Introduction

• The keys to diagnosing elbow injury are a comprehensive history and physical examination of the elbow and the surrounding anatomy, such as the shoulder, wrist, hand, and cervical spine, to rule out possible causes of referred pain.

• A detailed history can help to narrow the differential diagnosis.

• Many specialized tests exist for confirming the diagnosis of specific pathologic entities about the elbow.

• Diagnostic tests, such as radiography, computed tomography (CT), and magnetic resonance imaging (MRI) can help in making a diagnosis or ruling out potential disorders.

acceleration and follow-through phases often indicates radio-capitellar joint injuries, such as osteochondritis dissecans lesions.

PHYSICAL EXAMINATION

Inspection

Careful inspection of the elbow joint and surrounding areas is the next step in evaluating the elbow. First, the examiner should note atrophy or hypertrophy of muscle groups of the arm or forearm and should obtain girth measurements. Hypertrophy of the forearm musculature often is present in the dominant extremity of the throwing athlete and should be considered a normal variant. Atrophy of arm and forearm musculature, however, could be the result of an underlying neurologic disorder.

Next, the examiner should measure the carrying angle of the elbow with the arm extended and the forearm supinated (Fig. 33-1). The normal carrying angle is 11 degrees in men and 13 degrees in women.13 An increase in the carrying angle is termed cubitus valgus. Often, this angle increases from 10 to 15 degrees in throwing athletes because of adaptive remodeling from repetitive valgus bony stress.9,14 A progressive cubitus valgus deformity can also be caused by a nonunited lateral condylar fracture, which can lead to a tardy ulnar nerve palsy.15 Cubitus varus, a decrease in the carrying angle, can be the result of a malunited supracondylar humeral fracture or a previous growth plate disturbance caused by trauma or inflammation.

Inspection of the four mentioned elbow regions should be performed next.16 First, on the lateral aspect, the soft spot, a

Figure 33-1 Observe the carrying angle of the elbow with the arm extended and forearm supinated.

Figure 33-2 Palpate the lateral "soft spot" for swelling from a joint effusion or synovial proliferation.

triangular region defined by the lateral epicondyle, olecranon, and the radial head, is evaluated. Swelling or fullness in this region can indicate joint effusion, synovitis, or bony deformity (Fig. 33-2). Next, inspection of the posterior region is performed. Swelling or a prominence in this region may indicate an olecranon bursitis, an olecranon traction spur, or nodules from gout or rheumatoid arthritis. The olecranon may also appear prominent as a result of a defect in the distal triceps tendon when there is a distal triceps tendon rupture. Swelling or fullness medially may indicate an avulsion fracture of the medial epicondyle, a UCL injury, a subluxated ulnar nerve, or, in the more chronic situation, an enthesophyte in the wrist flexor-pronator origin on the medial epicondyle. The anterior region should be inspected for any deformity. A more proximal position of the distal end of the biceps muscle belly compared with that of the contralateral muscle may be indicative of a distal biceps tendon rupture. A deformity in the more proximal portion of the lateral biceps muscle ("Popeye" deformity) is indicative of a rupture of the long head of the tendon proxi-mally, whereas a medial deformity in the proximal portion of the muscle belly suggests a rupture of the short head.17,18 Finally, the skin should be inspected for erythema, which can be a sign of an infectious or inflammatory process.

Palpation

The examiner palpates the medial and lateral epicondyles and views them from a posterior angle. When the elbow is in full extension, these landmarks normally form a straight line (Fig. 33-3). With the elbow in 90 degrees of flexion, however, they form an equilateral triangle. Any alignment abnormality can indicate fracture, malunion, unreduced dislocation, or growth disturbances involving the distal end of the humerus.19 The examiner should palpate all four regions of the elbow (anterior, medial, posterior, and lateral) in an orderly fashion. Beginning with the anterior structures, the distal biceps tendon is palpated anteromedially in the antecubital fossa with the patient's

Figure 33-2 Palpate the lateral "soft spot" for swelling from a joint effusion or synovial proliferation.

flexed to 90 degrees, these landmarks form an equilateral triangle.

forearm in supination and elbow in active flexion.1 Tenderness in this area without a defect could indicate biceps tendonitis or a partial biceps tendon rupture.20 Tenderness with a defect or decreased tension in the biceps tendon is consistent with a complete rupture. To avoid missing a distal biceps tendon rupture, it is imperative to make sure that one is not palpating an intact lacertus fibrosus, which can be confused with the biceps tendon. Deep, poorly localized tenderness can be caused by anterior capsulitis or coronoid hypertrophy due to hyperextension injuries or repetitive hyperextension stress.6 Next, the examiner should feel the brachial artery pulse deep to the lacertus fibrosus, which is just medial to the biceps tendon. Finally, one should conduct Tinel's test in the area of the lacertus fibrosus, which is a common site of median nerve compression.21 A positive Tinel sign can indicate pronator syndrome.

