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Appendix E.
https://t.me/med1917
Continued
Peripheral nerve
Muscles
supply and ap-
proximate nerve
root derivation
Supinator Posterior interos-
seous (radial)
(C5, C6)
Pronator quadratus
Anterior interosseous (median)
(C8, T1)
Action Clinical signicance
Supination of the
forearm.
Only acts alone when
the elbow is extended.
A relentless forearm supinator, like the brachialis during
elbow exion in its workhorse characteristics.
It is typically recruited for low-power tasks that require a
supination motion only, whereas, in activities requiring
moderate or high-powered supination, it is assisted by the
biceps.
Pronation of the
forearm.
Composed of supercial and deep heads, it is the only
muscle to attach to the ulna at one end and the radius at
the other end. e pronator quadratus is involved during
all pronation movements independent of contraction speed
or elbow position. One of its lesser-known functions is to
prevent the head of the ulna from impacting against the
carpal bones. As the line of force of this muscle is oriented
almost perpendicular to the forearm’s axis of rotation, it is
well-designed as a capable torque producer and a stabilizer
at the distal radioulnar joint. However, in the presence of
severe rheumatoid arthritis, or an excised radial head, the
stabilizing forces that occur in the healthy state may accelerate joint destruction.
Pronator teres Median
(C6, C7)
Flexor carpi
radialis
Flexor carpi
ulnaris
Extensor digitorum (extensor digitorum
Median
(C6, C7)
Ulnar
(C7, C8)
Posterior interosseous nerve
(C7, C8)
communis)
Extensor carpi
radialis longus
Radial
(C6, C7)
Pronation of the forearm, and assists with
elbow exion.
Primarily exes the
elbow and wrist.
Flexes and adducts
the wrist. Also stabilizes the pisiform
during the action of
hypothenar muscles.
Extends all joints of
the ngers.
Extends wrist.
Extends and abducts
the wrist.
Consists of 2 heads: humeral and ulnar, between which the
median nerve passes. It is primarily involved during strenuous forearm activities involving pronation (eg, loosening a
tight screw with a screwdriver). e vertical component of
its force is the highest among all components and is more
signicant in pronation and elbow extension. e radial
component becomes negative in pronation and reaches
lower values as the elbow exes.
Also functions to assist in pronation and radial deviation of
the wrist.
Contributes slightly to elbow exion.
Of its 4 tendons, tendons 3 and 4 usually fuse, and the
little nger just receives a slip.
Contributes slightly to elbow exion.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
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49
Appendix F.
https://t.me/med1917
Peripheral Nerves Crossing the Elbow: Potential Involvement and Signs and Symptoms
Nerve
Radial
(C5-C8, T1)
Sites/mechanism
of compression
1. Injury in the
axilla or proximal humerus
(fracture).
2. Injury at the
elbow: radial
tunnel or area
of the proximal
radius (fracture
or dislocation);
the radial nerve
divides into
a supercial
branch (sensory
only) and a deep
branch (PIN)
at the lateral
elbow.
Pain/symptoms
High radial
nerve injury: (eg,
humeral fracture,
‘Saturday night
palsy’) produces
mixed motor and
sensory symptoms.
Injury at the
elbow: possible
pain with repetitive forearm
supination.
Supercial
branch (radial
tunnel syndrome): pain
exacerbated by
repetitive forearm pronation.
Potential senso-
ry decits
High radial
nerve injury:
Variable sensory
changes occur
in the posterior
forearm, posterior hand, and
posterior aspect
of the thumb
and radial 2.5
digits.
Injury at the elbow: no sensory
loss.
Potential motor
decits
Injury in axilla:
loss of elbow
extension; weak
wrist and digit
extension; weak
forearm supination
Supercial
branch (radial
tunnel syndrome): normal
motor.
PIN: mostly
motor loss (weak
or absent wrist
extension generalized hand
weakness)
Injury at wrist:
no motor loss.
Special tests
Supercial branch (radial tunnel syndrome):
demonstrates specic
tenderness to palpation
5 cm distal to the lateral
epicondyle (over the
anterior radial neck).
