● Mill test : The patient is seated with the elbow extended and the forearm pronated. The examiner passively flexes the wrist to stretch the extensors (Ma & Wang, 2020) ● Maudsley test : The patient is seated with the elbow flexed to 90 degrees and the forearm pronated. The clinician instructs the client to extend the middle finger against resistance provided by the examiner. The test is positive if it creates lateral elbow pain. medial stress to the elbow. The test is positive if there is no firm end feel, if there is gapping of the medial joint, and/or there is reproduction of the patient’s pain. This test has a sensitivity of 66% and a specificity of 60% (Karbach & Elfar, 2017). ● Milking maneuver : The milking maneuver is used to specifically test the anterior bundle of the ulnar (medial) collateral ligament. For this test, the patient’s arm is externally rotated, and the elbow is flexed beyond 90 degrees. While one hand stabilizes the elbow and palpates the medial joint line, the other hand applies a valgus force by pulling the patient’s thumb (Karbach & Elfar, 2017). ● Moving valgus test : The moving valgus test is completed by placing the patient’s shoulder in 90 degrees of abduction and maximal external rotation with the elbow in maximal flexion. The examiner applies a constant valgus force to the elbow as the elbow is extended to 30 degrees of flexion. The test is positive if pain is reproduced over the ulnar collateral ligament between 70 and 120 degrees of flexion. To confirm a positive finding, the examiner may reverse the movement and flex the elbow while applying valgus force, with reproduction of pain expected in the same range of flexion. This test has been shown to be 100% sensitive and 75% specific for ulnar collateral injuries (Karbach & Elfar, 2017). subluxation: The examiner’s fingers and palm are positioned just proximally to the lateral humeral epicondyle, and the thumb is placed about 5 cm proximal to the medial humeral epicondyle. With the patient’s elbow in extension, the ulnar nerve is pressed by the thumb into the medial head of the triceps and then both structures are pushed laterally. This stabilizes the nerve behind the medial epicondyle. With the nerve stabilized, flexion of the elbow should no longer result in subluxation. Clinical Presentation Clinical presentation may include medial elbow pain that increases with heavy manual activities; a snapping at the medial elbow with flexion and extension; and paresthesias, such as tingling and burning, along the ulnar distribution (lateral two fingers; Xarchas et al., 2007). Those who frequently participate in heavy manual activities during sports performance (e.g., bodybuilders) or occupational performance (e.g., servers at restaurants) are more susceptible.
There are several special tests for lateral epicondylitis: ● Cozen test : The patient is seated with the affected elbow fully extended, the forearm pronated, and the hand in a fist. The clinician places their thumb over the lateral epicondyle and instructs the client to extend, pronate, and radially deviate their fist against resistance (Johns & Shridhar, 2020). This test is positive if it recreates the client’s lateral elbow pain. Ulnar (Medial) collateral ligament injury Injury to the medial collateral ligament (UCL) of the elbow is commonly seen in throwing athletes when high torque is generated by the trunk through the core muscles that is then transmitted to the upper extremity through different phases of the throwing motion ((Barco & Antuña, 2017). Risk factors for UCL injuries include pitching more than 100 innings per year, pitching while fatigued, pitching with higher velocity, pitching on consecutive days, and pitching while growing up in warmer climates (Jang, 2019). Clinical Presentation Clinical presentation typically includes medial elbow pain in the late cocking and/or acceleration phases of throwing with decreased throwing velocity and precision. Sudden pain may signify acute failure of the medial collateral ligament (Barco & Antuña, 2017). Positive physical examination findings include tenderness of the medial elbow just anterior and distal to the medial condyle and elbow valgus instability (Barco & Antuña, 2017). There may be loss of extension range of motion and/or pain with terminal extension (Jang, 2019). Special tests for UCL involvement include: ● Valgus stress test: The valgus stress test assesses stability of the medial aspect of the elbow. For this test, the patient’s elbow is placed in 20 to 30 degrees of flexion with the forearm supinated. The examiner applies Ulnar nerve subluxation and dislocation Hypermobility of the ulnar nerve in the cubital tunnel with resultant subluxation or dislocation is a condition sometimes seen in competitive athletes due to heavy upper extremity use (Tsukada et al., 2021). Specifically, ulnar nerve subluxation occurs when elbow flexion results in an anterior displacement of the ulnar nerve from the retrocondylar groove of the medial epicondyle (Mirza et al., 2020). According to Tsukada et al. (2021), approximately 75% of college athletes have hypermobility of the ulnar nerve at the cubital tunnel with or without subjective or objective findings. Other factors related to the onset of this condition include natural laxity, anatomical variation of the medial epicondyle and the retrocondylar groove, congenital disorders, developmental disorders, and trauma (Mirza et al., 2020). Repeated subluxation of the ulnar nerve can result in tractional and frictional neuritis (Xarchas et al., 2007). Physical exam reveals tenderness over the medial epicondyle. The examiner may be able to palpate the nerve subluxing during flexion and relocating with extension. Xarchas et al. (2007) describe a clinical test for ulnar nerve Cubital tunnel syndrome/ulnar nerve entrapment Cubital tunnel syndrome is a chronic condition that causes pain, numbness, and weakness in the hand. It is caused when the ulnar nerve becomes entrapped at the elbow as it passes behind the medial epicondyle of the humerus (An et al., 2017). It is the second most common peripheral
neuropathy after carpal tunnel syndrome (An et al., 2017). It commonly affects those whose occupational performance includes twisting motions of the forearm/arm, such as baseball pitchers. Left untreated, this condition may result in permanent hand disability.
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