CURRENT CONCEPTS
Examination of the Elbow: Current Concepts Michael R. Hausman, MD, Penelope Lang, MD
The elbow’s complex anatomy and synergism of bony and ligamentous stabilizers make physical examination challenging. Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment. Isolated elbow injuries are rare; fractures should be interpreted as proxies for associated, often unappreciated, soft tissue injuries. A careful elbow examination informs the need for and interpretation of radiological studies, including fluoroscopy, magnetic resonance imaging, and computed tomography scanning. (J Hand Surg Am. 2014;39:2534e2541. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow, examination, instability, ulnar nerve, biceps.
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3 articulations, medial and lateral ligamentous complexes, common tendons of origin for the flexor and extensor muscles, and capsule. When a patient presents with elbow pathology, one or more of these components can be involved. In addition, the elbow is a common site of nerve compression or iatrogenic nerve injury. Prior to physical examination, a complete medical history should be obtained, including activities, occupation, comorbidities (eg, systemic disease, osteoarthritis), and prior elbow surgery. This useful information helps to narrow the differential diagnosis. Even a remote history of childhood injury may be important, and any treatment that may have altered the normal course of the ulnar nerve must be considered. Common chief complaints include pain, locking, instability, stiffness, snapping, or deterioration in sport performance (especially in the overhead-throwing athlete). Pain, associated with arthrosis, should be carefully characterized as affecting the entire arc of motion or just terminal flexion and extension, because the latter can be indicative of HE ELBOW JOINT CONSISTS OF
From the Department of Orthopedic Surgery, Mount Sinai Medical Center, New York, NY.
Current Concepts
Received for publication March 10, 2014; accepted in revised form April 6, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael R. Hausman, MD, Hand and Elbow Surgery, Mount Sinai Medical Center, 5 East 98th Street, 9th Floor, New York, NY 10029; e-mail: michael. [email protected]. 0363-5023/14/3912-0035$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.028
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osteophyte impingement that can be improved with debridement. GENERAL ELBOW EXAMINATION Physical examination of the elbow should begin with assessing the shoulder, wrist, and hand. Comparison with the contralateral side may be helpful in diagnosing more subtle losses of motion, muscle weakness, or atrophy. Inspection The overall alignment of the limb is observed, noting any abnormality in carrying angle with the normal average valgus angle of 11 to 14 for men and 13 to 16 for women. A flexion contracture may obscure an abnormal carrying angle. Muscle hypertrophy or atrophy is noted, as are any cutaneous presentations of disease (eg, nodules, rashes), trauma (eg, ecchymosis, swelling), or scars from prior incisions. Ecchymosis along the distal brachium may be a sign of distal biceps rupture, although it is not always present, especially if confined deep to the lacertus fibrosus. Medial ecchymosis is frequently a sign of medial collateral ligament (MCL) rupture because of blood vessels along the posterior MCL forming the floor of the cubital tunnel. The ulnar nerve is palpable in the retrocondylar groove, posterior and distal to the medial epicondyle, allowing confirmation of the course of the nerve as well as palpation for tenderness and a Tinel sign (which should be compared with the contralateral side). Subluxation or dislocation of the ulnar nerve with elbow flexion and extension is evaluated.
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On the lateral aspect of the elbow, the soft spot (the triangular region bordered by the olecranon, radial head, and lateral epicondyle) normally has a subtle concavity, and a joint effusion is best seen in this area, especially when compared with the contralateral side. When the elbow capsule is distended, the elbow most commonly rests in a position of approximately 80 of flexion, maximizing potential capsular volume.1 Posteriorly, olecranon bursitis can cause significant swelling, and olecranon fracture and triceps rupture can also be associated with swelling and a palpable defect. Triceps tendon rupture can be overlooked because continuity of the lateral fascia and anconeus muscle can preserve elbow extension, masking the tendon rupture.
TABLE 1. Examination Maneuvers for Diagnosis of Elbow Pathology
Range of motion Normal elbow motion is from 0 to 140 of flexion and 80 of pronation and supination. A functional range of motion is 30 of extension to 130 of flexion and 50 of pronation and supination.2,3 If there is loss of elbow range of motion, the examiner should look for crepitus or pain either at the extremes or at the midarc of motion. Also, the presence of either a firm or a soft endpoint should be observed during flexion and extension, because these suggest different pathologies (eg, osteophytes cause a firm endpoint, whereas an effusion causes a soft endpoint).
Posterolateral rotatory instability
Condition Distal biceps rupture
Examination Maneuver Hook test Biceps squeeze test Biceps crease interval Passive pronation supination test
MCL tear
Valgus stress test Milking maneuver Moving valgus stress test
CubTS
Tinel sign Elbow flexion test SIRT Scratch collapse test
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Push-up test Stand-up test/chair push-up test Table-top relocation test Lateral elbow tendinopathy
Chair test
Triceps rupture
Triceps squeeze test
biceps tendon. The biceps tendon is palpated laterally rather than medially to reduce the chance of hooking around a still intact lacertus fibrosus. For the experienced examiner, this test is both easily performed and found to be 100% sensitive and 100% specific for complete distal biceps tendon rupture.4 A negative hook test with pain on resisted supination and tenderness at the distal biceps tendon may indicate partial biceps tendon tear, tendinosis, or inflammation of the biceps bursa.3 The biceps squeeze test is similar to the Thompson test for Achilles tendon rupture. With external compression placed on the biceps muscle, the forearm is supinated if the biceps tendon is intact. With slight pronation of the forearm and the elbow flexed at 60 to 80 (to allow for spatial separation of the biceps from the relaxed brachialis), the examiner firmly squeezes the biceps with 2 hands (1 on the myotendinous region of the biceps and the other on the belly of the muscle). Lack of supination of the forearm indicates a positive test, which is 96% sensitive for tear of the distal biceps tendon.5 The biceps crease interval was described as an objective measurement that can help diagnose a tendon rupture. It relies on the proximal retraction of the biceps muscle for diagnosis. The distance from the antecubital crease of the elbow to the cusp of the distal aspect of the Vol. 39, December 2014
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ELBOW EXAMINATION BY ANATOMICAL REGIONS Anterior elbow Distal biceps tendon rupture: Although distal bicep tendon ruptures usually present with loss of normal contour of the arm, absence of the palpable distal biceps tendon, swelling, ecchymosis, and pain and weakness with flexion and supination of the forearm, the diagnosis can be missed. This is especially true in muscular patients in whom a large brachialis muscle may obscure the biceps findings. Provocative tests that readily and reliably diagnose distal biceps tears have been developed (Table 1). O’Driscoll et al4 described the hook test as highly sensitive and specific for diagnosing distal biceps ruptures. With the patient’s shoulder abducted and the elbow flexed at 90 , the examiner hooks a finger around the lateral side of the distal biceps tendon while the patient actively supinates the forearm (Fig. 1). By having the patient supinate the forearm without actively flexing the elbow, an intact biceps tendon becomes more prominent, while the brachialis muscle remains relaxed and is less likely to be mistaken for the
Lateral pivot shift test
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FIGURE 1: The hook test as described by Driscoll et al.4 The patient’s shoulder is abducted, the elbow is flexed to 90 , and the forearm is actively supinated. The examiner hooks her or his index finger laterally around the distal biceps tendon to demonstrate its presence.