Also, positive on the
Long Finger Extension
Test: the patient fully
extends all ngers and
extends wrist to 30°. e
clinician pushes down
on the middle nger
over the distal end of
the proximal phalanx
while the patient resists;
positive if symptoms are
reproduced.
Ulnar
(C8, T1)
1. Injury at the
elbow: cubital
tunnel syndrome (CTS),
or ulnar nerve
irritation with
ulnar collateral
ligament deciency.
CTS: pain ulnar
side of the forearm.
CTS: there may
or may not be
paresthesias in
ulnar digits.
Injury at wrist:
paresthesias in
ulnar digits.
CTS: weakness
may occur but is
a late symptom.
If present, motor
ndings are
weak fth digit
abduction, weak
thumb adduction, and weak
thumb-index nger pinch. Power
grip is ultimately
aected.
CTS:
1. Tinel sign: Clinician
taps over the ulnar
nerve in the cubital
tunnel.
2. Elbow exion test:
e clinician passively maximally exes
the elbow and holds
for 1 minute. Positive
if the patient develops paraesthesia in
small and ring nger.
3. Ulnar nerve compression test. Same as
elbow exion test but
clinician also applies
direct pressure on the
nerve at the elbow.
50
Academy of Orthopaedic Physical erapy, APTA.
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For personal use only. No other uses without permission.
Appendix F.
https://t.me/med1917
Continued
Nerve
Median
(C6-C8, T1)
Sites/mechanism
of compression
1. e ligament of
Struthers.
2. e pronator
teres muscle.
3. e site of
branching of the
AIN.
Pain/symptoms
Injury at the
elbow: proximal
forearm pain.
Ligament of
Struthers: vague
pain over the
anterior elbow
and forearm.
Pronator teres
muscle: insidious
onset of proximal, anterior
forearm pain,
with occasional
hand pain that is
aggravated with
repetitive forearm pronation
and wrist exion.
Site of branching of the AIN:
proximal forearm
pain.
Potential senso-
ry decits
Ligament of
Struthers:
sensory changes
involving the
radial side of the
hand and radial
3.5 digits
Pronator syndrome: sensory
loss over the
thenar eminence
(not a nding
of carpal tunnel
syndrome)
Injury at the
wrist: sensory
loss in the thumb
and radial 2.5
digits, and thenar
eminence muscle
weakness.
Potential motor
decits
Proximal to the
elbow: active
pronation is
mostly missing.
Injury at the
elbow or forearm: Weak wrist
exion, no distal
interphalangeal
exion of the
thumb, index,
and long digit.
Site of branching
of the AIN: lack
of dexterity or
weakness when
attempting a
pinch.
Injury at the
wrist: none or
weak thumb
abduction.
Special tests
Pronator syndrome:
Tinel sign and Phalen
maneuver at the wrist
should be negative in
patients with pronator
syndrome.
Site of branching of the
AIN: Patient asked to
make the ‘OK’ sign with
thumb and index nger.
If positive, the patient
makes a triangle/box
sign instead of a circle.
Musculocutaneous
(C5-7)
1. Shoulder dislocation.
2. Hypertrophy of
the coracobrachialis.
3. Deep brachial
fascia of the elbow as the nerve
exits biceps.
Abbreviation: AIN, anterior interosseous nerve; PIN, posterior interosseous nerve
Academy of Orthopaedic Physical erapy, APTA.
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Deep brachial
fascia of the
elbow as nerve
exits biceps:
radial side of the
forearm (posterior and anterior),
but not hand.
51
Injury at
shoulder: loss
in biceps,
coracobrachialis,
and brachialis
strength.
Injury at the
elbow: none.
Rely on strength and
sensory function testing.
Appendix G.
https://t.me/med1917
e Patient Rated Tennis Elbow Evaluation (PRTEE)
Patient name: Date:
e questions below will help us understand the amount of diculty you have had with your arm in the past week. You
will be describing your average arm symptoms over the past week on a scale of 0-10. Please provide an answer to all the
questions. If you did not perform an activity because of pain or because you were unable, then you should circle a “10”. If
you are unsure, please estimate to the best of your ability. Only leave items blank if you never perform that activity. Please
indicate this by drawing a line completely through the question.
