1. Elbow Examination
John M. Lavelle, D.O.

2. Anatomy

3. Bones Bones: 3 articulations: Humerus, ulnar, radius
Trochlear, coronoid,
capitellum, radial head
3 articulations:
Radiocapitellar joint
Ulnarhumeral joint
Proximal radioulnar

5. Ligaments

6. Muscles

7. Muscles

8. Epicondyles

9. Nerves: Ulnar Nerve: Median Nerve:
Passes behind the medial epicondyles and lies over ulnar collateral ligament and under bicipital aponeurosis and pronator teres.
Median Nerve:
Passes medial to the brachial artery, in front of the point of insertion of the brachialis muscle and deep to the biceps.

10. Nerves
Radial Nerve:
Passes posterior to the distal humerus.

11. Observe Effusions Cubital vein Muscles Scars Deformity Bursitis
Fistula
Thrombus
Muscles
Tear
Scars
Track marks
Deformity
Dislocations

12. Palpate Active ROM & Passive ROM Lateral Epicondyle Medial Epicondyle
Flexion: 0° to 160°
Pronation: 80°
Supination: 85°
Include ab/adduction
Appreciate crepitus, tenderness
Lateral Epicondyle
Brachioradialis, ECRL, ECRB, EDC
Medial Epicondyle
Pronator teres, FCR, PL, FDS, FCU

13. Palpate Olecranon Radial head Ulnar nerve
Bursa
Radial head
Superior/Inferior dysfunction
Ulnar nerve
Dislocation
Biceps tendon and Triceps tendon
Cubital fossa syndrome,
Clicking triceps syndrome
Forearm tension
Muscles
Fascia

14. Neuro Exam MMT Sensation
Biceps, Triceps, Wrist Extensors, Flexion of 3rd DIP joint, Abduction of digiti minimi
Sensation
Radial, median, ulnar, medial/lateral/posterior antebrachial cutaneous nerves

15. Muscle Tests Lateral Epicondylitis Medial Epicondylitis Distal Bicep
Resisted third digit extension – worsens pain as it tightens fascia over ECRB
Resisted wrist extension- ECRB (Cozen’s test)
Medial Epicondylitis
Resisted wrist flexion- FCR (Cozen’s Test)
Distal Bicep
Yergason’s test
Triceps
Resisted elbow extension
Pronator Syndrome - Median Neuropathy
Resisted forearm pronation

16. Ulnar Collateral ligament
Palpate optimally at 30-60° flexion

17. Ulnar Collateral ligament
Milking Maneuver:
Arm at 70° and elbow at 90°, a valgus pressure is applied by supporting the elbow and placing traction on the thumb…like milking a cow.
Moving valgus stress test:
Shoulder abducted to 90° and elbow flexed fully, apply a valgus force to the elbow, until shoulder fully externally rotated. While maintaining valgus pressure elbow is quickly extended.

18. Ulnar Collateral Ligament
Valgus Stress:
Patient sitting with the elbow flexed to 20 to 30°. Examiner stands with distal hand around the athlete's wrist (medially) and the proximal hand over the athlete's elbow joint (laterally) Examiner stabilizes the wrist and applies a valgus stress to the elbow with the proximal hand

19. Lateral Collateral Ligaments
Radial Collateral Ligament
Lateral Ulnar Collateral Ligament
Acc. Lateral Collateral Ligament
Annular Ligament

20. Lateral Collateral Ligaments
                                                           
Lateral Collateral Ligaments
Pivot Shift Test:
Nursemaid Elbow
Performed with the patient in the supine position, with the affected arm positioned overhead. The wrist and the elbow are lightly forced into supination while a valgus strain is applied to the elbow as it is moved from extension to flexion and back again. A positive test result is an apprehension response by the patient and/or frank subluxation or dislocation with a "clunk" as the radial head reduces during manipulation.

21. Ulnar Nerve Flexion Test Tinel sign Pinch Grip Test
Athlete maximally flexes the elbow and holds the position for 3 to 5 minutes. Radiating pain into the median nerve distribution in the athlete's arm and/or hand – Cubital Fossa Syndrome
Passive Flexion Test/Ulnar nerve subluxation test
As above but move elbow into flexion/extension
Can palpate snapping triceps and/or ulnar nerve over medial epicondyle
Tinel sign
Patient sitting with the elbow in slight flexion. Examiner grasps athlete's wrist (laterally) with distal hand. Examiner stabilizes the wrist and taps on the ulnar nerve in the ulnar notch with the index finger
Pinch Grip Test
Patient sitting or standing. Examiner instructs patient to pinch the tips of the thumb and index finger together – Positive test shows anterior interosseous nerve impinged between the two heads of the pronator muscle.

22. Thank You!