Current Concepts
biceps muscle belly is measured: an absolute value of greater than 6 cm or a ratio of the noninjured to the injured arms of greater than 1.2 indicates a ruptured tendon with 96% sensitivity and 93% specificity.6 The passive pronation supination test is performed with the elbow supported in 90 of flexion. The biceps muscle is palpated while the forearm is passively pronated and supinated. Proximal excursion of the biceps with supination and distal migration with pronation indicates an intact distal biceps tendon.7 Devereaux and ElMaraghy8 found that a clearly positive hook test, passive pronation supination test, and biceps crease interval ratio are 100% sensitive and 100% specific in diagnosis of a distal biceps rupture. If results from the 3 examination maneuvers are equivocal, magnetic resonance imaging is indicated to aid in diagnosis.8 Medial elbow MCL injury: MCL injuries of the elbow are commonly seen in overhead-throwing athletes or with major elbow trauma. The anterior bundle of the MCL is the primary
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stabilizer to valgus stress within the midarc range of elbow motion.9,10 The patient often presents with complaints of acute onset of medial elbow pain associated with a “pop” during overhead throwing activity, with inability to continue to throw or chronic medial elbow pain during the late cocking to early acceleration phases of the throw and a progressive loss in accuracy, endurance, and velocity. These athletes are frequently taller and heavier, although it is unclear if the risk of injury is related to increased strength of the athlete or a longer forearm lever that generates larger valgus forces on the elbow.11 Traumatic MCL tears involving the posterior band of the ligament frequently present with ecchymosis. However, sports-related injuries of the anterior band or chronic overload injuries usually do not cause bleeding. Tenderness to palpation over the course of the MCL is 81% to 94% sensitive but only 22% specific for a tear.9 Chronic injury often presents with flexor-pronator tendinopathy with pain when gripping. Other associated pathologies of chronic MCL injury include ulnar neuropathy and valgus extension overload syndrome that can lead to painful radiocapitellar overload and posterior compartment pain and impinging osteophytes. In a study of 29 baseball players, glenohumeral internal rotation deficit (GIRD) is encountered in athletes with MCL insufficiency, with an average deficit of 28.5 .12 Diagnosis of GIRD in patients with MCL injuries has clinical importance because treating the shoulder pathology can prevent worsening of the MCL injury, and its presence alters the postoperative rehabilitation of MCL reconstruction. Multiple examination maneuvers (Table 1) aid in the diagnosis of MCL injury. In the valgus stress test, the examiner applies a valgus stress to the affected elbow, assessing for the lack of a firm endpoint or medial joint space opening. Examination is compared with the contralateral elbow. Traditionally, the test is done with the elbow at 20 to 30 of flexion to unlock the ulnohumeral joint and olecranon. However, a cadaveric study determined that the elbow is most unstable when valgus stress is applied at 70 of elbow flexion.13 More recently, Safran et al,14 in another cadaveric study, determined that valgus laxity was greatest with the forearm in neutral position compared with pronation or supination. They found no difference when the elbow was at 30 , 50 , or 70 of flexion. Overall, the original valgus stress test has been found to be 66% sensitive and 60% specific for detecting injuries to the anterior band of the MCL.9
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The milking maneuver tests the integrity of the posterior band of the anterior oblique portion of the MCL. With the forearm supinated and the shoulder extended, the elbow is flexed beyond 90 and a valgus stress is applied by pulling on the patient’s thumb with the other hand. A positive result is suggested when the patient reports medial joint pain, apprehension, or instability. A modification to this test removes the shoulder as a confounding variable and places the elbow in a position of maximal valgus laxity.9,13 The patient’s shoulder is adducted with maximal external rotation and the patient’s elbow is flexed at 70 while the examiner’s hand supports the elbow using his or her thumb to palpate the medial joint space and detect any widening9 (Fig. 2A). O’Driscoll et al15 described the moving valgus stress test that was 100% sensitive and 75% specific for detecting MCL tears when compared with surgical exploration or arthroscopic examination with valgus. In this dynamic examination maneuver, the patient’s shoulder is abducted and externally rotated as the examiner applies a constant moderate valgus torque to the flexed elbow and then quickly extends the elbow (Fig. 2B). Medial-sided elbow pain (from which the patient often withdraws) at the midarc of motion between 120 and 70 suggests a positive result. The mean angle with maximal pain is 90 . This dynamic test incorporates multiple stresses on the elbow in addition to valgus stress, and more accurately mimics the stress on the MCL during overhead throwing, providing a more sensitive and specific test. J Hand Surg Am.
