How to Ace your Assessment of the Elbow
Can you recall those moments when you found yourself grappling with a patient’s persistent elbow pain, desperately seeking a solution? Countless attempts made, yet the situation remained unchanged, leaving you yearning for the right assessment skills to unravel the mystery and offer the best possible care. If you’ve ever experienced this frustration, you’re not alone. The presentation of elbow injuries can appear deceptively simple, but the underlying differential diagnosis can be a labyrinth of complexity.
But fear not! In this blog based on Dr Leanne Bisset’s fantastic Practical on the ‘Assessment of Elbow Pain’ (where you can watch a 1 hour video recording showing exactly how she assess the elbow), I will outline a thorough approach to assessing elbow conditions and how to plan a course of physiotherapy accordingly. It will also help you understand the anatomy of the elbow joint better and provide insights into different types of elbow conditions.
Mastering the Subjective Assessment
From youth to seniors, elbow pain can present in all age groups with a spectrum of symptoms. When it comes to assessing elbow pain, understanding an individual’s demographic history and their involvement in sports is key. Typically, this type of pain is observed in young, highly active individuals engaged in throwing sports, as well as in the older working population aged between 35 and 60 years, often linked to work-related activities. However, it’s important not to jump to conclusions when it comes to diagnosing lateral elbow tendinopathy, especially in younger adults, as it tends to be more of a degenerative condition rather than a primary cause of pain.
In cases where the patient experiences radiating pain, which is rare but not impossible, neural involvement should be considered. Exploring the potential connection to the cervical spine is crucial, as radiating pain down the posterior shoulder and medial scapula may indicate neural issues. Keep an ear out for any history of past trauma or intense weightlifting, as these factors can provide valuable insights. Often, patients with radial nerve involvement report muscle weakness and numbness, though pins and needles sensations are less common.
In the realm of sports like baseball, volleyball, javelin throwers, and tennis players, the frequent occurrence of abduction forces raises concerns. These forces can lead to chronic excessive valgus stresses, causing potential damage to the medial collateral ligament during throwing motions. Meanwhile, lateral elbow tendinopathy often emerges among individuals engaged in gripping and wrist extension activities such as tennis, squash, plumbing, and carpentry. The peak incidence of such issues arises between the ages of 40 and 60 years.
When it comes to acute pain, the signs are fairly straightforward, often accompanied by a clear history of trauma, such as a fall from a skateboard. However, insidious onset pain tends to manifest after prolonged periods of intense activities. It’s crucial to pay attention to the factors that worsen or alleviate the pain. If discomfort arises while extending the elbow, it could be indicative of misalignment of the olecranon in the fossa due to instability. Additionally, if stiffness becomes a complaint, it’s essential to consider joint pathology rather than tendon-related issues.
Mastering the Objective Assessment
Neck and Shoulder Screening
It is important to evaluate the neck and shoulder to rule out radiculopathy, shoulder weakness, or referred pain before diving into the elbow. It is prudent to routinely clear out the cervical spine and shoulder because if, for instance, there are restrictions in the range of motion and limitations in control at the level of the shoulder, it could have a direct impact on the loads acting on the elbow joint.
As a quick screen, the patient can be asked to perform cervical rotation and cervical side bending and we have to look out for neck, scapular and shoulder symptoms. Screen the global ranges of the shoulder by taking both arms into full forward flexion and abduction in standing. Presence of symptoms with shoulder abduction to 90 and externally and internally rotating the shoulder with supination and pronation and following the same process with arms down at the sides can be indicative of not only joint or muscle issue but also could be indicative of mechanically sensitive neural tissue.
See this in action in the video below from Leanne’s Practical.
Observation of the carrying angle of the shoulder is important to find if there are any telling differences in resting carrying angles between sides, particularly in athletes engaged in unilateral sports like cricket bowling and tennis. These subtle variations may serve as a window into underlying structural changes.
Good palpation skills can help us in the differential diagnosis of elbow pain by identifying the location and possible cause of the pain. It is crucial to pinpoint the exact location of the pain, considering the various somatic structures surrounding the joint. By palpating the area, particularly the common extensor tendon, one can begin to narrow down the provisional diagnosis. Don’t forget to explore other possibilities by examining the radiohumeral joint line, checking for lateral collateral ligament and radial head stability, as the annular ligament plays a significant role in maintaining the joint’s integrity.
In her Practical, Leanne emphasizes the importance of testing both sides, exploring the presence of swelling in the olecranon bursa and considering the ulnar nerve as a possible culprit for medial elbow pain.
Range of Motion
Checking the passive range of motion of the elbow joint in supine is done to assess the articulating structures and whether there are any joint related contributions to the patient’s problems. But that’s not all – pronation and supination of the forearm provide valuable insights into potential radioulnar and radiohumeral involvement, alerting us to any changes in symptoms. With a trained eye, appreciate the bony end feel and witness the application of valgus and varus forces, listening for hints of crepitus or clicking – a possible sign of articular changes.
See this in action in the video below from Leanne’s Practical.
Ligament Stress Tests
Knowledge of anatomy is key in evaluating the integrity of the ligaments. Palpation of the ligaments needs to be spot on for evaluating ligament integrity by applying varus force at different degrees of elbow flexion, and observing the valgus force throughout the entire range.
Special Tests and Neurodynamic Testing
When evaluating a patient experiencing lateral elbow pain, certain indicators can help identify the issue. These include the presence of tenderness when pressing on the lateral epicondyle, as well as discomfort during resisted muscle tests such as wrist extension and extension of the middle finger. To further assess the condition, it is crucial to evaluate the patient’s pain-free grip strength using a dynamometer and compare it with the unaffected side.
Additionally, neurodynamic testing with a focus on the radial, median, and ulnar nerves can provide valuable insights. A detailed demonstration of radial nerve neurodynamic testing can be seen in the video below taken from Leanne’s Practical.
In contact sports or during a fall with an outstretched hand and the shoulder abducted, axial compression of the forearm in supination, followed by forced flexion of the elbow, posterior dislocation can occur. This dislocation may cause recurrent elbow instability when the ligaments are not sufficiently competent. Watch out for signs of recurrent painful clicking or snapping, accompanied by locking sensations, particularly when the forearm is supinated.
To assess for this condition, the relocation test can be performed, using the patient’s body weight to create an axial load and applying valgus torque at the elbow, which results in posterolateral subluxation of the joint. To confirm the findings, the test can be replicated with the examiner’s thumb placed on the radial head, providing relief of symptoms as it prevents dislocation of the radial head.
When it comes to elbow conditions, precision in assessment is crucial. To unravel the intricacies of these conditions, Leanne emphasizes the significance of meticulous questioning and comprehensive history taking. Her Practical delves into the realm of anatomy, ensuring a thorough examination that accounts for differential diagnoses and mechanically sensitive neural tissue in cases of referred pain. While the elbow is the focal point, Leanne urges practitioners to widen their scope and consider the interconnectedness of the neck, shoulder, wrist, and elbow for a truly systematic evaluation. By harnessing this knowledge, clinicians can ensure their patients receive tailored care of the highest quality for their specific injury.
To watch Leanne’s fantastic Practical on the Assessment of the Elbow, click HERE.
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