msk term 3 bott elbow diff diagnosis Flashcards
(24 cards)
- Patholophysiliogy:
- “Tennis Elbow”
- Macro- or microtears in the common
extensor tendon - Repetitive overuse, with the wrist
positioned in extension
Lateral Epicondylalgia
- Subjective Reporting:
- Pain in the lateral elbow
- Points to the lateral epicondyle, or just
distal to the common extensor tendon - Reports gradual onset after a spike in
workload - Can report chronic history (“I thought it
just would go away but it hasn’t”) - Objective Findings:
- Painful palpation to lateral epicondyle,
and/or common extensor tendon - Cozen’s test
- Mill’s test
- Maudsley’s test
Lateral Epicondylalgia
- Pathophysiology:
- “Golfer’s Elbow”
- Caused by medial tension overload of the
elbow associated with repetitive micro-trauma
of flexor-pronator musculature at its origin on
medial epicondyle - Normal collagen response is disrupted by
fibroblastic, immature vascular response and
incomplete reparative phase
Medial Epicondylalgia
- Subjective Reporting:
- Pain usually associated with activity, more so afterward,
at medial epicondyle - Onset of pain associated with wrist flexion and/or
pronation activities - Pain with pinching, squeezing, holding heavy objects, wringing
Objective Findings:
* Medial Epicondylitis Test #1
* Active Resisted
* Medial Epicondylitis Test #2
* Passive
* Resisted Pronation
Medial Epicondylalgia
- Pathophysiology:
- Two mechanisms:
- Tendinopathy from repetitive overuse
- Traumatic tendon rupture from high load
eccentric contraction
Distal Biceps Tendon Injuries
Subjective Reporting:
* Tendinopathy:
* Tenderness to palpation of the distal biceps belly, the musculotendinous portion of the biceps, or the bicipital insertion into the radial tuberosity
* Pain reproduced with resisted isometrics of elbow flexion and/or supination
* Tendon Rupture:
* Trauma
* Objective Findings:
* Tendinopathy:
* Pain with repetitive loading of the biceps brachii muscle
* Tendon Rupture:
* Observation due to bulge left by deformed muscle (“Popeye sign”)
* Palpation of gap at elbow
* Manually testing supination strength compared with uninvolved side.
* Biceps Hook Sign absent
* Biceps squeeze test
* Diminished strength of elbow flexion and supination
Distal Biceps Tendon Injuries
- Pathophysiology:
- Repetitive valgus tension on the ligament
in 20-120 degrees of elbow flexion puts
repetitive overload on the ligament, which
may lead to tissue failure or attenuation. - Usually pain comes on more gradually over
time in overhead athletes. - Can have a singular moment “pop,” but not
as common as a slow chronic inability to
throw without pain.
Ulnar Collateral Ligament (UCL) Injuries
UCL may be injured in frank elbow
dislocations
Subjective Reporting:
* Reports of medial elbow pain
* Pain/difficulty during throwing
* Pain, laxity, and gapping with valgus stress tests
* May report history of “pop”, numbness/tingling into hand
* Difficulty with weight bearing
* Stiffness secondary to effusion which may limit ADLs
* Objective Findings:
* Valgus stress test (0, 20 degrees)
* Moving Valgus Stress Test
* Milking Maneuver
* Direct palpation (ME, sublime tubercle)
Ulnar Collateral Ligament (UCL) Injuries
- Pathophysiology:
- Repetitive throwing before growth plates fully fuse can
cause traction injury to the physes. - Continued throwing can fracture the bone at the level
of the growth plate (Medial epicondyle avulsion fracture)
Little League Elbow
Medial Epicondylar Apophysitis
- Subjective Reporting:
- Same as UCL injury, but in a youth player
- Risk factors:
- Rapid growth in size and/or throwing velocity
- Scapular dyskinesis
- Decreased kinetic chain activation/control
- Decreased coordination and neuromuscular
control. - Catching, pitching, or playing both catcher and
pitcher - Playing on multiple teams and leagues
- High pitch counts
- Pitching with arm fatigue
- Pitching with improper mechanics
- Objective Findings:
- Need to get radiographs
- Valgus stress testing / UCL tests are positive
Little League Elbow
Medial Epicondylar Apophysitis
- Pathophysiology:
- High force trauma to the elbow complex, both a direct blow or a FOOSH, may cause a fracture
