Praxis of the Elbow Diagnosis

00:01 Osteopathic evaluation of the elbow joint So elbow joint is a hinge joint located between the shoulder and the wrist.

00:08 and we’re going to evaluate the elbow to see if we could detect any sort of pathology so we’re going to follow look-feel-move.

00:16 First we’re gonna observe, we’re gonna look at the elbow, you wanna check both surfaces, you wanna compare left and right, you wanna see if the patient has a normal carrying angle by letting their arms come to the side and observing how far the carrying angle might be.

00:31 That’s good.

00:32 After observation, we’re going to perform some palpation, so you want to palpate the elbow joint, you want to make sure that there’s no tenderness.

00:40 the epicondyles, the condyles of the humerus the epicondyles here is where a lot of different forearm muscles attach, a lot of muscles attached control the hand and wrist and sometimes they could be irritated, they could have some pain in the regions so you want to palpate the muscles, check for tension.

00:58 You want to palpate the cubital fossa region, a lot of times this is where you're going to draw blood when you’re doing phlebotomy Posteriorly, you want to check the olecranon, you want to make sure that the structures here are sound and that there's no tenderness you have your triceps tendon back here too and that's where you strike when you perform motor testing of the triceps.

01:21 So after performing your observation and your palpation, we're going to move the joint.

01:27 So the elbow joint has limited motions, in most of the planes except for in the sagittal plane, so in the sagittal plane, the elbow has the most range of motion.

01:39 So this is anatomical 0 for the elbow where we're motion testing the elbow we're going to perform flexion, and flexion should be about 150 degrees passively and then extension, and really there's not a lot of play because the olecranon, the head of olecranon of the ulna locks into the humerus here, so there really shouldn't be no more than 2 degrees of extension, 2-5 degrees of extension So other than flexion and extension in the sagittal plane, we could have some limited ABduction and ADduction, so ABduction or valgus strain of the elbow really is tested passively, it's about less than 5 degrees and ADduction also and this is because if the elbow's straight, the olecranon locks into the humerus and there's really not a lot of play so when you test a valgus and varus, you should have the elbow slightly bent to about 30 degrees.

02:43 There is motion about the transverse axis, it is the radius and ulna crossing over each other so there is a pronation where the hand is pointing down, palm down and the radius is crossing over the ulna and then you have supination where the bones are parallel and not crossing over, so with the forearm, this would be considered 0 degrees, and so I could pronate and then I could also supinate the elbow joint .

03:15 So here we're loking at pronation and supination to see if there's any sort of restrictions, you always want to compare both sides.

03:24 So if we're diagnosing a somatic dysfunction, what I might find is that there might be a restriction to full flexion, and if there's a restriction to full flexion, that will be an extension somatic dysfunction.

03:35 or if someone hurt their elbow and they can't fully extend their elbow, and you can't strain it out fully, then that would be a extension restriction but then a flexion dysfunction.

03:48 at the forearm, we could note any sort of restrictions in the pronation or supination, you could also compare both sides by having the patient put their elbow along their sides here and then starting at 0, we're going to have you turn your palms up as much as you can and I'm looking at how far they could supinate and bring your palms towards the floor.

04:08 It's important to keep the elbow close to the body as you're doing this and they're not kinda turning their, bringing their elbow out, as you could see, it could falsely cause a change in the degrees.

04:21 So osteopathically, we will focus a little bit more on the radial head, so the radial head is the proximal connection of the radius to the elbow joints and this radial head kinda feels a little bit like a nailhead posteriorly here and you could kinda grasp the radial head in your hands.

04:41 Sometimes elbow dysfunctions could disrupt what's going on at the radial head so we want to diagnose the radial head specifically in terms of its motion in relation to the elbow so the radial head will glide posteriorly when you pronate and that's just the hand-palm motions and movements that occur here, so I'm holding on to the radial head between my thumb and my first finger and I'm pronating the forearm and I'll feel it kinda go more to my fingers in the back here posteriorly When I supinate the forearm, I'll feel the radial head come more anteriorly towards my thumb.

05:21 So the radial head could glide posteriorly and anteriorly and you could name any dysfunction of the radial head for its relative freedoms.

05:29 You could also check for the association of the motion of the forearm and supination and pronationa and correlate that with the radial head diagnosis so if I had the patient supinate and pronate themselves and I ask them to supinate but one side is able to fully supinate but the other cannot, then this left side will be the problem side and if someone cannot fully supinate - that's the restriction, that means pronation is the freedom, and if you pronate the forearm that would cause a posterior radial head, so that will be a posterior radial head dysfunction.

