MusculoSkeletal Exam

Figure 9.13 Palpation of the wrist extensor-supinator muscles.

The muscle mass should be examined for tenderness and swelling, which can occur after overuse or strain. Inflammation of this area is commonly involved in tennis elbow. The specific test is described later in this chapter (p. 228).

Posterior Aspect

Bony Structures

Olecranon

Move your fingers to the posterior surface of the elbow and you will palpate a very prominent process that tapers to a rounded cone. This is the olecranon process (Figure 9.14). The olecranon is more distinct when the patient flexes the arm, bringing the olecranon out of the olecranon fossa. The relationship between the medial and lateral epicondyles and the olecranon can be examined in both the flexed and extended positions. In flexion, as the olecranon moves out of the fossa, it becomes the apex of an isosceles triangle formed by the three structures. As the arm moves back into extension and the olecranon moves back into the fossa, the three structures form a straight line (Figure 9.15). Disruption of these geometric figures can be caused by a fracture of any of the structures, or dislocation of the olecranon.

Olecranon Fossa

Once you have found the olecranon, move your fingers proximally and allow them to drop into a small depression, which is the olecranon fossa (see Figure 9.14). This fossa cannot be palpated when the patient’s elbow is in extension, as it is filled by the olecranon process. When the elbow is completely flexed, the fossa is blocked by the tension in the triceps tendon. Therefore, the optimal position for palpation is at 45 degrees of elbow flexion.

Olecranon fossa

Olecranon

Figure 9.14 Palpation of the olecranon and olecranon fossa.

Ulna Border

Go back to the olecranon process and allow your fingers to move distally along the superficial ridge of the ulna. The ulna border is easily followed and can be traced along the length of the bone until you reach the ulna styloid process (Figure 9.16). Point tenderness and an irregular surface can be indicative of a fracture.

Soft-Tissue Structures

Olecranon Bursa

The olecranon bursa lies over the posterior aspect of the olecranon process. It is not normally palpable. If the bursa becomes inflamed, you will feel a thickening in the area under your fingers. The inflammation can be so significant that it may appear as a large swelling resembling a golf ball over the posterior olecranon and is sometimes referred to as student’s elbow (Figure 9.17).

Triceps

The triceps muscle is comprised of three portions. The long head originates from the infraglenoid tubercle of the scapula, the lateral head originates from the

Olecranon

bursa

Figure 9.17 Palpation of the olecranon bursa.

posterior surface of the humerus, and the medial head originates from the posterior aspect of the humerus below the radial groove. All three heads insert distally by a common tendon to the olecranon.

The superior portion of the long head can be palpated on the proximal posterior aspect of the humerus as it emerges from under the deltoid. The lateral head can be palpated on the middle posterior aspect of the humerus. The medial head can be located on both sides of the triceps tendon just superior to the olecranon. The contour of the muscle can be made much more distinct by resisting elbow extension

(Figure 9.18).

Trigger Points

Myofascial pain of the elbow region is relatively uncommon. Referred pain patterns from trigger points in the biceps and triceps muscles are illustrated in Figures 9.19 and 9.20.

Active Movement Testing

The major movements of the elbow (humero-ulnar and humero-radial) joint are flexion and extension on the transverse axis. To accomplish the full range of flexion and extension, the radius and ulna must be able to abduct and adduct. The major movements of the superior radioulnar joint are supination and pronation around a longitudinal axis. These should be quick, functional tests designed to clear the joint. If the motion is pain free at the end of the range, you can add an additional overpressure to “clear” the joint. If the patient experiences pain during any of these movements, you should continue to explore whether the etiology of the pain is secondary to contractile or noncontractile structures by using passive and resistive testing.

A quick screening examination of the movements can be accomplished by asking the patient to reach for the back of the neck on the ipsilateral side of the elbow being tested. Then ask the patient to return the arm to the side in the anatomical position. Symmetrical hyperextension of 10 degrees can be considered normal. Pronation and supination can be checked functionally

by asking the patient to place the elbow into the angle of the waist and turn the forearm as though he or she is turning a doorknob to the right or left. Observe the patient’s wrist as he or she may try to substitute for the movement by abducting or adducting the arm. These tests can be performed with the patient in either the sitting or standing position.

Passive Movement Testing

Passive movement testing can be divided into two areas: physiological movements (cardinal plane), which are the same as the active movements, and mobility testing of the accessory (joint play, component) movements. You can determine whether the noncontractile (inert) elements are causative of the patient’s problem by using these tests. These structures (ligaments, joint capsule, fascia, bursa, dura mater, and nerve root) (Cyriax, 1979) are stretched or stressed when the joint is taken to the end of the available range. At the end of each passive physiological movement you should sense the end feel and determine whether it is normal or pathological. Assess the limitation of movement and see if it fits

into a capsular pattern. The capsular pattern of the elbow is greater restriction of flexion than extension so that with 90 degrees of limited flexion there is only 10 degrees of limited extension (Kaltenborn, 1999;

Cyriax, 1979). The capsular pattern of the forearm is equal restriction of pronation and supination, which usually only occurs with significant limitation in the elbow joint (Kaltenborn, 1999).

Physiological Movements

You will be assessing the amount of motion available in all directions. Each motion is measured from the zero starting position. For the elbow, both the arm and the forearm are in the frontal plane, with the elbow extended and the forearm supinated. For the forearm, the elbow should be flexed to 90 degrees with the forearm midway between supination and pronation (Kaltenborn, 1999).

