Evaluation of the New Patient
Stephanie C. Bazylewicz
Gabrielle C. McIntyre
I. INTRODUCTION
Design your greeting and introduction. What does this entail? Typically, this includes a welcome greeting, your name, who your supervising physician is, and your position. A handshake and a warm smile go a long way toward establishing a positive rapport immediately. For example, “Hello! Welcome to our office. My name is … and I am Dr… .’s physician assistant (PA).”
Although the profession of PA has been established for nearly 50 years, and there are more than 130,000 certified PAs in the United States, many patients, or accompanying family or friends, will commonly ask you, “What is a PA?”1 Be able to concisely answer this question while instilling confidence in your patient that you are their advocate and part of their health care team. For example, “A PA is a licensed and certified practitioner that works in conjunction with a supervising physician. Today, Dr…. and I will be working together to answer your questions and address your concerns, and I am here to get things started.”
Do not be surprised, or offended, if the response is, “So why didn’t you study for a few more years to become a doctor?” or “So when will you become a doctor?” Be proud of your profession and respond politely. Despite having this conversation, patients often are unsure of how to address you and may say, “Doctor ….” By law it is your obligation to be sure the patient understands you are not a doctor. You may gently reiterate this point but recommending they refer to you by your first name or full name without a title.
This is a good opportunity to determine how the patient would like to be addressed as well. Some patients feel strongly about being addressed formally as Dr., Mr., Mrs., or Ms., just as others may be adamant about being addressed by their first name. Never use terms like “dear” or “sweetie.” Next, if there are any visitors present in the room, ask what the relationship is between the patient and the present parties. Do not assume. For example, “Please tell me how are you two related?” Once the relationship is established, and if the patient is 18 years or older, ask if they are comfortable moving forward with a history and physical with others present in the room. Do not forget, a parent or guardian must accompany all minors.
This is a good opportunity to determine how the patient would like to be addressed as well. Some patients feel strongly about being addressed formally as Dr., Mr., Mrs., or Ms., just as others may be adamant about being addressed by their first name. Never use terms like “dear” or “sweetie.” Next, if there are any visitors present in the room, ask what the relationship is between the patient and the present parties. Do not assume. For example, “Please tell me how are you two related?” Once the relationship is established, and if the patient is 18 years or older, ask if they are comfortable moving forward with a history and physical with others present in the room. Do not forget, a parent or guardian must accompany all minors.
If a patient is not English speaking, be sure to use an interpreter for the encounter. Avoid having family members or friends translate because key information may be lost in the translation or opinions other than the patients are interjected. Include the translator’s identification number in your official documentation.
In some situations, a patient will be brought in by emergency medical services or an ancillary service from a rehabilitation center or a nursing home. Always address the patient directly and determine their capacity for providing a history. The home institution will likely send paperwork that includes a current medication list and an additional sheet for orders and visit updates. If the patient is unable to communicate their history, contact the home institution and speak with the patient’s primary care physician or nurse. As a last resort, the transport team may be able to provide information.
Once you have covered all the above, segue into the history and physical with an open-ended statement. For example, “Please tell me what brings you in to the office today.”
II. HISTORY
During this portion of the patient encounter, you will collect subjective data. Must cover topics include chief complaint, past medical history, past surgical history, family history, social history, current medications, and allergies to drugs or foods.
The Chief Complaint
This is the patient’s reason for seeking care. Once they have explained the reason for their visit, further characterize the complaint by determining the history of the present illness. Begin with onset of symptoms: acute vs. gradual, and length of time symptoms have been present. Was there an inciting event and if so what was the mechanism of injury? Next, determine if there are any palliative or provocative factors. Palliative factors may include: rest, medication, heat, ice, physical or occupation therapy, injections, bracing devices, position/posturing, or previous surgical intervention. Provocative factors may include: repetitive motion, position/posturing, range of motion, resistive movements, and ambulation. Next determine the quality and characteristics of symptoms: if the complaint is pain, is it sharp, dull, aching, or burning? What is the region the symptoms are located in, and do they radiate to another location? What is the severity of symptoms? You may use a 1 to 10 scale to quantify severity. What is the timing of symptoms and are they constant, intermittent, or progressive? The chief complaint may include symptoms such as pain, weakness, stiffness/loss of range of motion, instability, numbness, and tingling.
