Evaluation of the Elbow in Throwing Athletes

Abstract

Background:

Elbow injuries are becoming increasingly prevalent in throwing athletes. Early diagnosis, especially in athletes, can allow for earlier intervention and return to play. It is important for clinicians to have a framework to systemically examine the elbow to accurately diagnose a variety of elbow pathologies in this unique patient population.

Indications:

The purpose of this video is to educate clinicians on how to diagnose a variety of elbow pathologies in the throwing athlete. Currently, there is no published video describing the evaluation of the elbow in throwing athletes with associated reliability measures for specific examination maneuvers. This video teaches how to perform these examination maneuvers, interpret their findings, and review reliability measures associated with them.

Technique Description:

This video provides an overview of the physical examination of the elbow in throwing athletes, including evaluation of range of motion, neurologic pathology, and special examination maneuvers depending on the location at the elbow.

Results:

The discussed tools for evaluation can aid in accurate diagnosis of a variety of elbow pathologies. There is variability among physical maneuvers regarding their reliability measures, with many maneuvers having reliability measures that have not been fully studied.

Discussion/Conclusion:

Using a detailed history and focused physical examination, a variety of elbow pathologies can be diagnosed. Early and accurate diagnosis is crucial for early intervention for both nonoperative and operative management, allowing for earlier return to competition.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract.

This is a visual representation of the abstract.

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DOI: 10.1177/26350254241291590.M1

Video Transcript

In this video, we will discuss the evaluation of the elbow in the throwing athlete. This video is prepared by the listed authors from the Medical University of South Carolina in Charleston, South Carolina.

The authors have nothing to disclose.

The purpose of this video is to provide a framework for clinicians to effectively diagnose a variety of elbow pathologies in throwing athletes. We will start with a brief background of these injuries and how to obtain a thorough history of these patients to aid in diagnosis. This will be followed by a discussion of the physical examination specific to location, including inspection, range of motion, palpation, and special examination maneuvers. We also will describe pearls and reliability measures for these examination techniques.

Background

Elbow injuries in throwing athletes are becoming more common.^6,7 With regard to the elbow, unique stresses and changes in the valgus carrying angle of the elbow increase the risk for injury during the pitching cycle, particularly during the phases of late cocking and early acceleration. ⁵ Elbow injuries result from a variety of factors, including increased workload, throwing while fatigued, high-velocity throwing, and improper pitching mechanics. ⁸

The effective evaluation of the throwing athlete begins with a thorough history. Important elements of the history include age, position, current level of activity, and level of competition. Risk factors for elbow injuries include >100 pitches in a game, pitching consecutive days, playing pitcher or catcher, loss of shoulder range of motion, loss of hip range of motion, high-velocity pitching when fatigued, and core weakness. ⁸ Characterizing the patient’s pain based on location, quality, radiation, timing, and exacerbating/relieving factors can help narrow the differential diagnosis. Changes to their throwing velocity, strength, accuracy, and stamina should be evaluated, in addition to previous elbow injuries, elbow surgeries, or pain in nearby joints.

Physical examination of the elbow should start with inspection. The valgus carrying angle, the angle between a line drawn down the axis of the arm and down the axis of the forearm, is normally 11° to 14° in men and 13° to 16° in women.^2,17 It is common to see a valgus carrying angle in throwing athletes over 15°.^10,12 It is also common to see medial epicondyle hypertrophy in the throwing arm.^10,12 The clinician should also look for previous incisions, trauma, or signs of atrophy compared to the contralateral elbow.

