I took my 13-year-old son in to see a specialist because he was complaining of elbow pain and it was affecting his pitching for his team. The surgeon poked and prodded until I was sure if the kid didn't already have a problem, he would develop one. Is all this type of hemming and hawing around really necesary? I'm just wondering.

Any time a young person (and especially an athlete) injures his or her elbow, an accurate diagnosis is absolutely essential to providing the best treatment. Whether the examiner is an orthopedic surgeon, physician's assistant, or physical therapist, there is a recommended order to the patient history and physical examination.

In a recently published article, surgeons from the Center for Shoulder, Elbow, and Sports Medicine at Columbia University in New York City provided a step-by-step approach to the evaluation of elbow injuries in throwing athletes. They suggested that a thorough understanding of normal elbow anatomy and elbow joint biomechanics will help the examiner assess for and recognize abnormal or pathologic conditions.

The first step is to take a thorough patient history (e.g., what happened, when did it happen, how did the injury occur, what has been the patient's health history up to the date of the examination). When taking a patient history there are the usual questions about the location, type, duration, and intensity of pain. Hand dominance (right or left handed) is also recorded.

The athlete is asked to give as many details as possible about the symptoms. Anything that the athlete can tell makes the problem better or worse is important information. Type of sport activity engaged in at the time of the injury is also important (e.g., overhead throwing, specific tennis strokes). Information about previous injuries or surgeries is gathered.

The examiner often has a pretty good idea what's wrong with the elbow even before examining it. The list of possible diagnoses can be formulated just based on the patient's responses to questions. For example, pain on the medial (inside) of the elbow points to the possibility of a ligamentous problem.

On the other hand, symptoms like numbness and tingling down the arm may point more to a problem with nerve compression. There are special tests used to evaluate the status of the three nerves that pass through the elbow and other ligamentous tests to determine how stable the joint is.

Moving the patient's arm through elbow flexion, extension, supination (palm up), and pronation (palm down) can reveal important diagnostic information. Too much elbow motion suggests ligamentous injury. A block in motion, locking, catching, or other causes of decreased joint motion point more to a possible fracture, bone spurs, or other type of intra-articular (inside the joint) injury.

Tests can be done from all four directions around the elbow (anterior or front, posterior or back, medial or side closest to the body, and lateral or side away from the body). There are various tests possible to perform (e.g., joint compression tests, pivot-shift test for stability, valgus-varus tests, hook test for biceps tendon rupture).

A well organized assessment of elbow injuries in throwing athletes will lead to the most appropriate treatment and therefore, faster return-to-sports. This may seem like quite a bit of poking and prodding, but by using a step-by-step interview and exam, the examiner can stay focused and produce an accurate diagnosis. An accurate diagnosis leads to proper treatment and faster return-to-sportsl

Reference: 

Stephanie H. Hsu, MD, et al. Physical Examination of the Athlete's Elbow. In The American Journal of Sports Medicine. March 2012. Vol. 40. No. 3. Pp. 699-708.

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