Next, the clinician should palpate the structures in the medial region of the elbow, beginning with the supracondylar ridge. If a congenital medial supracondylar process is present in this area, it gives rise to a fibrous band (ligament of Struthers) that inserts on the medial epicondyle. This band can compress the brachial artery and median nerve and result in neurovascu-lar symptoms with strenuous use of the extremity. The examiner should palpate the medial epicondyle and flexor-pronator mass. Tenderness at the origin of the flexor-pronator mass on the epicondyle suggests an avulsion fracture in adolescents or medial epicondylitis in adults. Flexor-pronator strains produce pain anterior and distal to the medial epicondyle. The UCL also is present in this area as it courses from the anteroinferior surface of the medial epicondyle to insert on the medial aspect of the coronoid at the sublime tubercle (Fig. 33-4).22 Palpation of the ligament can be facilitated by using the "milking maneuver."23,24 During this maneuver, the patient grasps the thumb of the affected arm with the opposite hand. With the injured elbow flexed to greater than 90 degrees, a valgus stress is applied to the elbow by pulling on the thumb. This hyperflexion isolates the anterior bundle of the UCL, and the valgus stress places the anterior bundle under stretch. This elbow position facilitates the location and palpation of the tensioned ligament under the mass of the flexor-pronator origin. This position alone can elicit pain

Figure 33-4 The examiner flexes the patient's elbow to 100 degrees to facilitate palpation of the ulnar collateral ligament (UCL) and to uncover the distal insertion of the anterior oblique portion of the UCL.

over the medial elbow as the anterior bundle is placed on stretch.

In the posteromedial area of the elbow, the ulnar nerve is easily palpable in the ulnar groove. An inflamed ulnar nerve is tender and can have a doughy consistency. The examiner should conduct Tinel's test in three areas: proximal to the cubital tunnel (zone I), at the level of the cubital tunnel where the fascial aponeurosis joins the two heads of the flexor carpi ulnaris (zone II), and distal to the cubital tunnel where the ulnar nerve descends to the forearm through the muscle bellies of the flexor carpi ulnaris (zone III).25 A positive test produces paresthesia in the fifth digit and ulnar-innervated half of the fourth digit and suggests a diagnosis of ulnar neuritis due to entrapment, trauma, or subluxation. The clinician also should test the nerve for hypermobility. The examiner brings the patient's elbow from extension to terminal flexion as he or she palpates the nerve to determine whether it subluxates or completely dislocates over the medial epicondyle (Fig. 33-5).26

In the posterior region of the elbow, the clinician evaluates the olecranon bursa for swelling or fluctuation, which would indicate olecranon bursitis. One should also palpate this region for any palpable osteophytes on the subcutaneous border of the olecranon that could contribute to the overlying bursitis. The medial subcutaneous border is then palpated for tenderness that could be caused by a stress fracture in a throwing athlete.27 Next, the triceps insertion is examined (Fig. 33-6); tenderness here indicates triceps tendonitis or an avulsion injury if there is an associated defect. Finally, the clinician palpates the posterior,

Figure 33-5 As the patient's elbow is brought from extension to flexion, the examiner might feel the ulnar nerve subluxate or dislocate anteriorly over the medial epicondyle as in this subject who has a hypermobile nerve.
Figure 33-6 Tenderness over the triceps tendon insertion on the olecranon might indicate triceps tendonitis or triceps avulsion injury.

medial, and lateral aspects of the olecranon in varying degrees of flexion to detect osteophytes or loose bodies. Palpation of the posteromedial olecranon can reveal an osteophyte and swelling, which are present in the throwing athlete with valgus extension overload syndrome.8

Examination of the lateral region of the elbow begins with palpation of the lateral epicondyle. Tenderness directly over the lateral epicondyle is typical of lateral epicondylitis (Fig. 33-7). Tenderness approximately 4 cm distal to the lateral epicondyle over the wrist extensor muscle mass is present in a patient with radial tunnel syndrome, which is a compressive neuropathy of the radial nerve as it travels from the radial head to the supina-tor muscle.25 Finally, tenderness distal to the location of the radial tunnel can be due to compression of the posterior interosseous nerve as it descends beneath the arcade of Frohse and the supinator muscle.

