Making the Clinical Diagnosisin Elbow Injury

Christian Veillette MD MSc FRCSCAssistant Professor, University of TorontoShoulder & Elbow Reconstructive Surgery

Toronto Western Hospital @ University Health NetworkUTOSM @ Women’s College Hospital

Email: orthonet@gmail.com

Objectives

• to understand the important clinical history to distinguish from other diagnoses

• to understand the physical examination maneuvers that differentiate between causes of elbow pain

• to understand how the physical tests work

Introduction

• Cause of elbow pain often misdiagnosed

• Physicians often rely on MRI/US to “diagnose” elbow problems

• Physical examination of the elbow remains unsolved problem for many physicians

– Lack of familiarity with the elbow anatomy– Wide variety of elbow diseases

http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html

History is the key!

• Each question should have specific purpose that affects decision-making

• 7 “Questions”1. Demographics (Age, Handedness, Occupation) – How old are you?

What hand do you write with? What do you do for a living?2. Duration/Onset/Trauma – When did the pain start? What were you

doing? Has the pain gotten worse or better? (Acute, Chronic, Gradual, Progressive)

3. ***Location - Point with 1 finger where the pain is the worst?4. Severity - Does the pain keep you up at night? What % of normal is

your elbow?5. Precipitating factors – What activities make your pain worse? What

activities are you unable to do because of the pain?6. Treatment – Have you had any treatment? – NSAIDs, Physio, Injection7. Associated symptoms – Do you have any numbness or tingling in your

hand or neck pain?

Elbow ROM

Medial elbow pain

• 25 yo male, RHD college pitcher

• Medial elbow pain with throwing

• Progressively worsened over last 3 starts

• Unable to pitch• Loss of velocity – 10-15 mph• Intermittent tingling small

finger with pitching

Medial elbow pain DDx

• 6 causes of medial elbow pain1. Medial collateral ligament insufficiency2. Medial epicondyl”itis”/FPO tear3. Ulnar neuritis4. Subluxating/snapping medial triceps5. Posteromedial trochlear chondral lesion6. Posteromedial impingement/Fractured

osteophyte/Loose bodies

1. Medial collateral ligament insufficiency

Presentation• Overhead athlete (throwing

sports, tennis)• Medial sided elbow pain

– Insidious (acute “pop” uncommon)– Only when playing/throwing

• Late cocking/early acceleration phase

• Loss of control / velocity / performance

• May be associated with ulnar neuritis

Exam• Tenderness at MCL• +/- pain on static valgus stress• Positive MVST/milking

maneuver• Often have additional findings

of DDx

• Diagnostic Test(s)– Moving Valgus Stress Test– Milking maneuver

Moving Valgus Stress Test (MVST)

• Medial elbow pain reproduced with valgus stress while moving elbow from flexion to extension (shear angle 120o –70o, max at 90-95o)

• Biomechanical rationale for MVST– Recreates internal shear stresses in MCL of throwing

• Algorithm for diagnosing MCL in medial elbow pain

– Is pain coming from MCL? – MVST– Is the MCL lax? – Valgus stress test– Is MCL torn (partial/complete)? – Surgical exploration

O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medialcollateral ligament tears of the elbow. Am J Sports Med. 2005 Feb;33(2):231-9.

Moving Valgus Stress Test

O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medialcollateral ligament tears of the elbow. Am J Sports Med. 2005 Feb;33(2):231-9.

2. Medial epicondyl”itis”/FPO tear

Presentation• Pain with activities requiring

active wrist flexion / forearm pronation

• History of non-throwing overuse

• Acute episode resisted eccentric wrist flexion /forearm pronation

Exam• Tender “medial epicondyle”• Palpable defect at origin• Pain pressing against cheek

with extended middle finger• T.E.S.T (Tennis Elbow Shear

Test)

3. Ulnar neuritis

Presentation• Pain radiates into medial

forearm and hand• Paresthesia / dysesthesia /

hypoesthesia in 4th and 5th

fingers• Occasional hand clumsiness

and weakness

Exam• Tinels• Tenderness – 3 locations• Subluxation

4. Subluxing/Snapping medial triceps

Presentation• History of weight-lifting• Painful posteromedial snaps

with elbow flexion• May be associated with ulnar

neuritis

Exam• Subluxation• 2 snaps• Push-Up Test• Tenderness posteromedial –

usually at intermuscular septum

Snapping medial head of triceps

Spinner RJ, Goldner RD. Snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve. Anatomical and dynamic factors. J Bone Joint SurgAm. 1998 Feb;80(2):239-47.

5. Posteromedial trochlear chondral lesion

Presentation• Young athlete with joint laxity• Baseball / volleyball / tennis –

shear injury• Medial pain mostly in

deceleration / follow-through

Exam• “Trochlear Shear Test” – pain

on MVST at 40-10o

6. Posteromedial impingement/Fracture osteophyte/Loose bodies

Presentation• Posteromedial pain mostly in

terminal extension• Loss of elbow extension• Mechanical symptoms

(catching/locking)

Exam• “Posterior Impingement Test” –

pain on passive terminal extension

Lateral elbow pain

• 25 yo female, soccer player• Fall onto outstretched arm

during slide tackle• Immediate pain, primarily

laterally• Swollen, painful ROM x weeks• Told “sprained” elbow• Lateral elbow pain lifting

backpack• Feels “click/pop” when

pushes up with it• Doesn’t trust her elbow

Lateral elbow pain DDx

• 6 causes of lateral elbow pain1. Posterolateral rotatory instability2. Lateral epicondyl”itis”/CEO tear3. P.I.N entrapment4. Radiocapitellar plica5. Capitellar OCD6. Radiocapitellar arthritis