06:04 Now once you find the motion restriction in the forearm then you could diagnose the radial head either based on supination and pronation or you could motion test it yourself and passively test it and try to pronate and supinate the forearm and see which way the radial head likes to move.

06:28 There's some special test that we could perform to try to screen and rule in or rule out specific elbow problems.

06:35 So if someone has pain on the medial aspect of the elbow by the epicondyle, that's called medial epicondylitis or golfer's elbow.

06:43 usually, it is overuse or inflammation of the flexor tendons of the wrist because that's what attaches to that elbow and when golfers kinda golf, they finish off and really flex their elbow joints so what we're gonna do is to monitor this region and we're gonna perform two different tests to assess whether or not there is medial epicondylitis present.

07:05 So the flexors could be tested by using a forced wrist extension test, so when I forcibly extend the wrist, what it does is it stretches the muscles that attach to that condyle Now if someone has medial epicondylitis, it's gonna cause them pain in that region, so I'm gonna monitor the medial epicondyle and I'm gonna just bring their wrist into extension and if there's pain there, then that's a positive test.

07:34 The other way to test for medial epicondylitis is to have the patient engage those muscles, so this is gonna be a resisted wrist flexion cause he's using his muscles and flexing his wrist, I'm gonna bring his wrist into extension and go ahead try to flex your wrist to bring your wrist up to the ceiling.

07:52 Good.

07:53 If that causes pain, then that'll be a positive test for medial epicondylitis because you're engaging those muscles thus pulling on the inflamed tendons causing pain in that region.

08:05 If we have pain on the lateral aspect of the elbow, then that could be potentially lateral epicondylitis Because it's on the lateral side, this is the attachment of the wrist extensors, so this is also called tennis elbow because tennis players, they do a lot of backhand, so it's a lot of force extending their wrist.

08:24 So in order to test for lateral epicondylitis, we could do a couple of test so the first thing to do is to try to challenge the wrist extensors by forcibly flexing the wrist, so this test is called forced wrist flexion which then stretches the muscles attaching to the lateral epicondyle So I'm gonna take the wrist, and just slowly push the wrist into flexion if that causes pain, that would be a positive test.

08:51 We could also engage these muscles by asking the patient to extend their wrist so we could also engage the wrist extensors, so we could also engage the wrist extensors and have the patient push their wrist against my resistance and so this is resisted wrist extension, this will engage the wrist extensors and if pain occurs, that is a positive sign for lateral epicondylitis.

09:21 If you have a patient that comes in with plenty of pain more shooting down from the elbow into the distal hand where the pinky finger maybe half the forefinger - that's the innervation of the ulnar nerve So the ulnar nerve sometimes could be entrapped at the elbow at the cubital tunnel.

09:37 So we could perform a Tinel's test for the ulnar nerve, so what we're gonna do is for the Tinel's test, we're gonna find the medial aspect of the olecranon fossa and that's the cubital tunnel where the ulnar nerve runs we're gonna take our fingers and just gently tap over the region and if that recreates the pain shooting down into the fingers and the hand, then that's a positive test, there might be some sort of entrapment of the ulnar nerve within the cubital tunnel.

10:05 If a patient has elbow pain, especially on the medial aspect and there was some sort of trauma, and you want to assess whether or not that ligament- the medial collateral ligament is still intact, we can perform a valgus stress test.

10:21 So valgus is to take the distal forearm and bring it lateral, almost forming a shape of a L So I'm gonna support the elbow above the joint, I'm gonna monitor at the medial collateral ligament which is between the humerus and the ulna here and I'm gonna take the distal portion of the hand and bring it at lateral creating that valgus stress so I'm stressing the medial collateral ligament here, if I have any sort of increased joint laxity, if there's increased pain, then that would be a positive test for instability or possible tear of the medial collateral ligament of the elbow To test the lateral collateral ligament integrity, patients may come in with complaints of lateral elbow pain, they might have had some sort of trauma that caused their hand and forearm to come in medially, we could test the lateral collateral ligament by performing a Varus Stress Test So a varus stress test is when we take the hand and bring it medially.

11:27 and so that gaps the lateral aspect of the elbow joint and if this ligament, the lateral collateral ligament is disrupted, you're gonna have increased joint laxity or pain when you perform the varus stress test so a positive varus stress test would indicate that the lateral collateral ligament may have been damaged, might have been torn, you'll have increased joint laxity and pain in that region.