The radial head and radiocapitellar joint distal to the lateral epicondyle are palpated next. Pronation and supination of the forearm enhance this evaluation. Tenderness or crepitation in this area could indicate fracture or dislocation of the radial head, osteochondritis dissecans, or Panner's disease in the adolescent athlete, or articular fragmentation and bony overgrowth with possible progression to loose-body formation in the young adult athlete.1,28 Finally, palpation of the lateral recess, or soft spot, is performed to evaluate elbow joint effusion.

Range of Motion

Range of motion of the elbow occurs about two axes: (1) flexion and extension and (2) pronation and supination. The normal arc of flexion and extension ranges from 0 to 140 degrees of flexion,29 but the functional arc about which most activities of daily living are performed ranges from 30 to 130 degrees (Fig.

33- 8).30,31 The examiner must compare the range of motion to that of the contralateral extremity to account for normal individual variance. An athlete who has pitched many innings may have a flexion contracture on the dominant side that increases as the season progresses and can decrease between seasons. Injuries that cause loss of extension include capsular strain, flexor muscle strain, intra-articular loose bodies, and an intra-articular fracture. In a recent study, lack of full extension in an acute situation was found to be 97% sensitive in diagnosing a significant bone or joint injury; therefore, if a patient has full extension of the elbow after an acute injury, there is a very low likelihood of a significant bone or joint injury.32 Injuries that cause abnormal lack of flexion include loose bodies, capsular tightness, triceps strain, anterior osteophytes, and coronoid hypertrophy.

To measure pronation and supination, the examiner has the patient flex the elbows to 90 degrees while holding pencils in each hand (Fig. 33-9). The examiner must immobilize the humerus in a vertical position when evaluating forearm rotation because patients tend to adduct or abduct the shoulder to compensate for loss of forearm pronation or supination. Acceptable norms for full pronation and supination are 70 and 85 degrees, respectively.19 The functional arc of motion is 50 degrees for both pronation and supination.19 Loss of pronation or supination can be caused by loose bodies, radiocapitellar osteochondritis, radial head subluxation, radial head fractures, or motor nerve entrapment lesions resulting in weakness of the biceps, prona-tor teres, pronator quadratus, or supinator muscles.1 The examiner also should assess the wrist because wrist injury can cause loss of forearm rotation.

When testing range of motion, the examiner also should note the presence or absence of crepitus. He or she must test both

Figure 33-8 The normal arc of extension (A) and flexion (B).

Figure 33-8 The normal arc of extension (A) and flexion (B).

active and passive range of motion because crepitus might not be present on passive range of motion and might be unveiled only through active range of motion. In addition, the clinician should compare active and passive range of motion; if motion is full on passive testing but limited on active testing, pain or paresis might be the limiting factor rather than a mechanical block. Finally, the quality of the endpoint should be noted. Firm endpoints often mean that there is a bony block to motion such as loose bodies, osteophytes, or other joint incongruities. Soft endpoints, on the other hand, most likely are a result of soft-tissue contractures, such as flexion contractures seen in baseball pitchers.

Strength Testing

It is important to examine the strength of elbow, wrist, and hand muscle groups when evaluating an elbow disorder to assess for a neurologic problem or tendon injury. Biceps brachii muscle strength testing is best conducted against resistance with the forearm supinated and the shoulder flexed from 45 to 50 degrees (Fig. 33-10). Triceps strength testing, on the other hand, is best performed with the shoulder flexed to 90 degrees and

Figure 33-7 Lateral epicondylitis causes tenderness over the lateral epicondyle.

Figure 33-10 Biceps muscle strength is assessed with the forearm supinated and the shoulder flexed from 45 to 50 degrees. The examiner applies resistance to flexion.

Figure 33-9 While the patient holds pencils in each hand and flexes the elbows to 90 degrees, measure pronation (A) and supination (B). Due to a previous fracture in the distal radius, this patient demonstrates a slight loss of pronation in the left extremity compared with the right extremity.

Figure 33-10 Biceps muscle strength is assessed with the forearm supinated and the shoulder flexed from 45 to 50 degrees. The examiner applies resistance to flexion.

Figure 33-9 While the patient holds pencils in each hand and flexes the elbows to 90 degrees, measure pronation (A) and supination (B). Due to a previous fracture in the distal radius, this patient demonstrates a slight loss of pronation in the left extremity compared with the right extremity.

