this in mind. The following is aimed as a rough guide to give you some ideas however is by no means an exhaustive list.”
- Try to establish the structure involved. Pain at the end of the day after work may suggest the cause is postural or caused by work. If elbow pain is associated with shoulder and neck pain, worse in the AM this could be due to inflammation or neck position whilst sleep ie too many pillows.
- Poor Quality of movement – Does the patient avoid joint compression or avoid stretching soft tissue? Where is the restriction and what is causing it? Is it due to weakness or is the patient reluctant to move the joint/limb due to pain? If the patient is unable to do it actively without pain but has no pain when the examiner moves the arm this may suggest the muscle is involved?
- Throughout movements where does the patent feel their pain? Is it throughout range? Are there any bony blocks/crepitus which may suggest a loose body? If there is pain at end of range could this be due to compressed/stretched tissues?
- Does the patient present with significant guarding and unwillingness to move?
- Pins and needles of paraesthesia (numbness) in the arm or hand? This normally suggests a neural element which maybe coming from the neck or compression of the nerve somewhere along its course.
- If you press on a structure and this reproduces the patients symptoms this may suggest referred pain is occuring (ie trigger points within the shoulder musculature and forearm extensors can present has elbow pain).
Active movements are assessed first. What is causing the restriction? Is it restricted by pain/stiffness?
Neck and Shoulder ROM shoulder be checked to rule out involvement.
(If the movement is painful with active movement but not on passive this may indicate the muscle is the source of the problem. If the pain is elicited on AROM and PROM this suggests that the structures on stress(ie tight) are causing the pain or perhaps tissues are being compressed?)
Passive movements are those performed by the physiotherapist or surgeon. They allow structures to be tested without patient effort to help to identify the structure/structures involved. One position for this is to have the patient supine, take the full weight of the head and perform ROM gently. The range, pattern of movement, end feel and degree of pain are all noted.
- Valgus/Varus stress for instability.
- Nerve impingement and entrapment tests.
- Tinels sign
- Wartenberg’s sign
Patients arm is stabilized at the elbow and the other hand placed on the pt’s wrist. Ensure shoulder is in neutral ER, elbow flexed 10-15 degrees and apply a varus force.
Valgus stress test – (Detects rupture of the ulnar collateral ligament.) Pataients arm stabilized at elbow with the other hand above the patients wrist. Shoulder is placed in full ER, elbow flexed (10-15 deg) and apply a valgus force.
COMPARE laxity Left to Right.
Positive sign = Tingling sensation or pins and needles in ulnar nerve distribution.
Technique 1 –Detects medial epicondylytis.
Position: Forearm supination, elbow extension, wrist extension and radial deviation.
Palpation of the medial epicondylitis. Positive sign = Reproduces symptoms or pain over med epicondyle.
Test for pronator teres syndrome(impingement of the ulnar nerve via pronator teres). Position = 90 degrees elbow flexion. Clinician tries toe xtend and supinate patient elbow as patient tries to resist. Positive sign = Tingling/Paraesthesia in the median nerve distribution.
- Soft Tissue
Common Elbow DD
- Lateral epicondylitis
- Medial epicondylitis
- Olecranon bursitis
Less likely DD
- Ulnar Collateral Ligament rupture
- Radial collateral ligament rupture.
- Ulnar neuritis
- Cubital tunnel syndrome
- Posterior elbow sublxation/disclocation
- Median nerve neuropathies – Compression at elbow
- Superficial radial nerve compression
- Posterior interosseus nerve syndrome
Click here for a full list of elbow conditions.
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