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Cubital tunnel syndrome: The ulnar nerve should always be evaluated during the medial elbow examination. Neuropathy can occur alone or be associated with other elbow pathology. Multiple provocative maneuvers have been developed to diagnose cubital tunnel syndrome (CubTS) (Table 1). The Tinel sign is 54% to 70% sensitive16 and was found to be positive in 23.5% to 34% of normal volunteers.17,18 In the elbow flexion test, the patient’s elbow is passively maximally flexed, with the shoulder and wrist in neutral position for 1 to 3 minutes. Paresthesias in the ulnar nerve distribution indicate a positive result. The test has been found to be 46% to 75% sensitive, with sensitivity increasing as the testing continues from 1 to 3 minutes.16 Ten percent to 20% of normal elbows have tested positive with this maneuver.17,18 The shoulder internal rotation test (SIRT) can diagnose CubTS with a sensitivity of 80% in 10 seconds19 versus the elbow flexion test, which would require 3 minutes to reach similar sensitivities. At 10 seconds, the elbow flexion test was only 36% sensitive. The SIRT is performed with the patient’s shoulder at 90 abduction, maximum internal rotation, 10 flexion. The elbow is held at 90 of flexion with neutral position of the forearm and wrist and finger extension. Results are positive if any paresthesias or pain in the ulnar nerve distribution due to CubTS presents within 10 seconds.19 Although the exact mechanism of SIRT is unknown, it is a useful provocative test, requiring much less time than the elbow flexion test. Vol. 39, December 2014
Current Concepts
FIGURE 2: A Modified milking maneuver.9 The patient’s elbow is flexed to 70 while his or her shoulder is adducted and maximally externally rotated. The examiner applies a valgus stress by pulling on the patient’s thumb while using the other hand to palpate the medial joint space to detect any opening. B The moving valgus stress test is a dynamic maneuver. With the patient’s shoulder abducted and externally rotated, a moderate valgus torque is applied to the flexed elbow. The elbow is then quickly extended. Medial-sided elbow pain, during the midarc range of motion of the elbow (70 e120 ), indicates an MCL tear.15
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result (Fig. 4). This test was found to be 69% sensitive and 99% specific for diagnosis of CubTS,21 better than the Tinel sign (54% sensitive) or elbow flexion test (46% sensitive). After trauma to the MCL, such as that associated with dislocation or olecranon fracture, scarring of the middle and posterior sections of the MCL can occur, resulting in loss of the normal concavity or sulcus between the medial epicondyle and the olecranon. A positive sulcus sign means that the normal dimensions of the cubital tunnel may be narrowed, putting the ulnar nerve at risk during flexion. The ulnohumeral concavity should always be examined and, if diminished, constitutes an indication for ulnar nerve decompression during contracture treatment.
FIGURE 3: A modification of the elbow flexion test in which the shoulder is internally rotated.20
Current Concepts
Ochi et al20 described a modification for the elbow flexion test in which the shoulder is internally rotated, combining the elbow flexion test and SIRT (Fig. 3). They found that with the shoulder positioned at 90 abduction, 10 flexion, and maximal internal rotation and the elbow maximally flexed with the wrist extended, the patient’s symptoms were provoked within 5 seconds with 87% sensitivity and 97% specificity, providing a more rapid and useful method of diagnosis. The scratch collapse test was developed based on the concept that a painful cutaneous stimulus causes a period of inhibition in voluntary muscle activity. This mechanism is poorly understood but can diagnose CubTS.21 This is the only CubTS examination maneuver that does not rely on the patient’s report of pain or paresthesias for diagnosis, but rather on the examiner objectively noting a change in muscle tone. The patient faces the examiner with arms adducted, elbows flexed, and hands outstretched with wrists in the neutral position. The examiner places an adduction and internal rotation force on the patient’s forearm as she or he resists. Then the examiner scratches the medial aspect of the affected elbow in the region of the ulnar nerve. The examiner then immediately repeats the adduction and internal rotation force on the patient’s forearm. Any loss of the patient’s external rotation strength in the affected limb indicates a positive J Hand Surg Am.
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Lateral elbow Posterolateral rotatory instability: Posterolateral rotatory instability (PLRI) is the most common form of recurrent instability of the elbow. PLRI usually occurs following a traumatic event or iatrogenic injury to the lateral ulnar collateral ligament (LUCL) during an overzealous tennis elbow release. In this condition, instability of the radiocapitellar joint leads to posterior subluxation or even dislocation of the radial head. Historically, the lateral pivot shift test has been used to diagnose PLRI (Table 1). With the patient supine, the arm overhead, the shoulder in full external rotation, and the forearm fully supinated, the examiner applies an axial load and valgus stress to the elbow as it is brought from extension to flexion. As the elbow is flexed, the radiocapitellar joint reduces with a palpable clunk. Rotatory displacement is maximized at 40 of flexion, and the awake patient reports apprehension at that moment.22 A cadaveric study among physicians of various skill levels found that the lateral pivot shift test is a mechanically reproducible clinical examination.23 However, the examination maneuver is more difficult and less sensitive in the awake patient. Regan and Lapner24 found that this test is 100% sensitive in the anesthetized patient but only 38% in the awake patient, likely owing to guarding and secondary muscle stabilizers. The push-up, stand-up, and table-top relocation tests were developed as easier-to-perform alternatives to the lateral pivot shift test in the awake patient. In the push-up test, the patient attempts a push-up in the prone position with the forearm maximally supinated and again with the forearm maximally pronated. A positive result occurs when the symptoms of apprehension or radial head dislocation recur with the supinated forearm as the elbow extends3,24 (Fig. 5A). Vol. 39, December 2014
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FIGURE 4: Scratch collapse test.21 A The patient resists the examiner’s internal rotation force. B The examiner scratches the medial aspect of the affected arm C and then immediately applies the same internal rotation force to the forearms and detects any weakness in external rotation strength in the affected arm.
In the stand-up (or chair push-up) test, symptoms are reproduced in the affected elbow as the patient attempts to stand up from a seated position using his or her arms to push against the chair while rising. During the test, the patient’s arms are abducted, elbows flexed to 90 , and forearms supinated (Fig. 5B). The push-up and stand-up tests were found to be 87.5% sensitive when employed individually and 100% when employed together.24 In the table-top relocation test, the patient places the affected arm on the lateral edge of the table. Initially, with the elbow pointing laterally and the forearm in supination, the arm is axially loaded through the hand onto the table as the elbow is allowed to flex. In a J Hand Surg Am.
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patient with PLRI, apprehension and pain occur as the elbow reaches 40 of flexion. The maneuver is then repeated with the examiner placing a thumb over the radial head to prevent posterior subluxation of the radial head, thus eliminating the symptoms. The examiner then removes her or his thumb from the weight-bearing partially flexed elbow, allowing the radial head to sublux and reproducing the pain and apprehension. The table-top relocation test, specifically the presence of apprehension while first preventing and then allowing the radial head to sublux, confirms the pathology as instability rather than an intra-articular condition, theoretically making it a more specific test than the push-up or stand-up tests.25 Vol. 39, December 2014
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FIGURE 5: A The push-up test.24 The patient attempts a push up while the affected forearm is supinated. B The stand-up or chair pushup test.24 The patient’s arms are abducted, the elbows are flexed to 90 , and the forearms are supinated while the patient uses her or his arms to stand from a seated position. For both tests, the patient with posterolateral rotatory instability will experience apprehension or dislocation of the radial head as the elbow extends.