Figure 33-11 Triceps muscle strength is best tested with the shoulder flexed to 90 degrees and the elbow flexed from 45 to 90 degrees.

the elbow flexed from 45 to 90 degrees (Fig. 33-11).1 Elbow extension strength is normally 70% of flexion strength.29 Pronation, supination, and grip strength are best studied with the elbow in 90 degrees of flexion and the forearm in neutral rotation. Supination strength is approximately 15% greater than pronation strength, and the dominant extremity is from 5% to 10% stronger than the nondominant extremity.29

Finally, the examiner tests the forearm musculature and hand intrinsic strength. The extensor carpi radialis longus musculo-tendinous unit is best studied with the elbow flexed to 30 degrees and resistance applied to wrist extension.1 However, the extensor carpi radialis brevis musculotendinous unit is best isolated by providing resistance to wrist extension with the elbow in full flexion. The clinician studies the extensor carpi ulnaris muscle by resisted ulnar deviation of the wrist. Weakness in the wrist, finger, and thumb extensors may indicate a posterior interosseous nerve palsy. Weakness of the flexor pollicis longus and flexor digitorum profundus muscles of the index finger is present in an entrapment palsy of the anterior interosseous nerve, which branches from the median nerve approximately 5

Figure 33-11 Triceps muscle strength is best tested with the shoulder flexed to 90 degrees and the elbow flexed from 45 to 90 degrees.

cm distal to the medial epicondyle.33 Finally, weakness in the hand intrinsics can indicate ulnar nerve entrapment at the cubital tunnel.

Reflexes

Reflexes are evaluated to rule out potential sources of referred pain, such as cervical radiculopathy. An increased response to stimulation can indicate an upper motor neuron lesion, whereas a decreased response can signify a lower motor lesion. The examiner tests the C5 nerve root by the biceps reflex, the C6 nerve root by the brachioradialis reflex, and C7 nerve root by the triceps reflex.

Sensory Examination

Next, the examiner should conduct a comprehensive sensory examination to assess for a cervical radiculopathy or a peripheral neuropathy. Light touch and pinprick sensation are both assessed. Diminished sensation in the fifth and ulnar-innervated half of the fourth digits can signify an ulnar neuropathy. However, many entrapment neuropathies of the elbow and forearm, such as anterior interosseous neuropathy, pronator syndrome, posterior interosseous neuropathy, and radial tunnel syndrome, do not have abnormal objective sensory examinations.

Stability Testing

Either an acute traumatic event or a chronic overload syndrome can result in valgus instability of the elbow. Attenuation or rupture of the anterior oblique bundle of the UCL causes this pattern of instability.1,2 The elbow is examined with patient in either the seated or supine position and the shoulder in maximal external rotation.2 The manual valgus stress test is performed with the elbow flexed 20 to 30 degrees to unlock the olecranon tip from the olecranon fossa while stabilizing the humerus (Fig. 33-12). Valgus stress is then applied to the elbow with the forearm in maximal pronation. Any increased opening or reproduction of the patient's pain with valgus stress may be indicative of injury to the UCL.2 Often only pain can be elicited without any detectable opening when performing this test when the patient is awake due to patient guarding and the fact that even with complete sectioning of the anterior bundle of the UCL in cadaveric studies, there is only minimal valgus opening that may not be clinically detectable.34

Figure 33-12 Valgus stress testing is accomplished with the patient's elbow flexed from 20 to 30 degrees and his or her arm secured between the examiner's arm and trunk.

Figure 33-13 The lateral pivot-shift test. The examiner supinates the elbow, applies a valgus moment and axial compression, and moves the elbow from full extension (A) to flexion (B).

Figure 33-13 The lateral pivot-shift test. The examiner supinates the elbow, applies a valgus moment and axial compression, and moves the elbow from full extension (A) to flexion (B).