1. PAIN in your aected arm
Rate the average amount of pain in your arm over the past week by circling the number that best describes your pain on
a scale from 0-10. A zero (0) means that you did not have any pain, and a ten (10) means that you had the worst pain
imaginable.
RATE YOUR PAIN: No pain
Worst Pain
Imaginable
When you are at rest 0 1 2 3 4 5 6 7 8 9 10
When doing a task with repeated movement 0 1 2 3 4 5 6 7 8 9 10
When carrying a plastic bag of groceries 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its least 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its worst 0 1 2 3 4 5 6 7 8 9 10
2. FUNCTIONAL DISABILITY
A. SPECIFIC ACTIVITIES
Rate the average amount of diculty you experienced performing each of the tasks listed below, over the past week, by
circling the number that best describes your diculty on a scale of 0-10. A zero (0) means you did not experience any
diculty, and a ten (10) means it was so dicult you were unable to do it at all.
No diculty Unable to do
Turn a doorknob or key 0 1 2 3 4 5 6 7 8 9 10
Carry a grocery bag or briefcase by the handle 0 1 2 3 4 5 6 7 8 9 10
Lift a full coee cup or glass of milk to your mouth 0 1 2 3 4 5 6 7 8 9 10
Open a jar 0 1 2 3 4 5 6 7 8 9 10
Pull up pants 0 1 2 3 4 5 6 7 8 9 10
Wring out a washcloth or wet towel 0 1 2 3 4 5 6 7 8 9 10
52
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For personal use only. No other uses without permission.
Appendix G.
https://t.me/med1917
Continued
3. USUAL ACTIVITIES
Rate the amount of diculty you experienced performing your usual activities in each of the areas listed below over the
past week by circling the number that best describes your diculty on a scale of 0-10. By “usual activities,” we mean the
activities that you performed before you started having a problem with your arm. A zero (0) means you did not experience any diculty, and a ten (10) means it was so dicult that you were unable to do any of your usual activities.
No diculty Unable to do
1. Personal activities (dressing, washing) 0 1 2 3 4 5 6 7 8 9 10
2. Household work (cleaning, maintenance) 0 1 2 3 4 5 6 7 8 9 10
3. Work (your job or everyday work) 0 1 2 3 4 5 6 7 8 9 10
4. Recreational or sporting activities 0 1 2 3 4 5 6 7 8 9 10
Comments:
PRTEE Scoring Instructions
Minimize non-response by checking forms when the patient completes them. Make sure that if the patient left an item
blank because they could not do it, that they understand that they should have recorded this item as a “10”. If the patient
is unsure because they have rarely performed an activity in the past week, then they should be encouraged to estimate
their average diculty. is will be more accurate than leaving it blank. If they never perform an activity, they will not be
able to estimate and should leave it blank. If items from a subscale are left blank, then you can substitute the average score
from that subscale.
Pain Subscale: add up 5 items. Best score = 0; Worst score = 50
Specic Activities: add up 6 items. Best Score = 0; Worst Score = 60
Usual Activities: add up 4 items. Best Score = 0; Worst Score = 40
Function Subscale: (Specic Activities + Usual Activities)/2. Best score = 0; Worst score = 50
Total Score (pain and disability contribute equally to score): Pain Subscale + Function Subscale. Best Score = 0; Worst
Score = 100
e reliability of subscales and total score are suciently high that both subscales and total are reportable.
© MacDermid 2005. Data from Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a patient-rated forearm evaluation questionnaire
for patients with lateral epicondylitis. Journal of Hand erapy. 1999;12:31-37.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
53
Appendix H.
