The Elbow Physical Examination for Telemedicine Encounters

Introduction

The COVID-19 pandemic resulted in a decrease in outpatient clinic visits, with a corresponding increase in remote telehealth evaluations [24,30]. Modern technologies have allowed for user-friendly web-based videoconferencing platforms to facilitate patient-clinician interactions in a safe and effective manner [11]. The social distancing measures and in-person evaluation restrictions imposed by the pandemic have forced patients and clinicians to embrace this opportunity to continue receiving and providing care. Several studies have shown that telehealth visits reduce visit times, wait times, and overall health care costs, while providing a similar level of patient satisfaction as in-person visits [23,26,37,38]. Despite previous reports highlighting the benefits of telehealth, it has not been widely adopted in orthopedic surgery or sports medicine practices prior to the COVID-19 pandemic [18].

The efficiency and convenience experienced with telehealth will likely drive its continued use among musculoskeletal care providers [18,20,24,30]. A current concern with telehealth includes the ability to perform an effective physical examination, which is viewed by many to be a cornerstone of the clinical evaluation [3,4,14,15,32,33]. Few studies have addressed techniques to complete a comprehensive physical examination for the purposes of a musculoskeletal telehealth visit [30]. The purpose of this article is to provide clinicians with a detailed description of how to complete a comprehensive elbow physical examination during a telehealth visit.

Telehealth Visit Preparation

To facilitate efficiency, new patient forms can be completed prior to the telehealth visit. Information gathered should include the chief complaint, history of present illness, past medical history, past surgical history, allergies, home medications, social history, and a review of systems. The clinician can review this information prior to the visit to guide the patient interview. Furthermore, patients should review a patient instruction handout provided to them prior to their visit (Table 1). Instructing patients on proper clothing, examination space, and positioning of themselves and the camera will prevent delays once the visit starts.

Table 1.

Patient instructions.

Clothing: Exposure of both elbows is required. For males, shirtless or tank top. For females, tank top or sports bra. Examination space: 10–15 feet of open space should be available to allow the patient to move away from the camera and provide perspective during testing. Patient position: The examination will be conducted in 2 positions: 1. Standing; 2. Sitting. Initially, the patient should stand 4–5 feet from the camera but will be asked to move closer to or further away from the camera during portions of the examination. For some specialty testing, the patient should sit in a chair 4–5 feet away from the camera, with adjustments made as needed. Camera position: Both when standing and sitting, the camera should be at the elbow level (use a dresser or an assistant to position the computer/phone/tablet). Additional items: Common household items—Chair, plastic grocery bags (double bag) or similar, eight 16-ounce soup cans, or other canned goods.

Physical Examination

The elbow examination can be broadly divided into a core examination and pathology-specific special testing. The core examination includes inspection, palpation, range of motion, and neurovascular testing. Specialty tests can then be tailored to the patient’s working differential diagnosis [29,30]. Performing a complete core examination and specialty testing via a telemedicine platform requires slight modifications as detailed below.

Cervical Spine Virtual Physical Examination

Examining a patient with an elbow complaint should include screening for cervical spine pathology, which can coexist and/or produce symptoms inaccurately perceived by the patient as originating at the elbow (Supplemental Table 2) [41]. The patient should be asked if they experience any pain in their neck, and if so, asked to localize the pain by pointing to the most symptomatic location. Cervical spine range of motion should be tested in flexion, extension, and rotation to assess for decreased motion, symmetry, and pain. In patients with decreased and/or asymmetric motion and/or pain with range of motion, a more in-depth workup may be required to determine if the patient has cervical spine pathology that may be contributing to their symptoms. The Spurling test is a useful special test with a sensitivity of 30% to 50% and a specificity of 74% to 96% for the assessment of nerve root compression causing radicular symptoms [14,34,35].

Core Elbow Virtual Physical Examination

The bilateral elbows should be inspected for swelling, ecchymosis, erythema, scars, and incisions. The patient should be instructed to position the camera for visualization of the elbows while rotating stepwise for adequate visualization of the front, sides, and back of the affected elbow (Supplemental Table 3). Furthermore, inspection should include an assessment for deformity including resting elbow position, carrying angle, and deformity of the biceps muscle (Popeye deformity). The patient should be asked to identify the location of maximal pain by pointing to the area with a single finger. Range of motion testing should be performed while assessing for symmetry and/or pain. Elbow flexion and extension should be visualized from the side, while supination and pronation should be visualized with the patient directly facing the camera. Passive motion can additionally be assessed with the assistance of the patient’s contralateral extremity.

Previous studies have used technologies including smartphone applications, virtual goniometers, and motion-sensing devices such as accelerometers and gyroscopes to evaluate upper extremity range of motion [2,39,42]. Strength testing can be performed with the use of common household items, such as with plastic bags and canned goods. Sensory and peripheral vascular testing can be performed independently by the patient, and should be compared with the contralateral extremity.

