Palpation

The examiner palpates the medial and lateral epicondyles and olecranon tip and views them from a posterior angle. When the elbow is in full extension, these landmarks normally form a straight line (Fig. 3.3A). With the elbow in

FIGURE 3.2. Palpate the lateral soft spot for swelling from a joint effusion or synovial proliferation.

FIGURE 3.3. (A) The medial and lateral epicondyles and olecranon form a straight line with the elbow in full extension. (B) When the elbow is flexed to 90°, these landmarks form an equilateral triangle.

FIGURE 3.3. (A) The medial and lateral epicondyles and olecranon form a straight line with the elbow in full extension. (B) When the elbow is flexed to 90°, these landmarks form an equilateral triangle.

90° of flexion, however, they form an equilateral triangle (Fig. 3.3B). Any abnormalities of these alignments can indicate fracture, malunion, unreduced dislocation, or growth disturbances involving the distal end of the humerus.12 The examiner should palpate of all four regions of the elbow (i.e., anterior, medial, posterior, and lateral) in an orderly fashion. Beginning with the anterior structures, the cubital fossa is bound laterally by the bra-chioradialis, the extensor carpi radialis longus, and the extensor carpi radialis brevis muscles; medially by the pronator teres muscle; and superiorly by the biceps muscle. Palpation of the brachioradialis and flexor-pronator muscles might reveal hypertrophy from repetitive use or exercise-induced edema. The examiner can palpate the distal biceps tendon anteromedially in the antecubital fossa with the patient's forearm in supination and elbow in active flexion.1 Tenderness in this area can indicate biceps tendinitis or a biceps tendon rupture. Deep, poorly localized tenderness can result from anterior capsulitis or coronoid hypertrophy due to hyperextension injuries or repetitive hyperextension stress.5 Next, the examiner should feel the brachial artery pulse deep to the lacertus fibrosus, which is just medial to the biceps tendon. Finally, he or she should conduct a Tinel's test in the area of the lacertus fibrosus, which is a common site of median nerve compression.13 A positive Tinel's sign might indicate pronator syndrome.

Next, the clinician should palpate the structures in the medial region of the elbow, beginning with the supra-condylar ridge. A congenital medial supracondylar process might be present in this area, which gives rise to a fibrous band (known as the ligament of Struthers) that inserts on the medial epicondyle. This band can compress the brachial artery and median nerve and result in neu-

rovascular 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 can reflect an avulsion fracture in adolescents or medial epicondylitis (i.e., golfer's elbow) 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 process at the sublime tubercle.14 Flexing the patient's elbow to 100° facilitates palpation of the UCL and uncovers the distal insertion of the anterior oblique portion of the UCL1 (Fig. 3.4).

FIGURE 3.4. The examiner flexes the patient's elbow to 100° to facilitate palpation of the ulnar collateral ligament (UCL) and to uncover the distal insertion of the anterior oblique portion of the UCL.

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 testing in three areas: proximal to the cubital tunnel (zone I), at the level of the cubital tunnel where the fascial aponeurosis joining the two heads of the flexor carpi ulnaris muscle forms (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).15 A positive test produces paresthesias in the fifth digit and ulnar-innervated half of the fourth digit and indicates ulnar neuritis due to entrapment, trauma, or subluxation. The clinician also should test the nerve for hypermobility. The clinician brings the patient's elbow from extension to terminal flexion as he or she palpates the nerve to determine if it subluxates or completely dislocates over the medial epi-condyle16 (Fig. 3.5).

In the posterior region of the elbow, the examiner evaluates the olecranon bursa for swelling and fluctuation that indicate olecranon bursitis. He or she also examines this area for palpable osteophytes along the subcutaneous border of the olecranon that might contribute to an overlying bursitis. The examiner palpates the proximal one-third medial subcutaneous border of the olecranon because tenderness in this area can indicate a stress fracture. Next, he or she evaluates the insertion of the triceps tendon (Fig. 3.6). The three heads of the triceps converge to form an aponeurosis that attaches to the tip of the olecranon. Tenderness in this area can indicate triceps tendinitis or triceps avulsion injury if a palpable defect also is found. Finally, the clinician palpates the posterior, medial, and lateral aspects of the olecranon in varying degrees of flexion to detect osteophytes and loose bodies. Palpation of the posteromedial olecranon can reveal an osteophyte and swelling, which are present in the valgus extension overload syndrome of the throwing athlete.7

Examination of the lateral region of the elbow begins with the lateral epicondyle, which is readily palpable by tracing the lateral supracondylar ridge distally and with the mobile wad of Henry, which originates at the lateral region. Tenderness over the lateral epicondyle is typical of lateral epicondylitis (i.e., tennis elbow) (Fig. 3.7); however, tenderness approximately 4 cm distal to the lateral epicondyle and over the extensor muscle mass is present with radial tunnel syndrome, which is a compression neuropathy of the radial nerve as it travels from the radial head to the supinator muscle.15 Finally, tenderness distal

FIGURE 3.6. Tenderness over the triceps tendon insertion on the olecranon might indicate triceps tendinitis or triceps avulsion injury.
FIGURE 3.7. Lateral epicondylitis causes tenderness over the lateral epicondyle.

to the location of the radial tunnel might be due to compression of the posterior interosseous nerve as it descends beneath the arcade of Frohse and the supinator muscle.

Next, the examiner palpates the radial head and ra-diocapitellar joint distal to the lateral epicondyle. Pronation and supination of the forearm enhance evaluation. Tenderness in this area might indicate fracture or dislocation of the radial head, osteochondrosis 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 Finally, palpation of the lateral recess, or soft spot, easily identifies an elbow effusion.

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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