Chapter 8 Clinical Examination of the Elbow

John A. Mcauliffe, MD HISTORY PHYSICAL EXAMINATION SPECIFIC DIAGNOSTIC MANEUVERS ADDITIONAL DIAGNOSTIC MODALITIES SUMMARY CRITICAL POINTS Valgus Instability Valgus instability is due to attenuation or rupture of the anterior bundle of the medial collateral ligament. Symptomatic medial collateral ligament injury is almost exclusively a problem of throwing athletes (e.g., pitchers or javelin throwers). Athletes usually present with the gradual onset of pain while throwing or an inability to throw with great force or velocity, although acute rupture of the ligament occasionally occurs. Due to the repetitive valgus stress of throwing, other medial elbow complaints may occur simultaneously, including medial epicondylitis, ulnar nerve irritation, and posteromedial elbow pain due to osteophyte impingement (valgus extension overload syndrome). Physical examination seldom reveals obvious gapping or instability, but relies on the reproduction of pain during a variety of valgus stress maneuvers.

Posterolateral Rotatory Instability Posterolateral rotatory instability is due to attenuation or rupture of the lateral ulnar collateral ligament. Posterolateral rotatory instability is usually a late result of elbow dislocation or subluxation. Iatrogenic injury to the lateral ligament complex, which usually occurs during surgery for lateral epicondylitis or radial head fracture, is another cause of posterolateral rotatory instability. Although patients may suffer recurrent dislocation or obvious subluxation, symptoms are often much more subtle, including pain, snapping, clunking, or locking, particularly when the elbow is placed in extension and supination. Frank instability or subluxation can rarely be reproduced during physical examination, except under anesthesia; however, apprehension and pain during extension and supination stress to the elbow are suggestive.

A relatively limited number of symptoms prompt a patient with elbow dysfunction to seek medical attention. The most commonly voiced complaint is elbow pain that may arise from the joint itself or from any of the myriad surrounding soft tissues.[1] Although pain in or around a joint is usually the result of arthrosis, inflammation, or trauma of some sort, other, more subtle diagnostic possibilities must not be overlooked, including those of neurologic, metabolic, neoplastic, and even congenital origin. Complications related to prior surgical treatment or failed attempts at fracture fixation, specifically infection, nonunion, or malunion, may also be causes of pain.

Limitation of motion is the next most common elbow complaint. The elbow has the greatest functional range of motion of any joint in the upper extremity, and it has a great propensity for capsular contracture following even minor trauma or brief periods of immobilization.[2] The unfortunate association of these two circumstances in a single joint makes loss of elbow motion a significant problem. Instability of the elbow is encountered much less frequently than either pain or loss of motion, and for this reason it has only recently begun to be more clearly understood. Instability can be the result of a single traumatic event, such as dislocation, often accompanied by fracture and, in these circumstances, may even rarely manifest as recurrent dislocation.[3] Although it seems counterintuitive, instability after major trauma to the elbow may cause significant pain, leading to stiffness and joint contracture. Instability may also result from chronic attritional injury to ligamentous structures as seen, for example, in throwing athletes.[4] Patients with elbow instability often do not appreciate giving way, clunking, or other more obvious mechanical symptoms, but instead complain that they cannot use their elbows with force in certain positions or cannot perform certain activities with the power to which they are accustomed. Weakness associated with attempted use of the elbow may accompany other presenting symptoms. In the absence of more proximal neurologic injury, this complaint is usually the result of an underlying painful process causing reflex inhibition or instability leading to apprehension.[1] History Examination of the elbow begins with a thorough history of the presenting complaint. If a specific traumatic episode has occurred, an attempt should be made to define the mechanism of injury as accurately as possible. Such information often suggests subtle diagnoses or patterns of injury that may involve anatomic areas other than the elbow itself. In the absence of a specific traumatic event, it is often helpful to inquire about any new or different activities that the patient had engaged in during the days and weeks preceding the onset of symptoms. It is best to allow patients a minute or two at the beginning of the interview to explain matters in their own words; they may provide information that we would not think to ask about. Careful questioning then leads to establishing a list of differential diagnostic possibilities, which can guide the physical examination. Table 8-1 contains recommended questions to ask your patient during the history. Especially when visiting a specialist, patients often neglect to volunteer information that they believe is unrelated to the current problem. Associated complaints, including involvement of other joints, fever, malaise, and related constitutional symptoms, should be specifically sought. An accurate understanding of the general medical history is another important prerequisite for appropriate diagnosis and treatment. Table 8-1 -- Recommended Questions to Ask During History Taking 1 When did symptoms first appear, and how have they changed over time? 2 Are the symptoms constant or intermittent? 3 Have you noticed any activity or circumstance that makes them better or worse? 4 Where are the symptoms? (I ask patients to point with one finger in an attempt to get as precise a localization as possible, although this is not always successful.) 5 If pain is present, can you describe it (aching, burning, stabbing) and rate its severity? 6 Does the pain radiate to other areas? 7 Have you taken medication for the pain? If so, what medication, how much, and how often? 8 Have you tried anything else that has helped, or worsened the symptoms? 9 Is there anything else you can think of that we have not yet talked about?

We should endeavor to understand not only the constellation of elbow symptoms that prompts the patient's visit, but also, and perhaps more importantly, how these symptoms interfere with vocational and avocational function.[1] Dynamic elbow instability may incapacitate an athlete, interfering with his or her livelihood, whereas it is often a minor annoyance that can be managed symptomatically in an older, more sedentary individual. Relatively minor joint contracture that might not even be considered for treatment in the average individual may occasionally prove disabling for certain musicians or skilled craftsmen. When obtaining a history from an athlete with elbow complaints, detailed knowledge of the specific sport or activity can be of great benefit. For example, throwing athletes with ulnar collateral ligament insufficiency or other medial elbow disorders experience symptoms during the late cocking and acceleration phases of the throwing motion, whereas those with posterior elbow pathology more often complain of pain during deceleration and follow-through.[5],[6] Pitching style, innings pitched, average pitch count, and even the timing of the appearance of symptoms during training or seasonal play may all be important variables to consider. An understanding of the response to previous treatment is helpful in both establishing a diagnosis and making plans for further efforts. The details of surgical procedures are appreciated most clearly after reviewing the operative record. Such documentation may provide an invaluable firsthand description of the status of articular surfaces or supporting soft tissue structures. It is particularly helpful to know how the ulnar nerve has been handled during previous surgery: Has the nerve been transposed anteriorly? Is it subcutaneous or submuscular? Occasionally, it may be helpful to speak directly with prior caregivers if adequate records are unavailable.
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