https://t.me/med1917
Outcome Measures for the Elbow
Measure Description Clinical Value
American
Shoulder
and Elbow
Surgeons-Elbow Form
(ASES-E)
Disability of
Arm, Shoulder and
Hand Questionnaire
(DASH)
A condition-specic scale that allows the evaluation of elbow function
independently from the underlying diagnosis. It consists of 2 parts: a
patient questionnaire (pain, function, surgery success) and a form for
the clinician to record elbow impairment (motion, stability, strength,
and physical ndings). e rst section allows the patient to rate their
pain using a visual analog scale (VAS) from 0 (no pain) to 10 (worst
pain ever) for 5 criteria (pain at its worst, pain at rest, pain when
lifting a heavy object, pain when doing a task with repeated elbow
movements, and pain at night). e second section contains questions
relating to the function of the right and left arms, the scores of which
are made on a 4-point ordinal scale (0 = unable to do; 1 = very dicult to do; 2 = somewhat dicult; 3 = not dicult). e clinician can
assess active range of motion (AROM), valgus, varus, and posterolateral rotary instability, strength, and any signs of tenderness, scars, and
atrophy. Calculation of the score is somewhat more arduous than for
other elbow function scales. e nal pain score is calculated via an
independent formula, while the raw score from the functional questions is multiplied by a coecient to get the nal score for function.
e pain and functional portions are then summed to obtain the nal
ASES-E score, with higher scores indicating better outcomes.
A standardized questionnaire that evaluates impairments and activity
limitations and participation restrictions for both leisure activities and
work.
e DASH consists of 3 sections: the rst section includes questions
about symptoms and disabilities of the upper limb (30 items); the second and the third sections are optional. e optional sections produce
scores for participation in sports/music (4 items) and work activities
(4 items). All items of the DASH are scored with a 5-point scale: 1 =
no diculty; 2 = mild diculty; 3 = moderate diculty; 4 = severe
diculty; 5 = unable. For each section, the sum of the responses produces a score, which is then used to obtain the DASH score, ranging
between 0 (no disability) and 100 (severe disability) for each domain.
Almost all of the studies regarding
reliability, validity, and responsiveness have been done on the shoulder version of this tool. However,
this version has been determined
to be reliable and valid for use
with general elbow pathology, but
the minimal clinically important
dierence (MCID) has not been
reported. A limitation is that
higher functioning patients may
experience ceiling eects due to the
response structure.
While there is no set age limit for
DASH use, it is recommended for
patients who are 18 to 65 years old.
An MCID of 10 is suggested for diagnoses related to the proximal part
of the upper extremity (shoulder),
and 17 for diagnoses related to the
distal part of the upper extremity
(elbow, wrist, and hand).
QuickDASH
us, a high DASH score indicates severe disability while lower scores
are associated with improved function.
A shortened version of the DASH scoring system that consists of 11
items to measure physical function and symptoms in people with any
or multiple musculoskeletal disorders of the upper extremity with
each item having 5 response options (1 = no diculty; 2 = mild diculty; 3 = moderate diculty; 4 = severe diculty; 5 = unable). From
the item scores, a summative score is calculated.
e nal score ranges between 0 (no disability) and 100 (the most
disability).
Only 1 missing item can be tolerated, therefore, if 2 or more items are
missing, the score cannot be calculated.
54
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
ere is a high correlation between
the QuickDASH and DASH scores
(r > 0.97).
e minimal detectable change
(MDC) is 11 and the MCID is 19.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
Appendix H.
https://t.me/med1917
Continued
Measure Description Clinical Value
Musculoskeletal
function
assessment
(MFA) questionnaire
Short musculoskeletal
functional
assessment
(SMFA)
Patient-Rated Elbow
Evaluation
(PREE)
Comprises 100 items grouped into 10 categories: self-care;
sleep/rest; hand/ne motor skills; mobility; housework; employment/work; leisure/recreational activities; family relationships;
cognition/thinking; emotional adjustment/coping/adaptation.
All categories and total scores are calculated and standardized on
a scale of 0–100. Patients assess their function by answering ‘yes’
or ‘no’ to each item; each ‘yes’ response corresponds to 1 point,
and each ‘no’ response or unanswered question corresponds to
0 point.
e total score can range from 0 to 100 points, with 0 representing minimum dysfunction and 100 representing maximum
dysfunction.
A short-form of the MFA consisting of a self-reported 46-item
questionnaire divided in 2 parts: a dysfunction index and a
bother index.
e dysfunction index consists of 4 categories (daily activities,
emotional status, the function of the arm and hand, mobility)
and has 34 items: 25 items evaluate the amount of diculty
that patients have when performing certain functions, and
9 items evaluate how often the patients have diculty when
performing certain functions.
e bother index consists of 12 items and assesses how much
the patient is bothered by broad functional problems.