After inspection, range of motion should be assessed. Both active and passive range of motion should be evaluated and compared to the contralateral side. Elbow flexion contractures are commonly seen in pitchers up to 20°. ¹⁷ Painful loss of motion may be due to soft tissue swelling, contracture, bony impingement, and loose bodies. ¹⁷ Firm mechanical blocks may indicate osteophyte formation in the olecranon fossa if there is a block in extension or in the coronoid fossa if there is a block in flexion. Pain in the mid-arc of motion can be characteristic of an osteochondral lesion. ¹⁷

An examination of nerves at the elbow is also important, particularly the ulnar nerve. The superficial location of the ulnar nerve leaves it susceptible to injury from trauma, compression, and traction. ¹ There are several sites of compression at the elbow, including the arcade of Struthers, cubital tunnel, Osborne’s ligament, and flexor carpi ulnaris muscle bellies. After evaluating for sensory deficits in the ulnar nerve distribution, the patient should be evaluated for cubital tunnel syndrome. Tinel’s test should be performed along the length of the nerve. Tinel’s test at the elbow has a sensitivity of 62% and a specificity of 53% for ulnar nerve pathology. ¹ An elbow flexion test can also be performed to evaluate for pain or paresthesias along the ulnar nerve. The sensitivity of the elbow flexion test is 36% to 93%, and the specificity is 40% to 99%. ¹ Ulnar nerve stability should also be evaluated. Ulnar nerve hypermobility can be normally found in 37% of elbows. ¹ Unstable ulnar nerves can subluxate anteriorly to the medial epicondyle when the elbow is brought from extension to flexion. ⁴ This is important to note because it can have surgical implications.

Technique Description

We will now transition to discussing the physical examination based on the location. At the medial elbow, important structures to palpate for tenderness include the medial epicondyle, ulnar nerve, and the ulnar collateral ligament (UCL). Areas of point tenderness at the medial elbow can be used to differentiate between flexor pronator pain at the anterior portion of the medial epicondyle versus the UCL, which is painful directly over the UCL. UCL tenderness is 81% to 94% sensitive and 22% specific for UCL pathology.^11,14 The ulnar nerve can be assessed with Tinel’s test, an elbow flexion test, and ulnar nerve instability, as previously discussed. The UCL can be more specifically assessed with special examination maneuvers, including the milking maneuver and the moving valgus stress test. The reliability of the milking maneuver is unknown, but the moving valgus stress test has a sensitivity of 100% and a specificity of 60%.^11,14 Medial epicondylitis should also be assessed; reliability measures are unknown.

We are going to begin the medial elbow examination testing for valgus instability with the milking maneuver. The examiner will place the patient with the arm at maximum external rotation, elbow flexed past 90°. The examiner will stabilize the elbow, palpate the medial joint line, and produce a valgus force on the arm. A positive test will be a reproduction of pain, instability, or apprehension at the medial elbow for a positive milking maneuver.

For the modified milking maneuver, the shoulder will be placed in adduction, the elbow will be flexed to 70°, and the arm will be internally rotated. Again, you will stabilize the elbow, producing a valgus force on the thumb. A positive test would be pain, apprehension, or instability for a positive modified milking maneuver.

The next test is a valgus stress test. The arm is semi-extended. The elbow is flexed to approximately 20° to 30°. The medial joint line is palpated and a valgus force is placed on the elbow. A positive test is going to be pain at the medial joint line or if there is no firm endpoint that is able to be assessed with stress.

A moving valgus stress test is performed with the patient upright, shoulder abducted to 90°, and maximum external rotation. The elbow is flexed. The arm is stabilized against your palm, and a valgus force is applied while extending the elbow to 30°. A positive test is reproduction of pain, instability, or apprehension between 70° and 120° of flexion. This test can be reproduced by bringing the arm down or reversing it to confirm your diagnosis.

In the test for medial epicondylitis, the patient will be upright, and you will stabilize the patient’s humerus, palpate the medial epicondyle, extend the wrist, supinate the forearm, and extend the elbow. A positive test is pain at the medial epicondyle that is reproduced with this examination maneuver.

Moving on to the anterior elbow, important structures to evaluate include the brachial artery, radial nerve, and median nerve. The integrity of the biceps insertion can be evaluated with the hook test, which has a sensitivity of 81% to 100% and a specificity of 100%.^3,13 The dynamic supination test can also be used, but its reliability has not been studied.

