Physical Exam: Elbow Room

I\’ve spent a long time on the shoulder. I really didn\’t finish it, leaving out subjects like rotator cuff injuries and driving on a road without a shoulder. Truth be told, I am just getting sick of the shoulder.
Just don\’t let my shoulders hear about it.

So I am going downstream on the arm…or is it upstream? Oh, yeah, I am going distal on the arm and going to the next bend: the elbow.

Whenever I think about elbows, I think about Sesame Street. When my kids were young, there was a song sung by Kermit the Frog that I heard about 20 million times:

I love my elbows
Let\’s get straight to the point
I love my elbows
Yeah they\’re my favorite joint
They bend my arms with so much charm and finesse

I love my elbows
Take my ankles, please!
I love my elbows
So much I\’m weak in the knees
Without these two I\’d sure be blue I confess

Yeah thanks to elbows, I\’m a fella
Who\’s got a hook for his umbrella
And for cool and casual leaning,
Boy are they great!

The song goes on for a number of verses; if you want to see the rest of them go here. Just have a bunch of hankies with you when you do. In makes me quite verklempt.

If Kermit thinks elbows are cool, it pretty much clinches it.

So what about the exam of the elbow? Again, this joint gets largely overlooked during routine exams, and would probably be completely ignored without the kind reminders from our dear friend Kermit. When doctors do examine elbows, it is due to people saying subtle things like, \”I have this pain in my elbow, doctor.\”

The Exam

The normal elbow exam would be written as such:

Elbow – Normal ROM, no tenderness or effusion.

Doctors who specialize in elbows probably have some secret lingo they use, but I have not yet infiltrated their ranks to find out what it is. They probably abbreviate the elbow as \”Elb\”, but they may use a Latin or Latvian word as well. ROM means \”range of motion\” although there is a radical fringe of doctors who think it means \”range of movement.\” This group is soon to shrink, however, as the American College of Orthopedics got Max Baucus to hide a clause in the health care bill that allows the ethnic cleansing of doctors who do this.

Caps

The elbow sits at the junction of the humerus with the bones of the forearm: the radius and ulna. It\’s just like the knee, which is the intersection of the femur and the tibia and fibula, except there is no elbow equivalent to the kneecap. Why did the elbow get short-changed like this? Why is there no elbowcap? I was unable to find scholarly research on the subject, so I had to do some on my own.

I first asked myself: why are there no elbowcaps? That\’s how you do science, you know. You come up with a question you want to answer; then you test possible reasons for this and see if they hold up. In this circumstance I could think of a number of possible explanations for why elbowcaps don\’t exist:

1. The elbows couldn\’t afford caps – This did not hold up to scrutiny, however, because of the neighborhoods both of these joints inhabit. The knees are between the buttocks and the feet, which is the anatomic equivalent of living between a sewage treatment plant and a pig farm. The elbows, on the other hand, despite living near the armpits, are close to the head, hands and heart. It\’s clear that if money was the issue, the elbows would have won out.
2. The elbows don\’t need caps – This seems to have some credibility to it, as one would think that the knees would take more of a beating. The problems with this theory are: a) The elbows have the ulnar nerve, which is the \”funny bone\” to protect and it would be really nice to have protection; b) Your legs generally just go back and forth, while your arms go all over the place. It\’s far more likely for you to whack your elbow than your knee. c) Men have nipples, we are born with an appendix, and some people have way too much nose hair. Not needing something never stopped the body from having it.
3. Insurance companies don\’t allow them – This certainly makes a lot of sense in today\’s world. I would suppose the knees would have had to get prior authorization for their caps if it were up to United Healthcare. But the body is older than insurance company, and the words, \”I\’m sorry, your policy doesn\’t cover that\” do not appear in any documents of antiquity.

So after asking myself these questions (and getting funny looks while I did it), I asked my wife. She gave me one of those \”have you been sniffing the Silly Putty again?\” looks and walked away without answering.

Credit

The only other person at home at the time of my research was my dog Holly. I thought it might be interesting to find out the perspective of a different species. When I asked her, she gave me one of those \”I don\’t know what you are talking about, but I sure would like a pork tenderloin\” looks (and then added a Silly Putty look for good measure).  She then went back to sleep. I did note, however, that Holly doesn\’t have kneecaps at all. This made me postulate that kneecaps probably have something to do with a specific attribute of human legs versus dog legs.  The most obvious difference is the amount of hair on them (although I once knew a guy named Lenny who made it close).  But the theory that most made sense to me was that kneecaps allow us to talk. They must have some sort of speech generation software in them. Elbow caps, obviously, would allow humans to have psychic powers, which the insurance companies would never allow.

The Bends

The elbow is far different from the shoulder. It moves only in a hinge-like fashion, without any of the twirly ability the shoulder possesses. It also doesn\’t rhyme with as many things as a shoulder does. Despite these handicaps, however, one could argue that the elbow is at least as important as the shoulder, probably more.

Why do I make such audacious claims? Have I been smelling the Silly Putty again? Well, yes actually I have; but that has nothing do do with this. You can grasp this importance when you consider what life would be like without it.

• You would stink – If your arms were one straight bone between the shoulder and wrist, you would have a very difficult time putting on deodorant, brushing your teeth, and wiping after you use the toilet.
• You would be no fun – You couldn\’t throw a Frisbee, arm wrestle, or play guitar without elbows.
• You would go nuts – What happens when your nose itches? How do you put stuff in your pockets? How would you apply lip gloss? How would you whistle for a taxi? How would you put your arm under your armpit and make flatus noises? All of these are essential functions of daily living we all take for granted that would not exist without elbows.

It\’s not much better if the arms are fixed in a bent position. It is clear that Kermit has a much greater intellect than we give him credit for.

Golf or Tennis

The vast majority of time the elbow hurts is due to problems with one of the epicondyles. Epicondyle is a fancy way to say \”bumps near the end\” and refers to the bumps near the end of the humerus bone. The one that sits against the body when the hands are facing forward is called the medial epicondyle, and one on the opposite side is called the lateral epicondyle. When there is pain over the lateral epicondyle, it is called lateral epicondylitis; but this is better known as tennis elbow. Not to be outdone, pain to the medial epicondyle, or medial epicondylitis, is known as golfer\’s elbow.

Because of these names, several questions come immediately to mind:

1. Why golf and tennis? Why not rodeo elbow or tetherball elbow?
2. Are these conditions related to wearing argyle?
3. What were they called in ancient times, slave beater\’s elbow and pyramid making elbow?
4. Can a muppet get either of these conditions despite the fact that they can\’t play golf or tennis?

Wikipedia gave me no answers on this, so I guess it will remain a mystery. But these conditions do still hurt, and are best treated with anti-inflamatory drugs, ice, and rest from whatever activity brought them on.

Eat your Spinach

There is one more elbow condition to cover: olecranon bursitis. A bursa is a small sack under the skin that can potentially fill up with fluid. When these sacks get inflamed, they fill up with fluid and can sometimes hurt; this condition is called bursitis. You have these little sacks all over the body, and they only are significant when they mess up. This makes me a little suspicious that the American College of Orthopedics somehow got them included in the body so their members could afford to treat the epicondylitis they get from playing Golf and Tennis.

The olecranon bursa is over the flexor surface (or outside of the elbow when it is bent) and becomes inflamed from trauma or the depositing of uric acid crystals in the condition known as gout. It can also sometimes get infected. Traumatic olecranon bursitis is by far the most common, and typically presents in the office as a man who is tired being teased by his buddies. This is because the condition makes the patient look like a famous spinach eating sailor.

Me? I don\’t eat spinach. I get my strength from sniffing Silly Putty.