A 20-item self-report measure, consisting of 2 sections: pain
and function. e function section has 2 sub-sections: ‘specic
activities’ and ‘usual activities.’
Responses are rated on a numeric rating scale. e pain section
has 5 items: 4 of them rate pain from ‘no pain’ (0) to ‘worst ever’
(10). e fth item rates how often the patient has pain with
responses ranging from ‘never’ (0) to ‘always’ (10). e function
scale responses are anchored at ‘no diculty’ (0) and ‘unable to
do’ (10). e function section has 15 items regarding personal
care, household work, and occupation and recreational activities
out of which 11 items fall under the specic activities sub-section and 4 items are under the usual activities sub-section. e
raw function score is divided by 3, then added to the total pain
score to obtain a total score ranging from 0 to 100.
Has been extensively validated and tested
for reliability and responsiveness. Criterion validity was tested against physicians’
ratings of patient functioning (eg, upper
functioning, lower functioning, daily
activities, recreational functioning, emotional adjustment, and overall functioning) and standard clinical measures (eg,
grip strength, walking speed, ne motor
skills, knee, and elbow strength, and
ROM) and showed signicant correlations (p ≤ .05) between physicians’ ratings and clinical measures. Discriminant
construct validity was supported in an
analysis of MFA scores by patient disease
groups (p ≤ .01).
Swiontkowski and colleagues
247
found
that the questionnaire demonstrated
excellent internal consistency and stability
with most values greater than 0.90. ey
also found support for the content validity for both indices with convergent validity for the dysfunction and bother indices
with very little skew (less than 1.00), few
ceiling eects (less than 5%), and no oor
eects. Convergent and discriminant
construct validity of the SMFA indexes
were demonstrated (p < .01) in comparisons with clinical, demographic, Short
Form-36 (SF-36), and life-change data.
e MCID has been reported to be 7.3.
A few studies have found the PREE to be
valid with moderate to high correlations,
and to have a very high level of internal
consistency. A study by Overend et al
240
reported that substantial changes in the
PREE scores were required before they
could be considered clinically signicant.
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Higher PREE total scores reect greater pain and disability.
55
Appendix H.
https://t.me/med1917
Continued
Measure Description Clinical Value
Liverpool
Elbow Score
(LES)
Mayo Elbow
Performance
Index
(MEPI)
Broberg and
Morrey Rating System
(BMS)
Consists of 2 main components: a patient-rated questionnaire
that assesses elbow function, including a question about pain;
and clinical data, which can be measured objectively, regarding
the condition of the elbow.
e patient-answered questionnaire contains 9 items. Each of
them is graded using a 5-point scale, from 0 (worst/least function) to 4 (best/most function). e clinical assessment score
component contains 6 items, and some of them are graded
using a 4-point scale (from 0 to 3), whereas others are graded
using a 3-point scale (from 0 to 2). For calculation of the nal
score, all responses are transformed to a scale of 0–10. erefore, the nal score ranges between 0 (worst) and 10 (best).
Consists of 4 parts: pain, ulnohumeral motion, stability, and
the ability to perform 5 functional tasks. Pain is rated as none
(45 points); mild (30 points) if there is no limitation of activity
and occasional use of analgesics; moderate (15 points) if there
is a limitation of activity and regular use of analgesics; severe (0
points) if there is constant pain and regular use of analgesics.
e joint’s stability is graded as stable, mildly unstable, or unstable. e functional score is determined based on the patient’s
ability to perform normal activities of daily living. e total
score ranges from 5 to 100 points, with higher scores indicating
better function.
A 100-point system that summarizes data from clinical record,
personal interview, and biomechanics laboratory examination.
Consists of 4 sections: motion (40 points), strength (20 points),
stability (5 points), and pain (35 points). Pain is rated as none
(35 points); mild with activity but requiring no medication (28
points); moderate with or after activity (15 points); severe at
rest, requiring constant medication, and disabling (0 points).
e clinical and biomechanical assessments are obtained measuring motion with a goniometer for exion/extension of the
elbow and pronation/supination of the forearm. Grip strength is
measured with a specially designed torque dynamometer. Varus/
valgus stress tests are used to grade stability.
e LES has been validated for general
elbow disorders.