Past Medical History
First, begin with the patient’s pertinent past medical history. This includes diagnoses that may cause the chief complaint, may have the chief complaint as a symptom, or may make the patient susceptible to their specific injury or condition. For conditions identified, learn the details of onset, diagnosis, treatment to date, and complications.
Next, review the patient’s complete past medical history. This includes all chronic conditions and hospitalizations to be documented in reverse chronologic order. For conditions where laboratory assessments or diagnostic evaluations were likely performed, you may request their most recent testing results.
Common childhood illnesses: Asthma, measles, mumps, rubella, chickenpox, pertussis, rheumatic fever, recurrent ear infections.
Common adult illnesses: Hypertension, coronary artery disease, diabetes, high cholesterol, cerebral vascular accident, myocardial infarction, asthma, COPD, thyroid disease, renal disease, seizures, cancer, anemia, substance abuse, depression, and anxiety.
Common screening tests: Dual-energy X-ray absorptiometry (DEXA) scan, hemoccult, lipid panel, and metabolic panels.
Past Surgical History
It is important to document details of all prior surgeries. This includes: surgery performed, date of surgery, location of surgery (hospital name and city), surgeon, and indication for surgery as well as any adverse reactions to anesthesia. If relevant, limb and laterality and presence of an implant should be recorded. Note any prior adverse effects to anesthesia and severity of the effect.
Family History
Begin this section of history with an open-ended question such as, “Has anyone in your family had a similar condition or symptoms?” This will allow the patient to discuss past family history pertinent to orthopaedics. Documentation should also include major systemic conditions including: rheumatoid arthritis, osteoarthritis, hypertension, diabetes, high cholesterol, cerebral vascular accident, myocardial infarction, coronary artery disease, cancer, hematology/clotting conditions, etc. A thorough history will include three generations of direct blood relatives, and note the age and health status, or age at death of each immediate relative. For example, father, deceased, age 67, CVA. Mother, A&W, age 64.
Social History
This portion of the history allows you to learn more about a patient’s private lifestyle practices and activities of daily living, while identifying potential risk factors. It also provides an opportunity to initiate patient education and promote positive lifestyle changes. Many of the topics covered are of a sensitive nature so you may want to preface this discussion by reassuring your patient that
these questions are part of a routine history and they are asked of all patients.
these questions are part of a routine history and they are asked of all patients.
Tobacco Use
Documented as pack years: number of packs smoked daily × years smoked. If a patient reports they were a former smoker, document their pack years and quit date.
Alcohol
Document consumption quantity and frequency. For example, Do you consume any alcohol, and, if so, how often? Determine the type: beer, liquor, or wine; the volume consumed; and the frequency. If a red flag is raised that the patient may have alcohol dependence or addiction, continue the conversation by asking the CAGE questionnaire.2
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
If a patient answers yes to two or more questions, this is considered clinically significant, and further evaluation and treatment regarding alcohol abuse is recommended.
Illicit Drug Use
Document specific drug, quantity, and frequency. For example, Do you ever use drugs that are not prescribed to you? This includes marijuana, cocaine, heroin, etc. If so, determine the frequency and volume of consumption.
Occupation
Is the patient currently employed? If employed, is it on a full-time, part-time, or per diem basis. Does their profession in any way influence why they are present for this visit? If unemployed, for what length of time have they been out of work?
Functional Status and Independence
Do they live alone, with family, friends, or in an assisted living facility? Can they prepare their own meals and bathe independently? Are there stairs in their home, and can they be navigated safely? Do they drive a motor vehicle? Do they feel safe at home? If pertinent, you may also discuss: diet, sleep, religion, sexual status and activity, education, and military involvement.