Posterolateral rotatory instability is essentially a rotational displacement of the ulna and radius on the humerus that causes the ulna to supinate away from the trochlea.35 O'Driscoll35 describes four principal physical examination tests to diagnose this form of instability. The most sensitive is the lateral pivot-shift apprehension test. The patient is placed in the supine position with the affected extremity overhead, and the patient's wrist and elbow are grasped as the ankle and knee are held when examining a knee. The elbow is supinated with a mild force at the wrist, and a valgus moment and compressive force are applied to the elbow during flexion (Fig. 33-13). This results in an apprehension response with reproduction of the patient's symptoms akin to the anterior apprehension test of the shoulder. The next test is the lateral pivot-shift test or posterolateral rotatory instability test, which reproduces the actual subluxation and the clunk that occurs with reduction. This can usually be accomplished only with the patient under general anesthesia or occasionally after injecting local anesthetic into the elbow. The pivot-shift maneuver causes posterolateral subluxation or dislocation of the radius and ulna off the humerus that reaches a maximum at 40 degrees of flexion, creating a posterolateral prominence over the dislocated radial head and a dimple between the radius and capitellum. As the elbow is flexed past

Figure 33-12 Valgus stress testing is accomplished with the patient's elbow flexed from 20 to 30 degrees and his or her arm secured between the examiner's arm and trunk.

Figure 33-14 A, A positive test for posterolateral rotatory subluxation of the elbow. The posterolateral dislocation of the radiohumeral joint produces an osseous prominence and an obvious dimple in the skin just proximal to the dislocated radial head. B, Lateral radiograph made simultaneously with the photograph. The radiohumeral joint is dislocated posterolaterally, and there is rotatory subluxation of the ulnohumeral joint. The semilunar notch of the ulna is rotated away from the trochlea. (From Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in athletes. Clin Sports Med 2001;20:25-45.)

Figure 33-14 A, A positive test for posterolateral rotatory subluxation of the elbow. The posterolateral dislocation of the radiohumeral joint produces an osseous prominence and an obvious dimple in the skin just proximal to the dislocated radial head. B, Lateral radiograph made simultaneously with the photograph. The radiohumeral joint is dislocated posterolaterally, and there is rotatory subluxation of the ulnohumeral joint. The semilunar notch of the ulna is rotated away from the trochlea. (From Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in athletes. Clin Sports Med 2001;20:25-45.)

40 degrees, reduction of the ulna and radius together on the humerus occurs suddenly and produces a palpable and visible snap (Fig. 33-14). The third test is the posterolateral drawer test, which is a rotatory version of the Lachman test of the knee. During the test, the lateral side of the forearm subluxates away from the humerus, pivoting around the medial collateral ligament. The final test is the "stand-up test" in which the patient's symptoms are reproduced as he or she attempts to stand up from the sitting position by pushing on the seat with the hand at the side and the elbow fully supinated.

Provocative and Special Tests Lateral

Stress to the extensor carpi radialis longus and brevis muscles reproduces the discomfort associated with lateral epicondylitis. To create this stress, the patient fully extends the elbow and resists active wrist and finger extension (Fig. 33-15). Pain at the lateral epicondyle with this maneuver indicates lateral epi-condylitis. This is the most sensitive provocative maneuver for this disorder. Passive flexion of the wrist with the elbow extended can also cause discomfort as it stretches the extensor tendons. Finally, the "chair test" can also aid in the diagnosis.36,37 In this test, the patient raises the back of a chair with the elbow in full extension, the forearm pronated, and the wrist dorsiflexed (Fig. 33-16). As the patient attempts to lift the chair, he or she exhibits apprehension in anticipation of pain.

The most sensitive test for radial tunnel syndrome is resisted supination with the supinator and extensor carpi radialis brevis muscles in the stretched position (pronation and wrist flexion), which produces pain approximately 4 to 5 cm distal to the lateral epicondyle.38 Resisted third-digit extension can also cause pain in this area in patients with radial tunnel syndrome; however, this maneuver also causes similar pain in patients with lateral epicondylitis. Another indicator of radial tunnel syndrome is the pronator-supinator sign.39 The test is positive if direct tenderness over the radius at 5 cm distal to the lateral epicondyle is markedly greater in full supination than in pronation due to the fact that the radial nerve is located in this position in full supination but moves medially and distally with pronation. Passive pronation of the forearm to its end range with elbow extension also can recreate the symptoms of radial tunnel syndrome by causing a tightening of the origin of the extensor carpi radialis brevis muscles over the nerve.40 Recently, a neural tension test has been described to aid in the diagnosis of radial tunnel syn-drome.41 In this test, the radial nerve is placed under tension, which causes pain distal to the lateral epicondyle if the patient has radial tunnel syndrome. This nerve tension is created with shoulder girdle depression, forearm pronation, elbow extension, wrist and finger flexion, and shoulder abduction while the patient is in the supine position.

Finally, the clinician tests for damage to the articular surface of the radiocapitellar joint. With the patient's elbow extended,

Figure 33-15 Test for lateral epicondylitis. Stress to the origin of extensor carpi radialis brevis and longus tendons, which is created by resisting active wrist extension with the elbow fully extended, elicits pain at the lateral epicondyle.