It was found to have good-to-excellent
validity and high responsiveness when
used to evaluate joint function in patients
with elbow stiness.
e MCID for the LES has been estimated to vary between 0.7 and 1.8.
e LES was found to be a responsive
measure with no oor and ceiling eect
on patients with total elbow replacement.
Found to have strong reliability when
assessed at dierent times and when
compared with the ASES-E.
It has been validated for general elbow
disorders. Its construct validity is good
for patient-rated variables and excellent
for physician-rated variables. An MCID
of 15 was reported for patients with
rheumatoid arthritis after arthroplasty or
synovectomy.
is scale has been validated for general
elbow disorders and is more likely to
correlate to other elbow measures if raw
scores are reported rather than categorical
rank.
Its construct validity is intermediate for
patient-rated severity and excellent for
physician-rated severity. No MCID has
been reported for this scale.
56
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Appendix H.
https://t.me/med1917
Continued
Measure Description Clinical Value
e Hospital for
Special Surgery (HSS)
scoring
system
Oxford
Elbow Score
(OES)
Consists of 8 domains: pain, function, sagittal range, muscle
strength, exion contracture, extension contracture, pronation,
and supination.
Pain is evaluated during activities that involve elbow exion
and at rest; its maximum score is 30, reecting a condition of
no pain at any time. In the function’s evaluation, the ability to
perform activities that involve elbow exion and the ability to
perform a task are considered. e patient scores 8 points when
able to perform the activities that involve elbow exion for 30
minutes, and 0 points when they cannot use the elbow. Regarding ability to perform a task, patients score 12 points when
there is an unlimited use of the elbow, and 0 points when they
are completely unable. e maximum score for function is 20
(12 + 8). In the evaluation of the sagittal range, patients receive
1 point for each 7° of motion, to a maximum score of 20. Flexion and extension contractures have both a maximum score of
6, while pronation and supination have both a maximum score
of 4. An excellent result is considered to be a score of 90–100
points; a good result, 80–89 points; a fair result, 70–79 points;
a poor result, 60–69 points; a failed result, < 60 points.
e OES has 12 questions with 5 response options each. Each
item response is scored as 0 to 4, with 0 representing greater severity. Underlying the 12 items are 3 domains (subscales): elbow
pain, elbow function, and social-psychological eects. Scores for
each domain are calculated as the sum of each item score within
that domain. is gives a score range of 0–16 for each domain
and 0–48 overall, with 0 indicating the worst elbow score and
48 a ‘normal’ elbow score. Individual domain scores can be
further analyzed by being converted to a metric score of 0–100
(lower scores representing greater severity).
e HSS has been validated for general
elbow disorders.
Construct validity is intermediate for
patient-rated variables and intermediate
for physician-rated variables. A MCID
of 12 was reported for patients with
rheumatoid arthritis after arthroplasty or
synovectomy.
Designed specically to be a patient-focused outcome measure. e OES
development study results demonstrated
that it is reliable, valid, and acceptable
to patients, with a high completion rate.
It is considered a useful method for
assessing elbow surgery outcomes from
the patient’s perspective. No MCID data
are available.
e Elbow
Self-Assessment Score
(ESAS)
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e ESAS is a fusion of the scales included in the ASES-E, the
BMS, the PREE Questionnaire, the MEPS, the OES, and the
Quick-DASH and consists of 22 items addressing 3 domains:
pain (7 items), elbow function including ROM (12 items), and
quality of life (3 items). e best and least symptomatic score
for each item is set at 0 and the worst at 10. e overall score is
then converted to a 100% scale, whereas a 100% value indicates
an excellent result and a value of 0% a poor result.
57
One study found the ESAS to have a
high test-retest reliability with intraclass
correlation coecients of at least 0.71.
Also, construct validity and responsiveness were conrmed by correlation coecients of -0.80 to -0.84 and 0.72 to 0.84
(p < .05). Correlation coecients of the
ESAS with well-established elbow rating
systems (BMS, PREE, MEPS, OES, and
Quick-DASH) were between 0.70 and
0.90 (p < .05)
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