Current Medications
All current prescribed and over-the-counter medications or supplements should be listed in the patient record. Complete documentation includes: name of the medication, dosage, route and frequency of administration, and length of time patient has been taking the medication. For example, Metformin 500 mg, 1 tablet po, once daily, ×3 years.
Some other medications that are relevant to orthopaedics that can affect bone and soft-tissue health include: steroids, bisphosphonates, calcitonin, estrogen, parathyroid hormone, chemotherapy, nonsteroidal anti-inflammatories, proton pump inhibitors, and fluoroquinolones. It is important to document if your patient has taken any of these medications in the past, for what length of time, and when the medication was discontinued. Chapter 5 will further review these medications and why they are important to each specific class of orthopaedic patient.
Allergies
All food and drug allergies as well as reaction type and severity of the reaction must be documented. Many patients often, consider mild side effects of medications to be an allergy. For example, nausea is a common side effect many patients experience to narcotic medications. It is important to note such effects so you can determine the optimal medication to prescribe for your patient, but do understand this is not a true allergy. Be sure to delineate true allergies from adverse reactions. In addition, ask patients if they have experienced any metal sensitivity. This is commonly recognized when patients
have a reaction to costume jewelry. Because many orthopaedic patients may be operative candidates acutely or in the future, this information is important to help tailor which implants are selected for them. Often patients will indicate that they are uncertain of any sensitivity. You can further explore this possibility by asking if they have dental implants or a pacemaker or defibrillator.
have a reaction to costume jewelry. Because many orthopaedic patients may be operative candidates acutely or in the future, this information is important to help tailor which implants are selected for them. Often patients will indicate that they are uncertain of any sensitivity. You can further explore this possibility by asking if they have dental implants or a pacemaker or defibrillator.
III. PHYSICAL EXAMINATION
The physical examination for an acute musculoskeletal trauma patient will differ from that of a new patient seen in the outpatient office setting. Below is an example of a comprehensive outpatient or clinic physical examination. First remember to wash your hands and to follow necessary precautions for the given patient. Most patients will require standard gloves only. If you expect possible soiling, gowning is also advised. For open wounds or examinations requiring a procedure, sterile gloves are advised. Other precautions include: contact, enteric, droplet, airborne, and airborne respirator for which you must follow specific protocol. Before completing each portion of the examination, explain to the patient what you are going to do. If the patient is not able to be evaluated in their clothing, provide gown or loose shorts to allow necessary skin exposure.
General Survey
This portion of the examination comments on the overall appearance and well-being of the patient. Is the patient alert and oriented? Note their level of distress: no acute distress, mild, moderate, severe. Signs of distress include: crying, grimacing, groaning, and difficulty breathing. Behavior: are they anxious, agitated, cooperative, uncooperative, or withdrawn? Hydration status: well hydrated, dehydrated? Ambulation status: Normal gait, abnormal gait, use of assertive devices, wheelchair bound, bed bound? Do they appear well nourished, malnourished, or obese? Are they well kept or disheveled in appearance? Does their breath smell of: acetone, alcohol, smoke?
Vital Signs
Always document temperature (97°F to 100.4°F), pulse (60 and 100 beats/min), blood pressure (100/60 to 140/90), respiratory rate (12 and 20 respirations/min), and blood oxygen saturation (>93%). These measurements may identify an acute medical problem or evaluate a chronic medical condition. Often vital signs can be overlooked in an outpatient setting, but remember, vital signs are always vital. The patient’s height and weight should also be measured and BMI calculated. Pre-hypertension is a systolic blood pressure 120 to 140 mm Hg or diastolic blood pressure 80 to 90 mm Hg, whereas hypertension is a systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg.
Ophthalmologic
Note presence of: pupils equal, round, reactive to light and accommodative, Extraoccular muscles intact, and normal conjunctiva.
Head, Ears, Nose, Throat
Is the patient normocephalic, atraumatic? Does the patient have normal hearing? Nasal discharge? Evaluate the oral mucosa: dry, erythematous? Note dentition.
Neck
Is the neck supple? Nontender? Is the trachea midline? Note the presence of lymphadenopathy and thyromegaly. Scars present? Assess active range of motion (Table 4-1).