Special Testing Elbow Virtual Physical Examination

Pathology-specific special testing can be subdivided into instability, valgus extension overload, tendon, nerve, and generalized ligamentous laxity. The patient can complete most special testing independently, with only minor alterations to the originally described techniques. An additional remote examiner can help facilitate some provocative maneuvers, but this is not a prerequisite. Sensitivities, specificities, and predictive values for the in-person version of these examination maneuvers are provided when available (Supplemental Table 4).

Instability

The milking maneuver and moving valgus stress tests are excellent screening tests for ulnar collateral ligament pathology (Figs. 1 and 2, respectively) [22,29]. We modified these examination maneuvers to allow for a patient to perform these tests independently with household items (Supplemental Table 4). The chair push-up test is an excellent screening test for posterolateral rotatory instability, which can be performed independently by a patient with the use of a chair [25].

Fig. 1.

Virtual milking maneuver.

Fig. 2.

Virtual moving valgus stress test; snapshots illustrate progressive movement from a flexed to an extended position (a–c).

Valgus extension overload

The valgus extension overload test can be used to screen for posteromedial impingement (Fig. 3) [1,40]. We have modified this examination maneuver to allow for a patient to perform this test independently for a telehealth visit.

Fig. 3.

Virtual valgus extension overload test.

Tendon

The Maudsley test and chair test are 2 screening tests for lateral epicondylitis [16,29]. We made slight modifications to these tests to allow for patients to perform them independently with household items. For the evaluation of distal biceps tendon ruptures, the hook test and passive forearm pronation test can be performed [8,12,21]. If instructed effectively, both tests can be performed independently by the patient.

Nerve

The elbow flexion test and Tinel sign can be used to screen for cubital tunnel syndrome, and can be performed by patients with appropriate instruction [29]. Radial tunnel syndrome can be assessed with the passive pronation with wrist flexion test. The resisted supination test can be used to screen for posterior interosseous nerve syndrome. We have made slight modifications to this test to allow for patients to perform this examination independently with household items Pronator syndrome can be screened for by instructing the patient to perform the Tinel sign.

Beighton criteria

To evaluate for generalized joint hypermobility, a patient can perform the maneuvers comprising the Beighton score independently.

Postoperative Elbow Virtual Physical Examination

The postoperative elbow examination can typically be completed using a condensed version of the core elbow virtual physical examination. Inspection of the surgical site can easily be performed. Evidence of erythema or other concerns for infection should prompt an in-person evaluation. Range of motion testing (when appropriate) can be performed as described previously. Virtual goniometers can be useful to accurately assess range of motion, and subsequent progress in the postoperative period [10,30]. Special testing (when appropriate) can be assessed as described previously.

Discussion

The COVID-19 pandemic resulted in a dramatic increase in telehealth evaluations [24,30]. Due to the convenience and efficiency with telehealth visits, it is likely to persist past the current pandemic. Studies have found telehealth visits to be associated with reduced visit times, wait times, and overall health care costs, while maintaining patient satisfaction levels [23,24,37]. The ability to perform an effective physical examination is a current concern of telehealth visits for many musculoskeletal providers [3,4,14,15,32,33]. Few studies have addressed techniques to facilitate a comprehensive virtual physical examination for the purposes of a musculoskeletal telehealth visit [30]. The purpose of this article was to provide clinicians with a detailed description of how to complete a comprehensive elbow virtual physical examination during a telehealth visit.

Telehealth orthopedic visits have been shown to be effective for remote consultations, outpatient evaluation, and rehabilitation, improving access to care for patients with a musculoskeletal complaint [5,6,17,27,31,36]. While telehealth visits will not entirely replace outpatient evaluations, convenience and efficiency advantages will likely result in telehealth becoming a lasting patient evaluation method in the future. Furthermore, socioeconomic benefits will likely drive an increase in telehealth visits, given the increasing emphasis on value-based care [5,7,9,13,17,19,28]. At many institutions, clinicians are encouraged to continue telehealth visits to accommodate patients who require a flexible scheduling option, and those whose geographical location makes in-person evaluation difficult.

We recognize a telehealth evaluation will never completely replace in-patient evaluations, largely due to limitations in a clinician’s ability to perform an effective virtual physical examination. Continued work should be dedicated to exploring the ability to perform examination maneuvers via telehealth, even when slight modifications must be developed. Furthermore, investigation into the sensitivities and specificities of telehealth physical examination maneuvers should be pursued. Although the accuracy of telehealth physical examination maneuvers has not been adequately studied, treatment plans should be formulated when virtual physical examination findings corroborate the patient’s history and imaging findings. When examination findings are conflicting, or the diagnosis remains unclear, a formal in-person visit should be recommended.