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Lateral elbow tendinopathy/radial tunnel syndrome: Generally, lateral elbow tendinopathy presents with an insidious onset of lateral elbow pain due to overuse of wrist extensors.3,26 On examination, there is tenderness to palpation just anterior and distal to the lateral epicondyle at the site of the extensor carpi radialis brevis tendon origin.3,26,27 The pain can be elicited with resisted wrist extension, middle finger extension and forearm supination with the elbow in the extended position.3,26,28 The chair test (Table 1) is positive when lateral elbow pain is reproduced by lifting a chair with the arm in the pronated position.26,27 Dorf et al29 found that grip strength was 83% accurate in determining the affected from the unaffected elbow in patients with lateral epicondylitis when it was decreased by 8% on the affected side. The differential diagnosis for patients with lateral elbow symptoms includes radial tunnel syndrome (RTS) or intra-articular pathology such as radiocapitellar arthrosis or a plica. On physical examination, patients with RTS have tenderness to palpation 4 to 6 cm distal to the lateral epicondyle and pain with resisted supination while the shoulder is adducted and elbow flexed to 90 .30,31 Posterior interosseous nerve irritation is associated with vague aching in the wrist or forearm that is not characteristic of lateral tendinosis. A snapping plica can be palpated as the elbow is moved from extension and supination to flexion and pronation.32
Current Concepts
Posterior elbow Triceps tendon rupture: Triceps tendon rupture is a rare injury that is often misdiagnosed. It usually occurs from eccentric contraction associated with falling on an outstretched arm, although it can occur after direct trauma to the posterior arm or in weightlifters.3,33,34 Diagnosis of acute triceps rupture can be hampered by pain and swelling that may limit the ability of the examiner to palpate a defect in the tendon. With the aid of gravity, the anconeus triceps expansion may make it possible for the patient to extend the elbow.3 Placing the elbow over the patient’s head forces the patient to extend the elbow against gravity and is a more effective way to detect weakness in extension against resistance. A triceps squeeze test (Table 1), similar to the Thompson test for the Achilles, can be performed, although the sensitivity and specificity of these examination maneuvers have not been reported. A conclusive diagnosis may require ultrasound or magnetic resonance imaging. In conclusion, physical examination of the elbow continues to evolve and remains the basis for diagnosis of elbow pathology. Whereas this review highlights J Hand Surg Am.
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recent developments in physical examination methods for diagnosis of distal biceps rupture, MCL injury, CubTS, and PLRI, a comprehensive examination includes conventional maneuvers to diagnose a wide variety of elbow pathologies. REFERENCES 1. O’Driscoll SW, Morrey BF, An KN. Intraarticular pressure and capacity of the elbow. Arthroscopy. 1990;6(2):100e103. 2. Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39(2):141e154. 3. Hsu SH, Moen TC, Levine WN, Ahmad CS. Physical examination of the athlete’s elbow. Am J Sports Med. 2012;40(3):699e708. 4. O’Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865e1869. 5. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of tendon ruptures. Clin Orthop Relat Res. 2005;437: 128e131. 6. ElMaraghy A, Devereaux M, Tsoi K. The biceps crease interval for diagnosing complete distal biceps tendon ruptures. Clin Orthop Relat Res. 2008;466(9):2255e2262. 7. Harding WG III. A new clinical test for avulsion of the insertion of the biceps tendon. Orthopaedics. 2005;28(1):27e29. 8. Devereaux MW, ElMaraghy AW. Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med. 2013;41(9): 1998e2004. 9. Hariri S, Safran MR. Ulnar collateral ligament injury in overhead athlete. Clin Sports Med. 2010;29(4):619e644. 10. Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 2001;9(2): 99e113. 11. Han KJ, Kim YK, Lim SK, Park JY, Oh KS. The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging. Clin J Sport Med. 2009;19(4):271e276. 12. Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Am J Sports Med. 2009;37(3):566e570. 13. Sojbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987;218:186e190. 14. Safran MR, McGarry MH, Shin S, Han S, Lee TQ. Effects of elbow flexion and forearm rotation on valgus laxity of the elbow. J Bone Joint Surg Am. 2005;87(9):2065e2074. 15. O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231e239. 16. Hutchinson RL, Rayan G. Diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(9):1519e1521. 17. Kuschner SH, Ebramzadeh E, Mitchell S. Evaluation of elbow flexion and Tinel tests for cubital tunnel syndrome in asymptomatic individuals. Orthopedics. 2006;29(4):305e308. 18. Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg Am. 1992;17(1):86e89. 19. Ochi K, Horiuchi Y, Tenabe A, Mortia K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782e787. 20. Ochi K, Horiuchi Y, Tenabe A, Waseda M, Kuneko Y, Koyanagi T. Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome. J Shoulder Elbow Surg. 2012;21(6):777e781. 21. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am. 2008;33(9):1518e1524.
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28. Rineer C, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. 2009;34(3): 566e576. 29. Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME. Effect of elbow position on grip strength in the evaluation of lateral epicondylitis. J Hand Surg Am. 2007;32(6):882e886. 30. Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am. 2007;32(8):1271e1279. 31. Knutsen EJ, Calfee RP. Uncommon upper extremity compression neuropathies. Hand Clin. 2013;29(3):443e453. 32. Antuna SA, O’Driscoll SQ. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001;17(5):491e495. 33. Tom JA, Kumar NS, Cerynik DL, Mashru R, Parrella MS. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014;24(3):197e204. 34. van Riet RP, Morrey BF, Ho E, O’Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am. 2003;85(10): 1961e1967.
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22. Anakwenze OA, Kancherla VK, Iyengar J, Ahmad CS, Levine WN. Posterolateral rotatory instability of the elbow. Am J Sports Med. 2014;42(2):485e491. 23. Lattanza LL, Chu T, Ty JM, et al. Interclinician and intraclinician variability in the mechanics of the pivot shift test for posterolateral rotatory instability (PLRI) of the elbow. J Shoulder Elbow Surg. 2010;19(8):1150e1156. 24. Regan W, Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow. J Shoulder Elbow Surg. 2006;15(3):344e346. 25. Arvind C, Hargreaves DS. Tabletop relocation test: a new clinical test for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg. 2006;15(6):707e708. 26. Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, TytherweighStrong G, Ruston M. Lateral epicondylitis. A review of pathology and management. Bone Joint J. 2013;95(9):1158e1164. 27. Tosti R, Jennings J, Sewards JM. Lateral epicondyltitis of the elbow. Am J Med. 2013;126(4):357.e1e6.