We are going to begin the anterior elbow examination with the hook test. This is a test for a distal biceps rupture. The patient can be sitting or standing; you will flex the elbow to 90° and maximally supinate the elbow. You want to take your index finger and loop it underneath the distal biceps tendon. If the tendon is intact, you should be able to loop your finger underneath with tension. If the tendon is not intact, you will not be able to loop your finger underneath. It is important not to go from the medial side as you can confuse the intact lacertus fibrosus for an intact distal biceps tendon when it is not.

We will then continue with the dynamic supination test. This is again a test for a biceps rupture. The elbow will be flexed to 70°, and the shoulder will be abducted to 90°. The patient will supinate and pronate the forearm. The examiner will look at the contour of the biceps musculature. If there is no movement of the contour of the biceps, that is considered a positive finding for a biceps rupture.

Moving on to the lateral elbow, important structures that should be palpated for tenderness include the lateral epicondyle, radial head, radiocapitellar joint, and aconeus. Special examination maneuvers for lateral elbow pathology include Cozen’s test for lateral epicondylitis, which has a sensitivity of 84% and a specificity of 80% to 90%. ¹⁸ The radiocapitellar plica impingement test has a sensitivity of 83% and a specificity of 88%.^15,16 The sensitivity and specificity of the active radiocapitellar compression test have not been studied. The lateral pivot shift can be used to test for posterolateral instability.

We will begin the lateral elbow examination with Cozen’s test, which is a test for lateral epicondylitis. The examiner will palpate the lateral epicondyle. The examinee will pronate the forearm, radially deviate the wrist, and perform resisted active wrist extension. A positive test is reproduced pain at the lateral epicondyle.

The next test is testing for a radiocapitellar plica. This is testing using the radiocapitellar plica impingement test. The examinee can be sitting or upright. The arm is extended and the forearm is pronated. The examiner will place a thumb and apply direct manual pressure to the radiocapitellar joint. A positive test is pain with passive elbow flexion at a low flexion angle that markedly diminishes at a higher flexion angle.

Next, we will perform the active radiocapitellar compression test. The patient’s elbow will be fully extended. You will grasp the wrist and apply a direct axial pressure to the elbow joint. The wrist will then be fully pronated and supinated. A positive test is pain at the radiocapitellar joint or mechanical symptoms of locking or catching, which may be indicative of a loose body.

Finally, we will conclude with the posterior elbow. The triceps insertion and olecranon fossa should be palpated for tenderness. Tenderness at the posteromedial olecranon, posterior trochlea, or olecranon fossa is consistent with valgus extension overload syndrome or pitcher’s elbow. ⁹ Special examination maneuvers to evaluate posterior elbow pathology include the bounce test and resisted elbow extension; reliability measures for these examinations are unknown. ¹⁹

The next test for posterior elbow impingement is the bounce test or the repeated forced elbow hyperextension test. The examiner will grip the patient’s forearm and stabilize the lower arm. You will then perform repeated hyperextension maneuvers. A positive test is elicited with pain in the posterior elbow from an impinging osteophyte or a stress fracture.

The last test of the posterior elbow is testing for triceps tendinitis. The examiner can place the patient upright or sitting. The patient will perform resisted elbow extension. Pain at the triceps insertion is considered a positive test (Table 1).

Table 1.

Examination Summary

Exam portion	Testing maneuver	Associated pathology
Medial	Milking maneuver Modified milking maneuver Moving valgus stress test Medial epicondylitis test Tinel’s test Flexion compression test	Ulnar collateral ligament Ulnar collateral ligament Ulnar collateral ligament Medial epicondylitis Cubital tunnel/ulnar neuritis Cubital tunnel/ulnar neuritis
Anterior	Hook test Dynamic supination test	Distal biceps rupture Distal biceps rupture
Lateral	Cozen’s test Radiocapitellar plica impingement test Radiocapitellar compression test	Lateral epicondylitis Radiocapitellar plica Loose body/osteochondral defect
Posterior	Olecranon and posterior trochlea palpation Bounce test Resisted extension	Valgus extension overload syndrome Impingement/stress fracture Triceps tendonitis

These are our references and we thank you for your attention.