Figure 33-16 The "chair test." While holding the elbow in full extension, pronating the forearm, and dorsiflexing the wrist, the patient lifts the back of a chair. The test elicits apprehension in patients with lateral epicondylitis.

Figure 33-16 The "chair test." While holding the elbow in full extension, pronating the forearm, and dorsiflexing the wrist, the patient lifts the back of a chair. The test elicits apprehension in patients with lateral epicondylitis.

Figure 33-18 Elbow flexion test for ulnar nerve compression. With the patient's wrist neutral and forearm supinated, the examiner flexes the patient's elbow to 135 degrees as he or she applies digital pressure over the cubital tunnel.

the examiner applies an axial load to the joint while supinating and pronating the forearm repeatedly. Pain with this maneuver is a positive radiocapitellar compression test.

Medial

The most sensitive indirect maneuver for the diagnosis of medial epicondylitis is resisted forearm pronation, which is positive in 90% of patients with this disorder (Fig. 33-17).39 A positive test

Figure 33-17 Resisted forearm pronation elicits pain at the medial epicondyle in patients who have medial epicondylitis.

elicits pain at the flexor-pronator muscle mass origin on the medial epicondyle. The second most sensitive maneuver is resisted palmar flexion, which is positive in 70% of patients.39 Passive extension of the wrist and fingers also can elicit pain at the medial epicondyle in these patients.

The most sensitive and specific provocative test maneuver for diagnosing ulnar nerve compression at the elbow is the elbow flexion test conducted with direct pressure over the cubital tunnel.33 With the patient's wrist in neutral and forearm supinated, the examiner flexes the elbow to 135 degrees and applies digital pressure over the cubital tunnel for a period of 3 minutes or until the symptoms are elicited (Fig. 33-18).42 A positive test results in paresthesia or dysesthesia in the fifth and ulnar-innervated half of the fourth digit. A simple nerve compression test and Tinel's test also are used to aid in making the diagnosis. Positive findings with these tests without the use of electrodiagnostic studies have been shown to accurately predict the success rate of an ulnar nerve transposition procedure.43

Anterior

Vague anterior elbow or proximal forearm pain can be caused by entrapment of the median nerve at many sites. First, as discussed previously, the median nerve can become compressed under the ligament of Struthers. In this case, resisted flexion of the elbow between 120 and 135 degrees of flexion elicits the symptoms.25 Active elbow flexion with the forearm in pronation, which tightens the lacertus fibrosus, causes symptoms in patients with compression of the nerve by the lacertus fibrosus.25

Figure 33-17 Resisted forearm pronation elicits pain at the medial epicondyle in patients who have medial epicondylitis.

If resisted pronation of the forearm combined with flexion of the wrist reproduces the symptoms, the nerve may be compressed as it passes through the pronator teres muscle.25 Finally, if resisted flexion of the superficialis muscle of the third digit results in pain in this area, the nerve may be entrapped in the superficialis arch.25

Anterior elbow pain also can be due to biceps or brachialis tendonitis. These diagnoses are suggested when resisted forearm supination and elbow flexion produce increased pain. The clinician should also assess for the tension on the distal biceps tendon with resisted flexion and supination because decreased tension could be the result of a distal biceps tendon tear. Finally, a new clinical test has been described for the diagnosis of complete distal biceps tendon ruptures, the passive pronation-supination test (Warren Harding, MD, personal communication, 2004). With an intact biceps tendon, the biceps' muscle belly rises visibly and palpably in the arm with passive supination, returns to a normal position with return to the neutral position, and then flattens and moves to a more distal position with pronation. In an unpublished study of patients with MRI-documented complete biceps tendon avulsions, Harding found that the muscle belly did not rise and fall with passive supination and pronation of the forearm.

Posterior

The valgus extension overload test and valgus extension snap maneuver consistently produce discomfort in patients with valgus extension overload syndrome.1 With the patient in the seated position, the examiner applies a moderate amount of valgus stress to the elbow as he or she moves the elbow from 30 degrees of flexion to full extension. This maneuver simulates posteromedial olecranon impingement and recreates the pain that the athlete experiences during the late acceleration phase of throwing.

A modified Thompson test has been described to help diagnose a complete distal triceps tendon tear.44 This test is performed with the elbow flexed to 90 degrees and the arm abducted to eliminate the effect of gravity on elbow extension. The examiner squeezes the triceps muscle belly and observes the elbow for extension motion. If there is no motion, a complete tear is present.