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Examination of the Elbow: Current Concepts Michael R. Hausman, MD, Penelope Lang, MD
The elbow’s complex anatomy and synergism of bony and ligamentous stabilizers make physical examination challenging. Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment. Isolated elbow injuries are rare; fractures should be interpreted as proxies for associated, often unappreciated, soft tissue injuries. A careful elbow examination informs the need for and interpretation of radiological studies, including fluoroscopy, magnetic resonance imaging, and computed tomography scanning. (J Hand Surg Am. 2014;39:2534e2541. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow, examination, instability, ulnar nerve, biceps.
T
3 articulations, medial and lateral ligamentous complexes, common tendons of origin for the flexor and extensor muscles, and capsule. When a patient presents with elbow pathology, one or more of these components can be involved. In addition, the elbow is a common site of nerve compression or iatrogenic nerve injury. Prior to physical examination, a complete medical history should be obtained, including activities, occupation, comorbidities (eg, systemic disease, osteoarthritis), and prior elbow surgery. This useful information helps to narrow the differential diagnosis. Even a remote history of childhood injury may be important, and any treatment that may have altered the normal course of the ulnar nerve must be considered. Common chief complaints include pain, locking, instability, stiffness, snapping, or deterioration in sport performance (especially in the overhead-throwing athlete). Pain, associated with arthrosis, should be carefully characterized as affecting the entire arc of motion or just terminal flexion and extension, because the latter can be indicative of HE ELBOW JOINT CONSISTS OF
From the Department of Orthopedic Surgery, Mount Sinai Medical Center, New York, NY.
Current Concepts
Received for publication March 10, 2014; accepted in revised form April 6, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael R. Hausman, MD, Hand and Elbow Surgery, Mount Sinai Medical Center, 5 East 98th Street, 9th Floor, New York, NY 10029; e-mail: michael. [email protected]. 0363-5023/14/3912-0035$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.028
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osteophyte impingement that can be improved with debridement. GENERAL ELBOW EXAMINATION Physical examination of the elbow should begin with assessing the shoulder, wrist, and hand. Comparison with the contralateral side may be helpful in diagnosing more subtle losses of motion, muscle weakness, or atrophy. Inspection The overall alignment of the limb is observed, noting any abnormality in carrying angle with the normal average valgus angle of 11 to 14 for men and 13 to 16 for women. A flexion contracture may obscure an abnormal carrying angle. Muscle hypertrophy or atrophy is noted, as are any cutaneous presentations of disease (eg, nodules, rashes), trauma (eg, ecchymosis, swelling), or scars from prior incisions. Ecchymosis along the distal brachium may be a sign of distal biceps rupture, although it is not always present, especially if confined deep to the lacertus fibrosus. Medial ecchymosis is frequently a sign of medial collateral ligament (MCL) rupture because of blood vessels along the posterior MCL forming the floor of the cubital tunnel. The ulnar nerve is palpable in the retrocondylar groove, posterior and distal to the medial epicondyle, allowing confirmation of the course of the nerve as well as palpation for tenderness and a Tinel sign (which should be compared with the contralateral side). Subluxation or dislocation of the ulnar nerve with elbow flexion and extension is evaluated.
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On the lateral aspect of the elbow, the soft spot (the triangular region bordered by the olecranon, radial head, and lateral epicondyle) normally has a subtle concavity, and a joint effusion is best seen in this area, especially when compared with the contralateral side. When the elbow capsule is distended, the elbow most commonly rests in a position of approximately 80 of flexion, maximizing potential capsular volume.1 Posteriorly, olecranon bursitis can cause significant swelling, and olecranon fracture and triceps rupture can also be associated with swelling and a palpable defect. Triceps tendon rupture can be overlooked because continuity of the lateral fascia and anconeus muscle can preserve elbow extension, masking the tendon rupture.
TABLE 1. Examination Maneuvers for Diagnosis of Elbow Pathology
Range of motion Normal elbow motion is from 0 to 140 of flexion and 80 of pronation and supination. A functional range of motion is 30 of extension to 130 of flexion and 50 of pronation and supination.2,3 If there is loss of elbow range of motion, the examiner should look for crepitus or pain either at the extremes or at the midarc of motion. Also, the presence of either a firm or a soft endpoint should be observed during flexion and extension, because these suggest different pathologies (eg, osteophytes cause a firm endpoint, whereas an effusion causes a soft endpoint).
Posterolateral rotatory instability
Condition Distal biceps rupture
Examination Maneuver Hook test Biceps squeeze test Biceps crease interval Passive pronation supination test
MCL tear
Valgus stress test Milking maneuver Moving valgus stress test
CubTS
Tinel sign Elbow flexion test SIRT Scratch collapse test
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Push-up test Stand-up test/chair push-up test Table-top relocation test Lateral elbow tendinopathy
Chair test
Triceps rupture
Triceps squeeze test
biceps tendon. The biceps tendon is palpated laterally rather than medially to reduce the chance of hooking around a still intact lacertus fibrosus. For the experienced examiner, this test is both easily performed and found to be 100% sensitive and 100% specific for complete distal biceps tendon rupture.4 A negative hook test with pain on resisted supination and tenderness at the distal biceps tendon may indicate partial biceps tendon tear, tendinosis, or inflammation of the biceps bursa.3 The biceps squeeze test is similar to the Thompson test for Achilles tendon rupture. With external compression placed on the biceps muscle, the forearm is supinated if the biceps tendon is intact. With slight pronation of the forearm and the elbow flexed at 60 to 80 (to allow for spatial separation of the biceps from the relaxed brachialis), the examiner firmly squeezes the biceps with 2 hands (1 on the myotendinous region of the biceps and the other on the belly of the muscle). Lack of supination of the forearm indicates a positive test, which is 96% sensitive for tear of the distal biceps tendon.5 The biceps crease interval was described as an objective measurement that can help diagnose a tendon rupture. It relies on the proximal retraction of the biceps muscle for diagnosis. The distance from the antecubital crease of the elbow to the cusp of the distal aspect of the Vol. 39, December 2014
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ELBOW EXAMINATION BY ANATOMICAL REGIONS Anterior elbow Distal biceps tendon rupture: Although distal bicep tendon ruptures usually present with loss of normal contour of the arm, absence of the palpable distal biceps tendon, swelling, ecchymosis, and pain and weakness with flexion and supination of the forearm, the diagnosis can be missed. This is especially true in muscular patients in whom a large brachialis muscle may obscure the biceps findings. Provocative tests that readily and reliably diagnose distal biceps tears have been developed (Table 1). O’Driscoll et al4 described the hook test as highly sensitive and specific for diagnosing distal biceps ruptures. With the patient’s shoulder abducted and the elbow flexed at 90 , the examiner hooks a finger around the lateral side of the distal biceps tendon while the patient actively supinates the forearm (Fig. 1). By having the patient supinate the forearm without actively flexing the elbow, an intact biceps tendon becomes more prominent, while the brachialis muscle remains relaxed and is less likely to be mistaken for the
Lateral pivot shift test
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FIGURE 1: The hook test as described by Driscoll et al.4 The patient’s shoulder is abducted, the elbow is flexed to 90 , and the forearm is actively supinated. The examiner hooks her or his index finger laterally around the distal biceps tendon to demonstrate its presence.