1. Posterolateral rotatory instability

Presentation• History of:

– Previous trauma (dislocation, fracture-dislocation, sprain)

– Chronic attrition (long-standing cubitusvarus deformity, long-term crutch walkers)

– Iatrogenic injury (previous lateral sided elbow surgery)

• Instability may manifest as:– Recurrent dislocation– Subjective instability– Mechanical symptoms (snapping,

popping, catching)– Lateral sided elbow pain

• Difficulty with resisted elbow extension (pushing-up from seat)

• May be associated with lateral epidondylitis

Exam• Diagnostic Test(s)

– Posterolateral Rotatory Drawer Test

– Lateral Pivot-Shift Test– Lateral Pivot-Shift Apprehension

Sign– Push-Up Test

Posterolateral Rotatory Drawer Test

O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clinical Orthop Related Res. 2000 Jan;(37):34-43.

Lateral Pivot-Shift Test

O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow.J Bone Joint Surg Am. 1991 Mar;73(3):440-6.

2. Lateral epicondyl”itis”/CEO tear

Presentation• Chronic overuse (laborers,

computer use)• Pain with resisted wrist

extension/forearm supination• No history of instability• Acute episode of resisted

eccentric wrist extension / forearm supination

• Previous positive response to injections

• PLRI and lateral epicondylitis may coexist in the same patient

Exam• Tenderness lateral epicondyle

(ECRB origin)• Pain resisted wrist extension• Palpable defect at origin• Pain lifting laptop/folders out of

bag• T.E.S.T (Tennis Elbow Shear

Test)

3. PIN entrapment/Radial tunnel syndrome

Presentation• Pain located distal and radial

to the lateral epicondyle• Motor symptoms may occur

(rare)– Weakness in MCP joint extension– Radial deviation of the wrist when

wrist extension attempted

Exam• Tender 5-6 cm distal and

anterior to lateral epicondyle

4. Radiocapitellar plica

Presentation• Frequent history of trauma

(sprain, radial head fracture)• Normal range of motion• Painful lateral-sided

snapping/clicking– Usually between 90-110o of elbow

flexion with the forearm in pronation

Exam• Anterior

– Flexion-Pronation Plica Impingement Test

• Posterior– Extension-Supination Plica

Impingement Test

Anterolateral Plica - Flexion-Pronation PlicaImpingement Test

Antuna SA, O’Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy, 2001.

5. Capitellar OCD

Presentation• More common in pediatric

population• Throwing sports/Gymnastics• Associated stiffness (loss of

extension) and crepitus• Posterolateral pain• Occasional mechanical

symptoms (loose bodies)

Exam• “Capitellar Shear Test”

– valgus stress while moving, pain at ~45o

• Like MVST but in more extension and pain is lateral

6. Radiocapitellar OA

Presentation• Lateral elbow pain worsened

with gripping + rotation• Pain typically felt proximal

extensor muscles• Clicking and grinding with

rotation

Exam• Tender radiocapitellar joint• Crepitus with rotation• Resisted gripping + rotation

reproduces symptoms

Conclusions

• Physical examination of the elbow is a fundamental tool in the clinical diagnosis of elbow disorders

• The tests have to be performed correctly in order to be effective and preserve their accuracy

• Diagnosis of elbow pain can be determined with careful history and physical examination without need for imaging in most scenarios

Questions?

Anterior elbow pain

• 36 yo male, professional hockey goaltender

• Extended arm trying to make save

• Felt tearing sensation across arm

• Developed bruising down arm

• Anterior elbow pain with turning forearm

Anterior elbow pain DDx

• 5 causes of anterior elbow pain1. Distal biceps tear – partial or complete2. Cubital bursitis3. Bicipital tendonitis4. Anterior impingement syndrome5. Pronator syndrome

Distal biceps rupture

Presentation• Male patient• History of heavy weight-lifting• Sudden load on biceps

(usually eccentric)• Pop, tearing sensation• Anterior pain and weakness• Ecchymosis (proximal forearm)

delayed

Exam• May have altered biceps contour

(retracted)• No movement with pro-

supination (if rupture is complete)

• Bruising acutely• Weak supination – terminal• Pain/cramping with strength

testing/endurance• Diagnostic Test(s)

– “Hook Test”– Biceps crease interval– Squeeze test

Hook Test

O’Driscoll SW, Goncalves LBJ, Dietz P: The hook test for distal biceps tendonavulsion. Am J Sports Med. 35(11):1865-1869, 2007.

• Elbow flexed 90o, forearm fully supinated actively –examiner reaches under biceps tendon with index finger to “hook” tendon

• Abnormal hook test (no tendon to hook) = biceps rupture

Biceps Crease Interval

ElMaraghy A, Devereaux M, Tsoi K. The biceps crease interval for diagnosing complete distal biceps tendon ruptures. Clin Orthop Relat Res. 2008 Sep;466(9):2255-62. Epub 2008 Jun 13.

Normal BCI 4.8 +/- 0.6 cm, BCR 1.0 +/- 0.1BCI >6 or BCR >1.2 Sensitivity 96%

Squeeze Test

Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis ofdistal biceps tendon ruptures. Clin Orthop Relat Res. 2005 Aug;(437):128-31.