Flexion

The best position for measuring flexion is supine with the patient’s elbow in the zero starting position with the shoulder at 0 degrees of flexion and abduction. A small towel placed under the distal posterior aspect of the humerus will allow for full extension. Place one hand over the distal end of the humerus to stabilize it but be careful not to obstruct the patient’s range into flexion. Hold the distal aspect of the patient’s forearm and bring the hand toward the shoulder. The normal end feel is soft tissue caused by the muscle bulk of the biceps. If the patient’s muscles are very atrophied, a hard end feel can be noted as the coronoid process meets or compresses into the coronoid fossa. This motion can also be restricted by tightness in the triceps muscle and the posterior capsule, producing an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–150 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 9.21).

Figure 9.21 Passive movement testing of flexion of the elbow.

Figure 9.22 Passive movement testing of extension of the elbow.

Extension

Full extension is achieved when the patient is placed in the supine position. The hand placement is the same as for flexion of the elbow. The motion is accomplished by allowing the patient’s elbow to return to the zero starting position from flexion. The normal end feel is hard due to the contact between the olecranon and the olecranon fossa. The motion can also be restricted by tightness in the biceps and brachialis muscles and anterior capsule which produces an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). The normal range of motion is 0 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 9.22).

Pronation

The best position for measuring pronation is having the patient sitting with their forearm in the zero starting position and the shoulder at 0 degrees of flexion and abduction. Stand so that you face the patient. Stabilize the posterior distal aspect of the humerus by cupping your hand around the olecranon to prevent substitution by shoulder medial rotation and abduction. Support the distal end of the forearm with your other hand. Rotate the forearm so that the patient’s palm faces the floor. The normal end feel is hard due

Figure 9.23 Passive movement testing of pronation of the forearm.

Radius

Ulna

Figure 9.24 Passive movement testing of supination of the forearm.

Chapter 9 The Elbow

to the contact of the radius rotating over the ulna. The motion can be restricted by tightness in the supinator muscles, the interosseous membrane, and the inferior radioulnar joint which produces an abrupt and firm (ligamentous) end feel (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–80–90 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 9.23).

Supination

Supination is tested with the patient in the same position as pronation. Substitution can be accomplished by shoulder lateral rotation and adduction. Rotate the patient’s forearm so that the palm faces the ceiling. The normal end feel is abrupt and firm (ligamentous) due to tension in the pronator muscles, interosseous membrane, and the inferior radioulnar joint (Kaltenberg, 1999; Magee, 1997). Normal range of motion is 0– 80–90 degrees (American Academy of Orthopedic Surgeons, 1965) (Figure 9.24).

Mobility Testing of the Accessory

Movements

Mobility testing of accessory movements will give you information about the degree of laxity present in the joint. The patient must be totally relaxed and comfortable to allow you to move the joint and obtain the most accurate information. The joint should be placed in the maximal loose packed (resting) position to allow for the greatest degree of joint movement. The resting position of the elbow is 70 degrees of flexion and 10 degrees of supination. The resting position of the forearm (superior radioulnar joint) is 70 degrees of flexion and 35 degrees of supination (Kaltenborn, 1999) and the resting position of the humero-radial joint is the forearm fully supinated and the elbow fully extended.

Traction of the Elbow (Humero-ulnar) Joint

Place the patient in the supine position with the elbow flexed approximately 70 degrees and the forearm supinated approximately 10 degrees. Stand to the side of the patient facing the posterior aspect of the forearm to be tested. Stabilize by grasping the posterior distal aspect of the humerus. Allow the distal part of the forearm to rest against your trunk. Place your other hand around the anterior proximal portion of the ulna as close as possible to the joint line. Pull the ulna in a longitudinal direction until you have taken up the slack, producing traction in the humero-ulnar joint (Figure 9.25).

Lateral Glide of the Ulna

Place the patient in the supine position with the elbow flexed approximately 70 degrees. Stand on the side of the patient with your body facing the patient. Allow the patient’s forearm to rest against your chest. Place one hand around the lateral distal aspect of the humerus to stabilize it. Place your other hand around the proximal medial aspect of the ulna. Move the ulna in a lateral direction until all the slack has been taken up. This tests the ability of the ulna to glide laterally on the humerus (Figure 9.26).

Medial Glide of the Ulna

This test is performed with the patient in the same position as the lateral glide of the ulna except that your hand placement is reversed. Stabilize the humerus by placing your hand around the proximal medial aspect. Move the ulna medially, until all the slack has been taken up, by placing your hand around the proximal lateral aspect of the forearm over the radius and ulna (Figure 9.27).

Medial and Lateral Gapping (Varus-Valgus Stress)

Place the patient in the supine position with the patient’s elbow in slight flexion and supination. Stand on the side of the table and face the patient. Place your hand around the distal lateral aspect of the humerus to stabilize it. Place your other hand at the distal medial aspect of the forearm proximal to the wrist. Move the ulna laterally producing a gapping on the medial aspect of the elbow. This is also referred to as a medial (valgus) stress. This tests for the integrity of the medial collateral ligament (Figure 9.28).

To test the integrity of the lateral collateral ligament the same test should be repeated by reversing your hand placements. This will allow you to create a varus (lateral) force creating gapping on the lateral aspect of the elbow joint (see Figure 9.28).

Traction of the Humero-radial Joint

Place the patient in the supine position with the arm resting on the table and the elbow flexed to approximately 70 degrees. Stand on the side of the table and face