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Examination & Imaging
of the Elbow
Daryl C. Osbahr, M.D. Chief of Sports Medicine, Orlando Health
Chief Medical Officer, Orlando City Soccer Club
Orthopedic Consultant, Washington Nationals
Orthopedic Institute
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The Athlete’s Elbow
It is important to remember when
examining the elbow of any athlete or
manual laborer that adaptations to
repetitive stresses induced by sport/work
activities may result in “abnormal”
findings which may not represent true
pathology!!
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
![Page 5: Posteromedial Impingement of the Elbowforms.acsm.org/16tpc/PDFs/10 Osbahr.pdfExamination & Imaging of the Elbow Daryl C. Osbahr, M.D. Chief of Sports Medicine, Orlando Health Chief](https://reader035.vdocuments.mx/reader035/viewer/2022070721/5ee1e700ad6a402d666c9b62/html5/thumbnails/5.jpg)
Clinical History
• ? Dominant hand
• What, when, where, how?
• Work related
• Any previous injury
• Any previous treatment
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Clinical History
• Any Traumatic events • Falls, dislocations, lacerations, fractures
• Recent athletic activity • Throwing history
• When, where, how much, how well, how fast
• Changes in routine or training regimen
• Pain or instability with throwing • 85% of throwers with medial elbow instability complain
of pain in the acceleration phase of throwing • Neurologic symptoms with throwing
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Inspection
• Normal carrying angle in adult • Male = 10-11 degrees valgus
• Female = 13 degrees valgus
• Not uncommon for throwers to have > 15 degrees valgus at elbow
• Person with large elbow effusion will tend to hold elbow flexed 70-80 degrees as this corresponds to greatest volume of elbow joint capsule
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Inspection
13 degrees
Valgus
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Inspection
• Lateral recess, medial epicondyle, antecubital fossa, olecranon tip
• Prominence of the olecranon tip may indicate posterior/posterolateral dislocation or triceps avulsion
• Ecchymosis anteriorly may indicate biceps tendon rupture
• Ecchymosis medially may indicate a fracture of the medial epicondyle or avulsion injury
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Inspection
• Olecranon bursa should be inspected
• If enlarged may represent bursitis
• Aseptic vs. septic
• Ulnar nerve subluxation may be visible
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Inspection
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Range of Motion
• Active followed by passive ROM
• Normal ROM in adult
• 0 – 140 degrees +/- 10 degrees in
sagittal plane
• 80 – 90 degrees of forearm rotation in
each direction
• With progressive flexion, elbow moves
into increasing valgus
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Full Extension
Full Flexion
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Range of Motion
• Generalized ligamentous laxity is
associated with increased ROM
• Functional ROM is 30 – 130 degrees
flexion and 50 degrees of rotation in
each direction
• Morrey et al, JBJS 1981
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Range of Motion
• Pain, crepitus, and end feel must be assessed
• End feel in extension should be “bony” (Cain)
• Soft endpoint may indicate contracture
• End feel in flexion should be “soft”
• Firm endpoint may indicate bony impingement
• > 50 % of throwing athletes have some degree
of elbow flexion contracture • King et al, Clin Ortho 1969
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Palpation: Osseous
• Olecranon
• Posteromedial tip (impingement)
• Proximal shaft (stress fractures)
• Epicondyles
• Fractures
• Epicondylitis
• Radial Head
• Fractures
• Dislocations
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Palpation: Soft Tissues
• Anterior
• Biceps tendon
• Medial & Posterior
• Flexor-pronator
• UCL
• Ulnar nerve
• Triceps Tendon
• Lateral
• LUCL & LCL
• Extensor Tendon
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Medial Palpation
Posterior Palpation
Palpation: Medial & Posterior
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Palpation: Lateral
Lateral epicondyle
Radial Head
Lateral olecranon
Soft spot
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Palpation: Ligaments
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Strength Examination
• Any routine examination of the elbow should
include a strength examination (MMT)
• Rotator cuff
• Deltoid
• Biceps
• Triceps
• Pronation and Supination
• Wrist dorsal- and volar-flexion
• Grip, Intrinsics, and APL
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Sensory Examination
• Cursory sensory exam in all patients
• Bilateral comparison
• Subtle differences in sensory function may not represent true pathology, but may be the first indicator of more serious pathology
• Musculocutaneous, MABC, LABC, Radial, Ulnar, Median
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Sensory Examination
• Musculocutaneous
• Antecubital fossa
• Radial
• First dorsal webspace of hand
• Ulnar
• Ulnar aspect of 4th & 5th fingers
• Median
• Pad of Index & Middle
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Vascular Exam
• Pulses should be checked in both arms
and the quality of the pulse as well as
the rate should be compared.