Current Concepts
biceps muscle belly is measured: an absolute value of greater than 6 cm or a ratio of the noninjured to the injured arms of greater than 1.2 indicates a ruptured tendon with 96% sensitivity and 93% specificity.6 The passive pronation supination test is performed with the elbow supported in 90 of flexion. The biceps muscle is palpated while the forearm is passively pronated and supinated. Proximal excursion of the biceps with supination and distal migration with pronation indicates an intact distal biceps tendon.7 Devereaux and ElMaraghy8 found that a clearly positive hook test, passive pronation supination test, and biceps crease interval ratio are 100% sensitive and 100% specific in diagnosis of a distal biceps rupture. If results from the 3 examination maneuvers are equivocal, magnetic resonance imaging is indicated to aid in diagnosis.8 Medial elbow MCL injury: MCL injuries of the elbow are commonly seen in overhead-throwing athletes or with major elbow trauma. The anterior bundle of the MCL is the primary
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stabilizer to valgus stress within the midarc range of elbow motion.9,10 The patient often presents with complaints of acute onset of medial elbow pain associated with a “pop” during overhead throwing activity, with inability to continue to throw or chronic medial elbow pain during the late cocking to early acceleration phases of the throw and a progressive loss in accuracy, endurance, and velocity. These athletes are frequently taller and heavier, although it is unclear if the risk of injury is related to increased strength of the athlete or a longer forearm lever that generates larger valgus forces on the elbow.11 Traumatic MCL tears involving the posterior band of the ligament frequently present with ecchymosis. However, sports-related injuries of the anterior band or chronic overload injuries usually do not cause bleeding. Tenderness to palpation over the course of the MCL is 81% to 94% sensitive but only 22% specific for a tear.9 Chronic injury often presents with flexor-pronator tendinopathy with pain when gripping. Other associated pathologies of chronic MCL injury include ulnar neuropathy and valgus extension overload syndrome that can lead to painful radiocapitellar overload and posterior compartment pain and impinging osteophytes. In a study of 29 baseball players, glenohumeral internal rotation deficit (GIRD) is encountered in athletes with MCL insufficiency, with an average deficit of 28.5 .12 Diagnosis of GIRD in patients with MCL injuries has clinical importance because treating the shoulder pathology can prevent worsening of the MCL injury, and its presence alters the postoperative rehabilitation of MCL reconstruction. Multiple examination maneuvers (Table 1) aid in the diagnosis of MCL injury. In the valgus stress test, the examiner applies a valgus stress to the affected elbow, assessing for the lack of a firm endpoint or medial joint space opening. Examination is compared with the contralateral elbow. Traditionally, the test is done with the elbow at 20 to 30 of flexion to unlock the ulnohumeral joint and olecranon. However, a cadaveric study determined that the elbow is most unstable when valgus stress is applied at 70 of elbow flexion.13 More recently, Safran et al,14 in another cadaveric study, determined that valgus laxity was greatest with the forearm in neutral position compared with pronation or supination. They found no difference when the elbow was at 30 , 50 , or 70 of flexion. Overall, the original valgus stress test has been found to be 66% sensitive and 60% specific for detecting injuries to the anterior band of the MCL.9
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The milking maneuver tests the integrity of the posterior band of the anterior oblique portion of the MCL. With the forearm supinated and the shoulder extended, the elbow is flexed beyond 90 and a valgus stress is applied by pulling on the patient’s thumb with the other hand. A positive result is suggested when the patient reports medial joint pain, apprehension, or instability. A modification to this test removes the shoulder as a confounding variable and places the elbow in a position of maximal valgus laxity.9,13 The patient’s shoulder is adducted with maximal external rotation and the patient’s elbow is flexed at 70 while the examiner’s hand supports the elbow using his or her thumb to palpate the medial joint space and detect any widening9 (Fig. 2A). O’Driscoll et al15 described the moving valgus stress test that was 100% sensitive and 75% specific for detecting MCL tears when compared with surgical exploration or arthroscopic examination with valgus. In this dynamic examination maneuver, the patient’s shoulder is abducted and externally rotated as the examiner applies a constant moderate valgus torque to the flexed elbow and then quickly extends the elbow (Fig. 2B). Medial-sided elbow pain (from which the patient often withdraws) at the midarc of motion between 120 and 70 suggests a positive result. The mean angle with maximal pain is 90 . This dynamic test incorporates multiple stresses on the elbow in addition to valgus stress, and more accurately mimics the stress on the MCL during overhead throwing, providing a more sensitive and specific test. J Hand Surg Am.
