Physical Examination

Physical examination of the elbow for UCL injury entails assessing the integrity of the ligament and evaluating the joint and surrounding structures for associated injuries.

Inspection of the upper extremity in overhead athletes often reveals hemihypertrophy of the dominant extrem-ity.23 In acute cases of UCL injury, pain or guarding might limit elbow range of motion. In chronic cases and especially in throwers, motion might be limited at terminal extension due to bony changes in the posterior compartment, anterior capsular contracture, or loose bodies in the ole-cranon fossa. Crepitation with motion suggests the presence of loose bodies or degenerative changes in the joint.

Palpation over the ligament usually elicits tenderness along its course when the athlete has an acute injury. The anterior bundle of the UCL originates at the anteroinfe-rior portion of the medial epicondyle of the humerus and inserts on the medial border of the coronoid process at the sublime tubercle.16,17 Pain at the ligament's origin can mimic medial epicondylitis or, in extreme injury, rupture of the flexor-pronator muscle mass origin.12,22,23 Pain elicited at the origin of the tendon with resisted wrist flexion, resisted forearm pronation, or firm fist clench differentiates the isolated UCL injury from these other injuries.

Injury to the insertion of the UCL occurs distal to the medial epicondyle, and the location of the point of tenderness differentiates it from injury to the origin. The examiner uses the "milking maneuver" to facilitate identification and palpation of the ligament underneath the mass of the flexor-pronator muscle origin.27 During ex amination, the patient places the opposite hand under the elbow and grasps the thumb of the injured arm. With the injured elbow flexed to more than 90°, the patient applies a valgus stress to the elbow by pulling the thumb with the opposite hand. Hyperflexion isolates the anterior bundle of the UCL, and valgus stress stretches it. Positioning the elbow in this fashion facilitates location and palpation of the tensioned ligament beneath the mass of the flexor-pronator origin. Positioning for the maneuver alone can elicit pain over the medial elbow as the anterior bundle is placed on stretch.

Valgus stability of the elbow is best examined with the elbow positioned in approximately 30° of flexion, which frees the olecranon tip from the fossa posteriorly. Forearm pronation and wrist flexion relax the flexor-pronator mass and allow isolation of the UCL. While holding the pronated hand either in one of his or her hands or between his or her trunk and arm, the examiner places his or her other hand on the lateral side of the elbow and applies a valgus stress to the arm. While applying the val-gus stress, the examiner palpates the ligament for tenderness. The examiner also assesses the extent of joint opening and quality of the ligament's endpoint with this maneuver and compares the findings with the findings in the contralateral elbow. Even with complete ligament rupture, the side to side difference in joint opening might be only 3 to 4 mm, and the difference in endpoint quality can be subtle, making the maneuver difficult to master.

We recommend a variation of the stress test to aid the examiner in sensing the amount or extent of medial joint opening. After applying the valgus stress and palpating the endpoint, the examiner places a varus stress on the elbow. It often is easier to sense the amount of joint opening by the extent of joint-line closure when moving from the valgus to varus stress. As the ulnohumeral articulation closes, the endpoint palpated during varus stress is firm and discrete and can assist the examiner in determining the amount of medial joint laxity.

Complete examination of the elbow that might have a UCL injury requires assessment of other structures in the medial portion of the elbow. Ulnar nerve irritation can be mistaken for ligament injury or can occur in conjunction with it. Bony hypertrophy, medial joint spurring, or inflammation associated with UCL injury can compress the ulnar nerve in the cubital tunnel. Nerve subluxation, especially during the late cocking phase of throwing, can lead to pain in the medial portion of the elbow. Careful examination of the nerve is essential for ruling out isolated or associated ulnar nerve injury. The examination should focus on nerve sensitivity and tenderness, presence of Tinel's sign, and distal sensory and motor function. The examiner can assess nerve stability by looking for hypermobility or anterior subluxation. Nerve involvement associated with UCL incompetence might require nerve transposition in conjunction with ligament reconstruction.

Valgus extension overload associated with throwing can lead to several well-recognized bony changes across the posteromedial portion of the elbow.15 Olecranon tip spurring and osteophyte formation along with bony hypertrophy of the olecranon fossa and loose-body formation can lead to impingement of the olecranon tip in the fossa at terminal extension, especially in throwing athletes. Snapping extension of the elbow can elicit pain.

Chondral injury and degenerative changes in the posterior portion of the joint also can cause pain in the medial portion similar to the pain that UCL tears cause. Applying a valgus stress with the elbow in extension can reproduce pain in cases of posteromedial instability due to a UCL tear. The examiner must explore all sources of pain in the medial portion of the elbow and address any concurrent injury at surgery for a successful outcome in UCL reconstruction.

Radiographs are helpful in evaluating the elbow for UCL injury. Using plain radiographs, the examiner can identify degenerative changes in the elbow and loose bodies (Fig. 7.6). Chronic UCL injury can cause calcification along the course of the ligament and medial joint-line spurring (see Fig. 7.6B). Osteophytes in the posterome-dial portion of the elbow are seen easily on the antero-posterior and the hyperflexion lateral views as the tip of the olecranon is advanced out of the fossa (Fig. 7.6C). Secondary degenerative changes also can be seen at the radiocapitellar joint, and at the ulnohumeral joint in chronic cases of UCL insufficiency. Stress radiographs can be useful in the examination; however, we have found that they can be negative in known cases of UCL rupture. Use of computed tomography and arthrography can help in diagnosing an undersurface tear of the ligament.14,29

MRI has become the study of choice in evaluating the elbow that might have a UCL injury. It shows the integrity of the ligament and associated injuries (Fig. 7.7). By placing the patient's elbow in extension, the examiner can well visualize the anterior bundle on coronal section and can differentiate among proximal, distal, and mid-substance ligament tears. MRI also allows the examiner to view the articular surfaces and adjacent neu-romuscular structures for evaluation of any abnormalities identified on physical examination or radiographic evaluation (Fig. 7.8). The examiner can use MRI after surgery to evaluate graft integrity, placement, or reinjury (Fig. 7.9). Because of the small size of the ligament, technical considerations (e.g., arm positioning, signal-to-noise ratio, and signal sequencing) are important in producing an optimal image.30

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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