• Dampened pulses may indicate
proximal obstruction
• Capillary refill and general perfusion
should be checked in any patient
complaining of altered sensation in
fingertips
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Stability Examination
• No Inherent Stability to Elbow
• Full Extension – Olecranon Tip
& Olecranon Fossa articulation
provides some stability against
varus/valgus stresses
• Radial head provides some
stability against valgus laxity
• Pts with radial head fractures
may have increased valgus
carrying angle
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Examination & Imaging of the Elbow
• Clinical History
• Inspection
• Range of Motion
• Palpation
• Strength/Neurovascular
• Stability
• Imaging
• Sports Injury Specific Special Tests
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Elbow Imaging
Radiographs
AP Oblique ER Lateral Oblique IR Oblique Axial
0 15 0 15
Bilateral Stress Views
Dominant Arm
Non-Dominant Arm
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AP X-Ray
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Lateral X-Ray
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Radial Head-Capitellum View
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Pediatric Ossification Centers
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• Evaluation of bone
and soft tissue
abnormalities.
• Articular
deformities/injuries
• Complex fractures
Computed Tomography
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Magnetic Resonance Imaging
• Clearly define numerous types of
osseous and soft tissue pathology.
• Intra-articular Contrast: Ligament
Evaluation Improved with soft tissue
contrast.
• Intravenous Contrast: synovial
inflammation, osteomyelitis, neoplasms.
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Medial - Lateral
Axial MRI
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Medial - Lateral
Axial MRI
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Medial - Lateral
Coronal MRI
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Posterior - Anterior
Sagittal MRI
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
Elbow Sports Injury Specific Special Tests
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Biceps Tendon Injury
• Palpation in the antecubital fossa
• Absence of typically prominent tendon
• Resisted supination will increase
prominence
• +/- Pain in antecubital fossa
• Ecchymosis may be present
• + Biceps Hook Test
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Biceps Tendon Injury
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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Flexor-Pronator Pain
• Medial Epicondylitis (Golfer’s Elbow)
• Palpate medial muscle mass/epicondyle while resisting active pronation
• Pain either within muscle belly or directly over epicondyle
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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Posteromedial
Overload
UCL Injury
Muscle Fatigue
Microtrauma
Medial & Posterior Elbow: Throwing Athlete
Breakdown in Valgus Elbow Stability!!
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Throwing Elbow Injuries: Clinical History
• Symptoms
• Medial vs. Posterior Elbow Pain
• Swelling, Catching and/or Locking
• Phase of Throwing
• Acceleration/Late Cocking
(UCL Insufficiency?)
• Deceleration/Follow-Through
(Posteromedial Impingement?)