- Use your quadrant sectioning to determine a likely differential diagnosis
- Dislocations:
- FOOSH with supination, slight valgus, and axial loading
- Ulna dislocates posterior on the humerus
Fracture and/or Dislocation of the Elbow
- Subjective Reporting:
- Global elbow pain/swelling
- Describes a high velocity traumatic MOI
- Unable to move the arm
- Game Plan:
- Warrants immediate medial referral to the ED
- Or call EMS
- Perform first aid/emergency medical response as necessary
- Objective Findings:
- Check neurovascular status
- Elbow Extension Test for fracture
- Tuning Fork for fracture
- Deformity
- Traumatic swelling
- Needs imaging once stable
Fracture and/or Dislocation of the Elbow
- Pathophysiology:
- Arthritis of the elbow may result from numerous conditions including trauma, rheumatoid arthritis, crystalline diseases (gout, pseudogout), infection (septic
arthritis), and osteoarthritis. - We will focus on OA, but all present with similar impairments
- OA usually affects in weight bearing joints, making elbow one of the least common areas for OA
Osteoarthritis of the Elbow
- Subjective Reporting:
- Complaints of diffuse pain and loss in range of motion
- May state “grating” or “locking” sensation in the elbow
- Pain with ADLs
- Difficulty lifting, reaching
- Objective Findings:
- Stiffness, range deficits
- Valgus/varus stability tests to help rule out/rule in joint instability.
- Cozen test to help rule out/rule in lateral epicondylitis.
- Imaging
- Plain radiographs
Osteoarthritis of the Elbow
radial nerve
c6 - c8
median nerve
c6-c8
ulnar nerve
c8-t1
- Pathophysiology:
- Compression, traction, valgus stress of the ulnar nerve at the cubital tunnel of the elbow
- Leads to neuropathy, and symptoms seen distally into the hand
Cubital Tunnel Syndrome
Subjective Reporting:
* Night pain, numbness, tingling
* Ulnar sided sensory changes
* Clumsiness, hand weakness
- Objective Findings:
- Elbow flexion test
- Wartenberg sign
- Froment sign
- Claw hand / Bishop’s deformity
- Sensory changes in C8/T1
- Muscle weakness of:
- Flexor carpi ulnaris (FCU)
- Abductor digiti minimi
- Palmar and dorsal interossei
- Intrinsic-interossei & Lumbricles
Cubital Tunnel Syndrome
cubital tunnel syndrome
tests
elbow flexion test
wartenberg sign
froment sign
- Pathophysiology:
- Overuse injury of the forearm that results
in neuropathy of the median nerve due to
its compression as it passes between the
humeral and ulnar heads of pronator teres
Pronator Syndrome
- Subjective Reporting:
- Pain and paresthesia from anterior forearm, exacerbated by applied pressure to pronator teres
- Nocturnal pain uncommon
- Sensory deficits:
- Lateral aspect of palm, including proximal
part - Lateral 3½ fingers
- Motor Deficits:
- Reduced grip strength and impaired thumb movements (thenar muscles: abductor pollicis brevis, flexor pollicis brevis, opponens pollicis)
- Objective Findings:
- Tinel sign may be positive.
- The Phalen maneuver does not provoke
symptoms. - Pain can be reproduced with pressure applied over the pronator teres ~4 cm distal to the cubital crease with
concurrent resistance against pronation, elbow flexion, and wrist flexion. - Symptoms with resisted supination,
resistance of the long finger flexors
Pronator Syndrome
- Pathophysiology:
- Entrapment neuropathy, nerve becomes compressed, causing ischemic damage to the nerve
- Often associated with repetitive motions or sustained position of the elbow
Radial Tunnel Syndrome
- Subjective Reporting:
- Burning/aching pain in dorsal forearm exacerbated by repetitive activity in forearm pronation with wrist flexion including:
- Using a screwdriver, typewriter, computer keyboard or during handwriting
- Pain reported over anatomical snuff box and dorsal thumb
- Grip strength weakness due to pain
- Rest pain and night pain are common
- Difficulty with grasping and manipulation
activities due to pain - Impaired sensation
- Loss of grip strength in advanced cases (PIN)
- Objective Findings:
- Radial nerve dermatomal sensory testing
- Radial nerve motor testing
- Tinel’s test to the course of the radial nerve
- Compression test to the radial nerve in attempt to
elicit neuropathy
Radial Tunnel Syndrome