TABLE 4-1 Full Active Range of Motion of the Neck | ||||||||||
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Respiratory System
Observation and Inspection
Are their breaths regular and deep? Does their breathing pattern appear labored, distressed, or involve accessory muscles of breathing, that is, scalene, sternocleidomastoid muscles, or trapezium? Are their lips pursed? Evaluate the color of lips and nail beds. Observe their posture. What is their ability to speak? If the patient is unable to speak in complete sentences, count how many words they can speak before taking a breath. Are there any audible noises that do not require use of the stethoscope, that is, wheezing or gurgling?
Evaluate for Chest and Spinal Deformities
Deformities may impair a patient’s normal breathing ability. Look for barrel chest (increased AP diameter, associated with emphysema and hyperinflation), pectus excavatum (posterior displacement of the inferior sternum), kyphosis (excessive convexity of the cervical, thoracic, or sacral spine), lordosis (increased concavity of the cervical or lumbar spine), and scoliosis (sideways curvature of the spine).
Palpation of the Chest
Palpation will aid in evaluating chest excursion and to allow you to perform tactile fremitus which may identify lung consolidations or pleural fluid.
Percussion
Striking a surface that covers an air-filled structure (healthy lung) produces a resonant tone vs. displaced tissue full of fluid (pleural effusion) produces a dull tone vs. infiltrated space (pneumonia) which produces a deadened tone.
Auscultation
Remind yourself of lung lobe anatomy. With the patient sitting upright, instruct them to take slow deep breaths through their mouth while auscultating posteriorly then anteriorly for clear lungs (vesicular breath sounds), wheezes (high-pitch whistling sound most pronounced during expiration because of narrowed airways),
rales (scratchy crackling sound most commonly associated with fluid accumulation), or rhonchi (continuous low-pitched rattling sound common with obstruction and secretions). Patients with large breasts may be asked to lay down allowing their breasts to fall to the side improving ability to auscultate the lungs.
rales (scratchy crackling sound most commonly associated with fluid accumulation), or rhonchi (continuous low-pitched rattling sound common with obstruction and secretions). Patients with large breasts may be asked to lay down allowing their breasts to fall to the side improving ability to auscultate the lungs.
Cardiovascular
Observation and Inspection
Evaluate for jugular venous distention which, if present, indicates an increase in central venous pressure and comments on the patient’s intravascular volume status and overall cardiac function. Remember the internal jugular vein is located between the two heads of the sternocleidomastoid muscle (SCM) and anterior to the ear. Have you patient turn their head to the left and apply resistance to define the SCM.
Palpation
Determine the point of maximum impulse.
Auscultation
With the diaphragm of your stethoscope, auscultate for S1 and S2. Volume: how loud is the sound? The majority of murmurs are evaluated as 1 to 3/6. Are there additional heart sounds (S3, S4) described as a gallop? In a patient >30 years old, this often indicates pathology.
During the cardiovascular examination, you may also want to evaluate the distal extremities for cardiac dysfunction and peripheral vascular disease or you may save this portion of the examination for the musculoskeletal examination. A brief examination may begin with evaluating for peripheral edema (Table 4-2).
Next evaluate distal pulses to determine the presence of arterial vascular disease (Table 4-3). This includes the dorsalis pedis and the posterior tibial arteries. The dorsalis pedis terminates at the proximal aspect of the first intermetatarsal space. It can be palpated just lateral to the extension hallucis longus tendon just distal to the navicular bone (Figure 4-1). The posterior tibial artery is just posterior to the medial malleolus.
TABLE 4-2 Subjective Edema Grading System | ||||||||
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TABLE 4-3 Subjective Distal Pulse Grading System | ||||||||||
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 Figure 4-1 Dorsalis pedis pulse. Dorsalis pedis artery depicted in red and location of pulse palpation depicted by X. |
Lastly, evaluate capillary refill. Press on the nail of the great toe or fingers until blanching occurs. Then, release and measure time for blood inflow to the distal aspect of the lower extremity. Within normal limits: immediate to 2 seconds. Greater than 2 seconds is abnormal and indicates arterial insufficiency or hypovolemia.