Imaging Studies Plain Radiography

Plain radiographs may be ordered to supplement the information obtained during the history and physical examination. They enable the clinician to gather formative information on bone, joint positioning, and the presence or absence of soft-tissue swelling, loose bodies, ectopic ossification, and foreign bodies. Standard radiographic views include anteroposterior and lateral projections, which can be supplemented by oblique and axial views as necessary.45 An anteroposterior view is taken with the arm in full extension and the forearm supinated (Fig. 33-19). This position allows good visualization of the medial and lateral epicondyles, the radiocapitellar joint, and the trochlear articulation with the medial condyle. The lateral radiographic view should be taken with the elbow flexed to 90 degrees and the forearm in neutral rotation and the beam should be reflected distally to account for the normal valgus position of the elbow (Fig. 33-20). The lateral projection provides visualization of the radiocapitellar and ulnotrochlear articulations, the distal

Figure 33-19 Anteroposterior radiographic view.

humerus, and the olecranon and coronoid processes. Fat pad signs are visualized on the lateral view and indicate capsular dis-tention or joint effusion, and, if present, intra-articular abnormalities should be suspected. The presence of the anterior fat pad sign sometimes is normal, whereas the presence of the posterior fat pad sign is always abnormal.

If an injury to the radiocapitellar joint is suspected, the clinician should order a radiocapitellar view, which is obtained with the elbow positioned as for a lateral projection, but with the beam angled 45 degrees anteriorly (Fig. 33-21). This provides an unobstructed view of the proximal radius and capitellum and is useful in making the diagnosis of osteochondral fractures of the capitellum or injuries to the radial head and neck.

Figure 33-20 Lateral radiographic view.
Figure 33-21 Radial head radiographic view.

The axial view is often helpful in evaluating injury in the throwing athlete. For this view, the elbow is flexed to 110 degrees with the forearm flat on the cassette, and the beam is directed perpendicular to the cassette (Fig. 33-22). This allows visualization of the posterior compartment, specifically visualization of the articulation of the posterior olecranon and the humerus. The clinician should closely evaluate this view for a posteromedial osteophyte, which occurs with valgus extension overload syndrome. The reverse axial projection, which provides better visualization of the olecranon and trochlea, is taken with the elbow in maximal flexion and the arm flat on the cassette.45

Stress Radiography

Stress views can be obtained in patients with suspected ligament disruption or elbow instability. The examiner applies varus or valgus stress to the elbow during radiography and assesses the films for any asymmetrical widening of the joint. A gravity stress view is obtained with the patient supine and the arm abducted to 90 degrees from the body; the beam is centered on the elbow. With maximal supination of the forearm, a valgus stress is applied to the elbow. Static views that demonstrate an increase in joint space of more than 2 mm are considered abnormal.45

Cain et al2 suggest obtaining anteroposterior views with 0, 5, 10, and 15 N of valgus stress applied to each elbow at 25 degrees. An increase in opening with increasing stress compared with the contralateral uninjured side is indicative of UCL injury. Dynamic evaluation under fluoroscopy can be helpful in identifying subtle abnormalities; however, instability is often not well visualized with these dynamic views.

Computed Tomography

CT provides excellent osseous detail and can be used to evaluate the elbow for loose bodies not evident on plain films, osteo-chondral defects, articular congruity, trabecular irregularities, and fractures for displacement (Fig. 33-23).45 Images are acquired in 1-mm intervals and can be reformatted into coronal, sagittal, or three-dimensional images to help with surgical planning.

CT arthrography may be indicated to detect intra-articular loose bodies, to evaluate capsular topography in patients with capsular contractures or tears, and to evaluate the articular-bearing surfaces.45 It may be the diagnostic modality of choice to examine these entities in patients in which an MRI is contraindicated (e.g., patients with loose metal fragments in

Figure 33-23 This 34-year-old woman had a traumatic elbow dislocation. After reduction, sagittal computed tomography scan reconstruction (A) shows a small coronoid fracture and posterior olecranon fossa intra-articular bone fragment, also seen in axial image (B).

their eye orbits or perispinal region or in those with pacemakers). Timmerman et al46 compared CT arthrography with nonenhanced MRI in 25 baseball players for the ability to correctly diagnose UCL injuries and discovered that CT arthrography had a sensitivity of 86% and specificity of 91% compared to nonenhanced MRI, which had sensitivity of 57% and specificity of 100%. Both techniques were 100% sensitive for complete tears; however, partial tears were more accurately diagnosed by CT arthrogram.