• Associated Findings: Fatigue Related
Symptoms, Loss of Velocity, Loss of
Control, Ulnar Nerve Symptoms
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UCL Palpation
• Deep structure covered by flexor-pronator mass
• Course of ligament from ME to Sublime tubercle of proximal ulna • Inserts just distal to articular surface
• Flexion of elbow will move muscle mass anteriorly, uncovering UCL
• Pain with palpation in this region may be indicative of UCL pathology (not specific)
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• Valgus Stress Test
• Positive if laxity and/or pain
• Moving Valgus Stress Test • Positive test if pain between
120º to 90º of elbow flexion
• Milking Maneuver
• Positive test if reproduces pain & provides apprehension
UCL Tests
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Arthroscopic UCL Stress View
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Posteromedial Impingement
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Posteromedial Elbow Tests
• Posteromedial Impingement Test • Elbow at 20º to 30º
• Valgus Stress
• Force Terminal Extension
• Other: Decreased Motion & Crepitus
Rule Out Other Pathology:
• Flexor-Pronator Symptoms • Resisted Flexion/Pronation Pain
• Ulnar Nerve Symptoms
• Olecranon Palpation & Percussion
• Lateral Elbow Assessment (Pain & Instability)
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Repeatedly move
elbow into full
extension with
valgus stress
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Oblique Axial (110º Flexion)
Medial & Posterior Elbow Imaging
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Medial & Posterior Elbow Imaging
Complete UCL Tear
Combined Injury
UCL & Flexor Pronator
Olecranon Stress Fracture
Partial UCL Tear
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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Ulnar Nerve Pathology
• Impingement
• Instability
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Ulnar Nerve Testing: Tinel’s Test
• Gentle percussion of the
ulnar nerve above or
within the cubital tunnel
should not elicit pain in
the normal elbow
• Pain or paresthesias in
the ulnar distribution is
considered a positive test
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Ulnar Nerve Impingement
• Compression Neuritis or Neuropathy
• i.e., Anomalous bands of triceps insertion may
impinge ulnar nerve as they snap over medial
epicondyle
• Sensation of “snapping” as the arm is actively
extended with ulnar nerve symptoms
• “Snapping Triceps Syndrome” • Spinner and Goldner, JBJS 1998
• Nerve is stable in cubital tunnel
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Ulnar Nerve Instability
• Ulnar nerve held in cubital tunnel by overlying and investing fascia
• Rupture or stretch of this tissue may lead to subluxation of nerve • Paresthesias
• Pain with subluxation
• May have pain with palpation
• Ulnar nerve subluxes anteriorly with increasing flexion of elbow
• Nerve “snaps” back with rapid active extension
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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Triceps Tendon Injury
• Presence of a palpable triceps gap
• Weakness or loss of active elbow extension
• Findings may be variable in the setting of
severe pain and swelling, especially if they are
present in a muscular athlete with large bulk
• Ecchymosis may be marked several days, but
not immediately, after injury
• Must determine whether injury is partial vs.
complete
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
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Extensor Tendon Injury
• Lateral Epicondylitis (Tennis Elbow)
• Palpate mobile wad while resisting active supination (ECRB most common offender)
• Pain within muscle belly or over epicondyle
Surgery ONLY if Non-op Fails!
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Elbow Sports Injury Specific Special Tests
• Anterior
• Biceps Tendon
• Medial & Posterior
• Flexor-Pronator
• Ulnar Collateral Ligament
• Posteromedial Impingement
• Ulnar Nerve
• Triceps Tendon
• Lateral
• Extensor Tendon
• Posterolateral Rotatory Instability
![Page 71: Posteromedial Impingement of the Elbowforms.acsm.org/16tpc/PDFs/10 Osbahr.pdfExamination & Imaging of the Elbow Daryl C. Osbahr, M.D. Chief of Sports Medicine, Orlando Health Chief](https://reader035.vdocuments.mx/reader035/viewer/2022070721/5ee1e700ad6a402d666c9b62/html5/thumbnails/71.jpg)
Lateral Ligamentous Exam
• LUCL & RCL make up
lateral ligament complex
• Apply varus stress with
elbow flexed 15-20 °
• Arm is internally
rotated to prevent
shoulder rotation
• Pain or increased
varus/PL laxity
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• PLRI due to insufficiency of LUCL
Posterolateral Rotatory Instability
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Posterolateral Rotatory Instability: Tests
Pivot Shift: Supine, flexed
to 70 degrees, axial load
w/ valgus stress
Chair Push Up Test
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Posterolateral Rotatory Instability: Imaging
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Summary
• Develop a System & Follow It
• Cover All Bases
• A Thorough Clinical History will help
guide & direct the Physical Examination
• Compare to Contralateral Elbow
• Supplement & Confirm Examination
with Imaging
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2016 ACSM Team Physician Course
Orthopedic Institute