Gastrointestinal
Inspect for surgical scars, feeding tubes, and ostomies. Palpate the abdomen and note if it is soft, nontender, and nondistended. Evaluate for organomegaly. Auscultate in all four quadrants for normal bowel sound.
Musculoskeletal Examination
Begin all examinations with inspection for skin changes, edema, erythema, ecchymosis, gross deformity, symmetry compared to the contralateral extremity, muscle atrophy, joint contracture, scars, and position extremity is held in. Muscle strength is graded in the following manner:
0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against gravity (test the joint in its horizontal plane)
3/5: movement possible against gravity, but not against examiner’s resistance
4/5: movement possible against some resistance by the examiner
5/5: normal strength
Upper Extremity Examination
Shoulder and Upper Arm Examination
The glenohumeral joint is the most mobile joint in the body and the arms’ connection to the axial skeleton (Figure 4-2). Because the shoulder has a significant amount of multidirectional range of motion, there is great potential for joint instability. Following inspection, continue your examination with palpation of the
bony structures: the sternoclavicular joint, the clavicle, the acromioclavicular (AC) joint, the coracoid process, the borders of the scapula, and the greater and lesser tuberosities of the humerus. Next, palpate the soft-tissue landmarks including: the trapezius, deltoid, infraspinatus, supraspinatus, and teres minor muscles, the subacromial bursa, the supraclavicular fossa, the biceps tendon, and other associated muscles and tendons. Make note of pain, muscle wasting/atrophy, increased warmth, or crepitus.
bony structures: the sternoclavicular joint, the clavicle, the acromioclavicular (AC) joint, the coracoid process, the borders of the scapula, and the greater and lesser tuberosities of the humerus. Next, palpate the soft-tissue landmarks including: the trapezius, deltoid, infraspinatus, supraspinatus, and teres minor muscles, the subacromial bursa, the supraclavicular fossa, the biceps tendon, and other associated muscles and tendons. Make note of pain, muscle wasting/atrophy, increased warmth, or crepitus.
 Figure 4-2 Anterior shoulder anatomy. (From Snell RS. Clinical Anatomy by Regions. Philadelphia, PA: Wolters Kluwer; 2011.) |
Next, assess the active range of motion of the shoulder (Table 4-4). The patient may be seated or standing for this examination. If there is no known injury to the shoulders, bilateral examinations may be conducted simultaneously. If the patient is unable to perform AROM of the shoulder joint, a passive range of motion examination may be completed. In some situations, both evaluations are valuable. Pain with AROM but not PROM may indicate muscle or tendon pathology because these structures are not activated during PROM. Note if limitations are due to pain, weakness, or fatigue and how
results compare to the contralateral joint. Remember, all range of motion measurements should be assessed with a goniometer for precise and reproducible measurements. Lastly, evaluate and grade the strength of the following muscles:
results compare to the contralateral joint. Remember, all range of motion measurements should be assessed with a goniometer for precise and reproducible measurements. Lastly, evaluate and grade the strength of the following muscles:
TABLE 4-4 Shoulder Range of Motion Values | |||||||||||||||||||||||||||
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Deltoid: shoulder abduction
Subscapularis: test internal rotation, may also evaluate with Lift-off test, see later
Supraspinatus: test abduction, may also evaluate with Empty Can test, see later
Teres minor and infraspinatus: test external rotation
Special Tests and Clinical Considerations for the Shoulder
Remember, none of the following tests are 100% sensitive or specific for any particular injury or condition.
Lift-off test (Figure 4-3): Subscapularis muscle and tendon:
Maneuver: Have the patient adduct and internally rotate their arm behind their back with their palm facing away from the back. Instruct them to lift their hand off their lower back.
Positive Examination: Inability to lift the dorsum of hand off the back may be suggestive of complete tear of subscapularis tendon or muscle. Incomplete tear may present as limited lift or pain with lift.