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Cubital tunnel syndrome: The ulnar nerve should always be evaluated during the medial elbow examination. Neuropathy can occur alone or be associated with other elbow pathology. Multiple provocative maneuvers have been developed to diagnose cubital tunnel syndrome (CubTS) (Table 1). The Tinel sign is 54% to 70% sensitive16 and was found to be positive in 23.5% to 34% of normal volunteers.17,18 In the elbow flexion test, the patient’s elbow is passively maximally flexed, with the shoulder and wrist in neutral position for 1 to 3 minutes. Paresthesias in the ulnar nerve distribution indicate a positive result. The test has been found to be 46% to 75% sensitive, with sensitivity increasing as the testing continues from 1 to 3 minutes.16 Ten percent to 20% of normal elbows have tested positive with this maneuver.17,18 The shoulder internal rotation test (SIRT) can diagnose CubTS with a sensitivity of 80% in 10 seconds19 versus the elbow flexion test, which would require 3 minutes to reach similar sensitivities. At 10 seconds, the elbow flexion test was only 36% sensitive. The SIRT is performed with the patient’s shoulder at 90 abduction, maximum internal rotation, 10 flexion. The elbow is held at 90 of flexion with neutral position of the forearm and wrist and finger extension. Results are positive if any paresthesias or pain in the ulnar nerve distribution due to CubTS presents within 10 seconds.19 Although the exact mechanism of SIRT is unknown, it is a useful provocative test, requiring much less time than the elbow flexion test. Vol. 39, December 2014
Current Concepts
FIGURE 2: A Modified milking maneuver.9 The patient’s elbow is flexed to 70 while his or her shoulder is adducted and maximally externally rotated. The examiner applies a valgus stress by pulling on the patient’s thumb while using the other hand to palpate the medial joint space to detect any opening. B The moving valgus stress test is a dynamic maneuver. With the patient’s shoulder abducted and externally rotated, a moderate valgus torque is applied to the flexed elbow. The elbow is then quickly extended. Medial-sided elbow pain, during the midarc range of motion of the elbow (70 e120 ), indicates an MCL tear.15
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result (Fig. 4). This test was found to be 69% sensitive and 99% specific for diagnosis of CubTS,21 better than the Tinel sign (54% sensitive) or elbow flexion test (46% sensitive). After trauma to the MCL, such as that associated with dislocation or olecranon fracture, scarring of the middle and posterior sections of the MCL can occur, resulting in loss of the normal concavity or sulcus between the medial epicondyle and the olecranon. A positive sulcus sign means that the normal dimensions of the cubital tunnel may be narrowed, putting the ulnar nerve at risk during flexion. The ulnohumeral concavity should always be examined and, if diminished, constitutes an indication for ulnar nerve decompression during contracture treatment.
FIGURE 3: A modification of the elbow flexion test in which the shoulder is internally rotated.20
Current Concepts
Ochi et al20 described a modification for the elbow flexion test in which the shoulder is internally rotated, combining the elbow flexion test and SIRT (Fig. 3). They found that with the shoulder positioned at 90 abduction, 10 flexion, and maximal internal rotation and the elbow maximally flexed with the wrist extended, the patient’s symptoms were provoked within 5 seconds with 87% sensitivity and 97% specificity, providing a more rapid and useful method of diagnosis. The scratch collapse test was developed based on the concept that a painful cutaneous stimulus causes a period of inhibition in voluntary muscle activity. This mechanism is poorly understood but can diagnose CubTS.21 This is the only CubTS examination maneuver that does not rely on the patient’s report of pain or paresthesias for diagnosis, but rather on the examiner objectively noting a change in muscle tone. The patient faces the examiner with arms adducted, elbows flexed, and hands outstretched with wrists in the neutral position. The examiner places an adduction and internal rotation force on the patient’s forearm as she or he resists. Then the examiner scratches the medial aspect of the affected elbow in the region of the ulnar nerve. The examiner then immediately repeats the adduction and internal rotation force on the patient’s forearm. Any loss of the patient’s external rotation strength in the affected limb indicates a positive J Hand Surg Am.
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Lateral elbow Posterolateral rotatory instability: Posterolateral rotatory instability (PLRI) is the most common form of recurrent instability of the elbow. PLRI usually occurs following a traumatic event or iatrogenic injury to the lateral ulnar collateral ligament (LUCL) during an overzealous tennis elbow release. In this condition, instability of the radiocapitellar joint leads to posterior subluxation or even dislocation of the radial head. Historically, the lateral pivot shift test has been used to diagnose PLRI (Table 1). With the patient supine, the arm overhead, the shoulder in full external rotation, and the forearm fully supinated, the examiner applies an axial load and valgus stress to the elbow as it is brought from extension to flexion. As the elbow is flexed, the radiocapitellar joint reduces with a palpable clunk. Rotatory displacement is maximized at 40 of flexion, and the awake patient reports apprehension at that moment.22 A cadaveric study among physicians of various skill levels found that the lateral pivot shift test is a mechanically reproducible clinical examination.23 However, the examination maneuver is more difficult and less sensitive in the awake patient. Regan and Lapner24 found that this test is 100% sensitive in the anesthetized patient but only 38% in the awake patient, likely owing to guarding and secondary muscle stabilizers. The push-up, stand-up, and table-top relocation tests were developed as easier-to-perform alternatives to the lateral pivot shift test in the awake patient. In the push-up test, the patient attempts a push-up in the prone position with the forearm maximally supinated and again with the forearm maximally pronated. A positive result occurs when the symptoms of apprehension or radial head dislocation recur with the supinated forearm as the elbow extends3,24 (Fig. 5A). Vol. 39, December 2014
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FIGURE 4: Scratch collapse test.21 A The patient resists the examiner’s internal rotation force. B The examiner scratches the medial aspect of the affected arm C and then immediately applies the same internal rotation force to the forearms and detects any weakness in external rotation strength in the affected arm.
In the stand-up (or chair push-up) test, symptoms are reproduced in the affected elbow as the patient attempts to stand up from a seated position using his or her arms to push against the chair while rising. During the test, the patient’s arms are abducted, elbows flexed to 90 , and forearms supinated (Fig. 5B). The push-up and stand-up tests were found to be 87.5% sensitive when employed individually and 100% when employed together.24 In the table-top relocation test, the patient places the affected arm on the lateral edge of the table. Initially, with the elbow pointing laterally and the forearm in supination, the arm is axially loaded through the hand onto the table as the elbow is allowed to flex. In a J Hand Surg Am.
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patient with PLRI, apprehension and pain occur as the elbow reaches 40 of flexion. The maneuver is then repeated with the examiner placing a thumb over the radial head to prevent posterior subluxation of the radial head, thus eliminating the symptoms. The examiner then removes her or his thumb from the weight-bearing partially flexed elbow, allowing the radial head to sublux and reproducing the pain and apprehension. The table-top relocation test, specifically the presence of apprehension while first preventing and then allowing the radial head to sublux, confirms the pathology as instability rather than an intra-articular condition, theoretically making it a more specific test than the push-up or stand-up tests.25 Vol. 39, December 2014
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FIGURE 5: A The push-up test.24 The patient attempts a push up while the affected forearm is supinated. B The stand-up or chair pushup test.24 The patient’s arms are abducted, the elbows are flexed to 90 , and the forearms are supinated while the patient uses her or his arms to stand from a seated position. For both tests, the patient with posterolateral rotatory instability will experience apprehension or dislocation of the radial head as the elbow extends.