Magnetic Resonance Imaging

MRI is the modality of choice for the evaluation of soft-tissue structures, such as ligaments, tendons, and muscles, and has largely replaced arthrography as the study of choice for intra-and periarticular soft-tissue structures. MRI is used to evaluate capsuloligamentous or musculotendinous disruption as well as intra-articular abnormalities, such as epiphyseal fractures or chondral defects (Fig. 33-24). Images are obtained in 1- to 3-mm intervals with formats in sagittal, coronal, and axial planes. Nonenhanced MRI can be used to evaluate tendons such as the biceps and triceps when physical examination is equivocal. MRI may be helpful to evaluate for partial-thickness distal biceps tendon ruptures (Fig. 33-25) when physical examination reveals an intact tendon but a patient has pain in the distal biceps tendon area with associated weakness.20 T1-weighted images demonstrate a replacement of the normal low signal intensity in the distal biceps tendon with intermediate signal intensity, and T2-weighted images reveal high signal edema surrounding the distal biceps tendon and its insertion. MRI can also aid in the diagnosis of tendonopathy and partial tears involving the wrist extensor and pronator-wrist flexor tendon origins seen in patients with lateral and medial epicondylitis, respectively. The changes that accompany tendinosis manifest as either intermediate to low signal intensity on T1-weighted images in cases of fibroblastic proliferation or high signal intensity in cases of fibroblastic proliferation with mucoid degeneration.47 Attrition on both T1- and T2-weighted images with high signal intensity is consistent with a partial tear of the tendon's origin. Discontinuity on both T1- and T2-weighted images with high signal intensity of the free ends is indicative of a complete tear (Fig. 33-26).

Saline-enhanced MRI direct arthrogram has been shown to be the most accurate study to evaluate UCL injuries (Fig. 33-27).48 Schwartz et al48 reported 92% sensitivity and 100% specificity with diagnosing UCL injury using this modality. Sensitivity was higher for complete tears (95%) than for partial tears (86%). Saline is injected through the lateral soft spot into the joint, and saline extravasation through the UCL indicates a full-thickness tear. MRI can also be used to identify disorders associated with UCL injury, such as posteromedial impingement changes. A recent study, however, cautions against diagnosing UCL injuries and associated disorders based solely on MRI findings.49 Sixteen asymptomatic professional baseball players with no history of injury to their elbows underwent MRI. UCL abnormalities (thickening, signal heterogeneity, or discontinuity) were present on 87% of players' dominant elbows, and findings consistent with posteromedial impingement were present in 13 of 16

subjects.49

Finally, MRI can also be used to evaluate for subtle avulsion fractures or stress fractures that may not be evident on plain radiographs (Fig. 33-28). Using a combination of radiographs and MRI scans, Salvo et al50 were able to identify eight avulsion fractures of the sublime tubercle of the ulna in 33 consecutive patients treated for UCL injuries. Regarding stress injury to bone, Schickendantz et al27 reported on a series of seven professional baseball players with proximal ulnar osseous stress injury detected on MRI with normal plain radiographs. Poorly defined, patchy areas of low signal intensity in the proximal pos-teromedial olecranon continuous with the cortex were seen on all of the T1-weighted images. All short tau inversion recovery

Figure 33-24 A, Magnetic resonance imaging (MRI) arthrogram in a 54-year-old man with previous football injuries and limited motion. Sagittal section shows loose body in anterior aspect of the elbow joint (arrow). Anteroposterior radiographic view (B) and coronal MRI (C) in a 20-year-old pitcher with elbow pain show osteochondritis dissecans of the capitellum. Arrow indicates chondral defect.

Figure 33-27 Contrast coronal magnetic resonance image reveals complete ulnar collateral ligament disruption. Arrow indicates positive capsular T sign.

Figure 33-28 Lateral radiographic view (A) and lateral magnetic resonance image (B) show posterior olecranon stress fracture in a teenage pitcher with posteromedial impingement. Arrows indicate area of stress.

Figure 33-28 Lateral radiographic view (A) and lateral magnetic resonance image (B) show posterior olecranon stress fracture in a teenage pitcher with posteromedial impingement. Arrows indicate area of stress.

images showed areas of high signal intensity in the posteromedial olecranon.

CONCLUSIONS

A comprehensive history and physical examination of the elbow and surrounding joints are the most important part of the evalu-

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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