 Figure 4-3 Lift-off test. Instruct patient to adduct and internally rotate arm. Then instruct patient to lift hand off lower back in resistance to practitioner. Weakness or inability to lift suggestive of subscapularis tendon or muscle pathology. |
 Figure 4-4 Empty can test. Instruct the patient to abduct arm to 90 degrees and adduct forward to 30 degrees with the thumbs pointing down toward the floor. Instruct the patient to maintain this position while practitioner applies downward resistance to the patient’s forearm. Decreased strength or pain may be suggestive of supraspinatus tendon or muscle pathology. |
Empty can test (Figure 4-4): Supraspinatus muscle and tendon:
Maneuver: Instruct the patient to abduct to 90 degrees and adduct forward to 30 degrees with the thumbs pointing down toward the floor (appears as if pouring out a can). Instruct the patient to maintain this position while the examiner applies downward resistance to the patient’s forearms.
Positive Findings: Decreased strength or pain which may be suggestive of tendon or muscle tear.
External rotators:
Maneuver: Perform with elbows flexed to 90 degrees and forearm in neutral. Place your hands on the outside of their forearms and instruct the patient to eternally rotate against your resistance.
Positive Examination: Decreased strength or pain may be suggestive of tendon or muscle tear. Significant weakness of the infraspinatus may indicate suprascapular nerve palsy or denervation.
Maneuver: Stabilize the scapula with one hand while grasping the ipsilateral forearm. The arm should be internally rotated with thumb posting down. Passively forward flex the arm to above the head.
Positive Findings: Pain in the anterior shoulder is suggestive of impingement, tendonitis, or bursitis.
Hawkin’s impingement test (Figure 4-6):
Maneuver: Instruct the patient to forward flex their arm to 90 degrees and their elbow to 90 degrees. Place one hand on top of the shoulder for stabilization and to prevent elevation while internally rotating the arm at the forearm.
 Figure 4-5 Neer’s test. Practitioner should stabilize ipsilateral scapula and passively forward flex patient’s internally rotated arm with downward pointing thumb. Anterior shoulder pain suggestive of impingement. |
 Figure 4-6 Hawkin’s test. Instruct the patient to forward flex their arm to 90 degrees and their elbow to 90 degrees. Practitioner should stabilize ipsilateral shoulder while internally rotating the forearm. Anterior shoulder pain suggestive of impingement. |
Positive Findings: Pain in the anterior shoulder is suggestive of impingement, tendonitis, or bursitis.
AC joint testing:
Maneuver: Identify the AC joint by palpating laterally along the clavicle until it articulates with the acromion. Gently push on the AC joint, noting if pain is reproducible. Another test is the cross arm adduction test (Figure 4-7).
Maneuver: Instruct the patient to adduct their arm across their chest stressing the AC joint.
Positive Findings: Reproducible pain may be suggestive of arthritis. In the setting of AC separation, the area may appear swollen and deformed when compared with the contralateral joint.
 Figure 4-7 Cross arm test. Instruct the patient to adduct their arm across their chest stressing the AC joint. Reproducible pain may be suggestive of arthritis. |
The apprehension test (Figure 4-8):
Maneuver: Instruct the patient to lie on their back with their arm off the examination table. Hold their elbow flexed at 90 degrees and abduct their shoulder to 90 degrees. While externally rotating their arm, gently push anteriorly on the head of the humerus with your other hand. Then, begin to relocate the humeral head.
Positive Findings: The patient becoming apprehensive, complains of pain, or you feel the humeral head is about to pop out of the glenoid, is suggestive of instability.
Biceps tendonitis: Remember: the biceps muscle functions to supinate and flex the forearm while assisting with forward flexion of the shoulder.
 Figure 4-8 Apprehension test. Instruct the patient to lie on their back with their arm off the examination table. Hold their elbow flexed at 90 degrees and abduct their shoulder to 90 degrees. While externally rotating their arm, gently push anteriorly on the head of the humerus with your other hand and locate the humeral head. Patient apprehensiveness or pain suggestive of glenohumeral instability. |
Maneuver: First, palpate the biceps tendon in the bicipital groove (between the greater and lesser tubercles of the humeral head). If having difficulty locating the tendon, instruct the patient to flex and supinate their forearm while you palpate. Yergason’s test: Instruct the patient to flex their elbow to 90 degrees and maintain their shoulder adducted against their body. Grasp the patient’s hand and instruct them to supinate their forearm while you provide resistance.