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Lateral elbow tendinopathy/radial tunnel syndrome: Generally, lateral elbow tendinopathy presents with an insidious onset of lateral elbow pain due to overuse of wrist extensors.3,26 On examination, there is tenderness to palpation just anterior and distal to the lateral epicondyle at the site of the extensor carpi radialis brevis tendon origin.3,26,27 The pain can be elicited with resisted wrist extension, middle finger extension and forearm supination with the elbow in the extended position.3,26,28 The chair test (Table 1) is positive when lateral elbow pain is reproduced by lifting a chair with the arm in the pronated position.26,27 Dorf et al29 found that grip strength was 83% accurate in determining the affected from the unaffected elbow in patients with lateral epicondylitis when it was decreased by 8% on the affected side. The differential diagnosis for patients with lateral elbow symptoms includes radial tunnel syndrome (RTS) or intra-articular pathology such as radiocapitellar arthrosis or a plica. On physical examination, patients with RTS have tenderness to palpation 4 to 6 cm distal to the lateral epicondyle and pain with resisted supination while the shoulder is adducted and elbow flexed to 90 .30,31 Posterior interosseous nerve irritation is associated with vague aching in the wrist or forearm that is not characteristic of lateral tendinosis. A snapping plica can be palpated as the elbow is moved from extension and supination to flexion and pronation.32
Current Concepts
Posterior elbow Triceps tendon rupture: Triceps tendon rupture is a rare injury that is often misdiagnosed. It usually occurs from eccentric contraction associated with falling on an outstretched arm, although it can occur after direct trauma to the posterior arm or in weightlifters.3,33,34 Diagnosis of acute triceps rupture can be hampered by pain and swelling that may limit the ability of the examiner to palpate a defect in the tendon. With the aid of gravity, the anconeus triceps expansion may make it possible for the patient to extend the elbow.3 Placing the elbow over the patient’s head forces the patient to extend the elbow against gravity and is a more effective way to detect weakness in extension against resistance. A triceps squeeze test (Table 1), similar to the Thompson test for the Achilles, can be performed, although the sensitivity and specificity of these examination maneuvers have not been reported. A conclusive diagnosis may require ultrasound or magnetic resonance imaging. In conclusion, physical examination of the elbow continues to evolve and remains the basis for diagnosis of elbow pathology. Whereas this review highlights J Hand Surg Am.
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recent developments in physical examination methods for diagnosis of distal biceps rupture, MCL injury, CubTS, and PLRI, a comprehensive examination includes conventional maneuvers to diagnose a wide variety of elbow pathologies. REFERENCES 1. O’Driscoll SW, Morrey BF, An KN. Intraarticular pressure and capacity of the elbow. Arthroscopy. 1990;6(2):100e103. 2. Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39(2):141e154. 3. Hsu SH, Moen TC, Levine WN, Ahmad CS. Physical examination of the athlete’s elbow. Am J Sports Med. 2012;40(3):699e708. 4. O’Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865e1869. 5. Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of tendon ruptures. Clin Orthop Relat Res. 2005;437: 128e131. 6. ElMaraghy A, Devereaux M, Tsoi K. The biceps crease interval for diagnosing complete distal biceps tendon ruptures. Clin Orthop Relat Res. 2008;466(9):2255e2262. 7. Harding WG III. A new clinical test for avulsion of the insertion of the biceps tendon. Orthopaedics. 2005;28(1):27e29. 8. Devereaux MW, ElMaraghy AW. Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med. 2013;41(9): 1998e2004. 9. Hariri S, Safran MR. Ulnar collateral ligament injury in overhead athlete. Clin Sports Med. 2010;29(4):619e644. 10. Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 2001;9(2): 99e113. 11. Han KJ, Kim YK, Lim SK, Park JY, Oh KS. The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging. Clin J Sport Med. 2009;19(4):271e276. 12. Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Am J Sports Med. 2009;37(3):566e570. 13. Sojbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987;218:186e190. 14. Safran MR, McGarry MH, Shin S, Han S, Lee TQ. Effects of elbow flexion and forearm rotation on valgus laxity of the elbow. J Bone Joint Surg Am. 2005;87(9):2065e2074. 15. O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231e239. 16. Hutchinson RL, Rayan G. Diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(9):1519e1521. 17. Kuschner SH, Ebramzadeh E, Mitchell S. Evaluation of elbow flexion and Tinel tests for cubital tunnel syndrome in asymptomatic individuals. Orthopedics. 2006;29(4):305e308. 18. Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg Am. 1992;17(1):86e89. 19. Ochi K, Horiuchi Y, Tenabe A, Mortia K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782e787. 20. Ochi K, Horiuchi Y, Tenabe A, Waseda M, Kuneko Y, Koyanagi T. Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome. J Shoulder Elbow Surg. 2012;21(6):777e781. 21. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am. 2008;33(9):1518e1524.
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28. Rineer C, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. 2009;34(3): 566e576. 29. Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME. Effect of elbow position on grip strength in the evaluation of lateral epicondylitis. J Hand Surg Am. 2007;32(6):882e886. 30. Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am. 2007;32(8):1271e1279. 31. Knutsen EJ, Calfee RP. Uncommon upper extremity compression neuropathies. Hand Clin. 2013;29(3):443e453. 32. Antuna SA, O’Driscoll SQ. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001;17(5):491e495. 33. Tom JA, Kumar NS, Cerynik DL, Mashru R, Parrella MS. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014;24(3):197e204. 34. van Riet RP, Morrey BF, Ho E, O’Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am. 2003;85(10): 1961e1967.
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22. Anakwenze OA, Kancherla VK, Iyengar J, Ahmad CS, Levine WN. Posterolateral rotatory instability of the elbow. Am J Sports Med. 2014;42(2):485e491. 23. Lattanza LL, Chu T, Ty JM, et al. Interclinician and intraclinician variability in the mechanics of the pivot shift test for posterolateral rotatory instability (PLRI) of the elbow. J Shoulder Elbow Surg. 2010;19(8):1150e1156. 24. Regan W, Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow. J Shoulder Elbow Surg. 2006;15(3):344e346. 25. Arvind C, Hargreaves DS. Tabletop relocation test: a new clinical test for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg. 2006;15(6):707e708. 26. Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, TytherweighStrong G, Ruston M. Lateral epicondylitis. A review of pathology and management. Bone Joint J. 2013;95(9):1158e1164. 27. Tosti R, Jennings J, Sewards JM. Lateral epicondyltitis of the elbow. Am J Med. 2013;126(4):357.e1e6.
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