Positive Findings: Pain upon palpation or with Yergason’s test may be suggestive of tendonitis.
Speed’s test (Figure 4-9):
Maneuver: Instruct the patient to flex their elbow to 30 degrees and supinate their forearm. Then, instruct the patient to further forward flex their shoulder while you provide resistance.
 Figure 4-9 Speed’s test. Instruct patient to flex elbow to 30 degrees and supinate their forearm. Then, instruct patient to flex shoulder against practitioner resistance. Anterior shoulder pain suggestive of biceps tendon pathology. |
Positive Findings: Pain in the anterior shoulder with resisted flexion is suggestive of biceps tendonitis.
Biceps tendon rupture: Owing to acute trauma or chronic tendonitis or trauma. On examination, there may be a palpable defect, and the biceps muscle will appear retracted and balled up, referred to as a “Popeye deformity” (Figure 4-10). Examination may also be positive for ecchymosis and edema on the anterior elbow. There will be loss of function most significantly manifested as weakened forearm supination, but also as weakened elbow flexion and forward flexion of the shoulder.
The Elbow and Forearm Examination
Begin with inspection and palpation of the bony structures of the elbow, a hinge-type joint (Figure 4-11). Palpate the medial and lateral epicondyles as well as the olecranon. Then assess active and passive ranges of motion (Table 4-5). Next, evaluate muscle strength. Muscles to evaluate:
 Figure 4-10 Popeye deformity. Popeye deformity demonstrating biceps retraction following biceps tendon rupture. |
Biceps brachii, brachialis: test elbow flexion with hand supinated
Brachioradialis: test elbow flexion with forearm in natural and thumb pointing up
Triceps brachii: test elbow extension
Pronator quadratus, pronator teres, and brachioradialis: test forearm pronation
Biceps brachii, supinator, and brachioradialis: test forearm supination
Special Tests and Clinical Considerations for the Elbow
Evaluation of lateral epicondylitis (tennis elbow) (Figure 4-12): Remember, the wrist extensors and supinator insert on the lateral epicondyle of the humerus.
Maneuver: First, palpate the lateral epicondyle. Then, instruct the patient to extend their wrist against your resistance.
Positive Findings: Reproducibility of pain with palpation or resistive movement in the absence of erythema or signs of acute infection is suggestive of lateral epicondylitis.
 Figure 4-11 Elbow anatomy. (From Wiesel SW, Williams GR, Ramsey ML, Wiesel BB. Operative Techniques in Shoulder and Elbow Surgery. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2011.) |
Evaluation of medial epicondylitis (Golfer’s elbow): Wrist flexors and forearm pronators insert on the medial epicondyle.
Maneuver: First, palpate the medial epicondyle. Then, instruct the patient to flex their wrist against your resistance.
TABLE 4-5 Full Active Range of Motion of the Elbow | |||||||||||||||
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 Figure 4-12 Tennis elbow test (Cozen’s test). While practitioner palpates patient’s lateral epicondyle, instruct patient to extend their wrist against practitioner’s resistance. Pain with palpation or resistance suggestive of lateral epicondylitis. Blue arrow is direction of patients resisted motion. |
Positive Findings: Reproducibility of pain with palpation or resistive movement in the absence of erythema or signs of acute infection is suggestive of medial epicondylitis.
Ulnar nerve entrapment: At the elbow, the ulnar nerve traverses the groove between the medial epicondyle and olecranon process known as the cubital tunnel. When entrapped, patients report neuropathic pain, that is, pins and needles, electric shock, or weakness in the ulnar nerve distribution. First, assess for normal motor strength: evaluate wrist flexion, finger flexion, and finger adduction/abduction. Next, evaluate for normal sensation utilizing two-point discrimination in the pinky and medial half of the ring finger. Last, perform the ulnar Tinel test (Figure 4-13).
Maneuver: With the elbow slightly flexed at 15 to 20 degrees, tap over the ulnar nerve at the location of the cubital tunnel.
Positive Findings: Tinel’s sign: reproducible pain with tapping.
Olecranon bursitis (Figure 4-14): Olecranon bursitis can present as infectious or noninfectious bursitis. Noninfectious bursitis: Often due to trauma, prolonged pressure, ie, persistent leaning on elbow, or excess fluid production within the bursa.
Positive Findings: Swelling at olecranon in the absence of pain, erythema, or warmth with full active painless range of motion.
Infectious bursitis: May result due to cut, abrasion, or insect bite of overlying skin, or other inflammatory processes, ie, rheumatoid arthritis, gout.
Positive Findings: Swelling at olecranon with associated erythema, warmth, and pain on palpation of the bursa. Elbow range of motion is not usually affected.
Evaluation of the lateral collateral ligament, radial collateral ligament:
Maneuver: Instruct the patient to flex their elbow to 20 to 30 degrees with their forearm in neutral position. With the patient’s arm stabilized at the medial distal humerus, apply a varus (adduction) force to the distal forearm.
Positive Findings: Pain or excessive gapping compared to contralateral joint may be suggestive of LCL sprain or tear.
Evaluation of the medial collateral ligament (MCL), ulnar collateral ligament:
 Figure 4-13 Ulnar Tinel sign. Practitioner to gently tap over ulnar nerve traversing the cubital tunnel. Reproducible pain, numbness, or tingling in the median nerve distribution suggestive of ulnar nerve entrapment. |
Maneuver: Instruct the patient to flex their elbow to 20 to 30 degrees with their forearm in neutral position. With the patient’s arm stabilized at the lateral distal humerus, apply a valgus (abduction) force to the distal forearm.
Positive Findings: Pain or excessive gapping compared to contralateral joint may be suggestive of MCL sprain or tear.
The Wrist and Hand Examination
Begin with inspection and palpation of the bony structures of the wrist and hand. Palpate the distal radius and ulna, radial and ulnar styloids, carpal bones, metacarpophalangeal joints, proximal interphalangeal joints, distal interphalangeal joints, the thumb interphalangeal joint, and the anatomical snuff box (Figure 4-15). Note the presence of Heberden’s or Bouchard’s nodes, contractures, and thenar, hypothenar, or interossei atrophy. Then, assess active and
passive ranges of motion (Table 4-6). Be sure to use a finger goniometer for CMC, MCP, PIP, DIP, and IP joints for increased precision in measurement. Next, evaluate muscle strength. Muscles to evaluate:
passive ranges of motion (Table 4-6). Be sure to use a finger goniometer for CMC, MCP, PIP, DIP, and IP joints for increased precision in measurement. Next, evaluate muscle strength. Muscles to evaluate:
 Figure 4-14 Clinical elbow bursitis. Note palpable swelling over olecranon. May be associated with tenderness to palpation. Red arrow points to fluctuant area. |
Extensor carpi radialis longus: wrist extension
Flexor carpi radialis and palmaris longus: wrist flexion
Supinator: wrist supination
Pronator teres and pronator quadratus: wrist pronation
Flexor digitorum superficialis: MCP and PIP finger flexion
Flexor digitorum profundus: DIP flexion
Extensor digitorum: MCP and IP extension
Extensor pollicis longus: thumb extension
Abductor pollicis brevis (APB): thumb abduction
Flexor pollicis longus: thumb IP flexion
Dorsal interossei: finger abduction
Palmar interossei: finger adduction
 Figure 4-15 Hand and wrist anatomy. (From Tank PW, Gest TR. Atlas of Anatomy. Baltimore, MD: Lippincott Williams & Wilkins; 2008.) |
 Figure 4-15 (continued) |
TABLE 4-6 Full Active Range of Motion of the Wrist and Hand | ||||||||||||||||||||||||
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