Elbow Examination

As with the other joints, elbow examination starts with obtained a full history, bearing in mind that certain conditions are more prevalent in certain age groups; for example, locking of the elbow in a young patient is likely to be due to osteochondritis dissecans whereas the same symptoms in an older patient would be due to loose bodies.

It is important to note if there are any other associated symptoms and if there is any instability to document the position at which the elbow feels most unstable. Also, as with all upper limb disorders it is vital to specifically ask the patient about neck symptoms as cervical spine pathology can cause referred pain to the elbow.

Elbow Examination Steps

As with other joints or regions examination in orthopedic surgery, the elbow examination steps include: inspection, palpation, movements and special tests.

Elbow Inspection

During elbow examination, you should note the position in which the elbow is held. A painful elbow is usually pronated with the forearm being supported by the contralateral hand. Also look closely at the skin for previous scars due to either trauma or surgery and also assess the condition of the skin. Finally look for the presence of swelling in the joint or for rheumatoid nodules on the extensor aspect of the elbow.

Palpation

As the elbow is a subcutaneous joint, systematic palpation will reveal the site of maximal tenderness and the cause of the patient’s symptoms. Ask the patient to abduct the shoulder 45° and stand at the side or behind the patient. This position allows the examiner to easily palpate the anterior, posterior, medial and lateral aspects of the elbow.

Lateral Palpation

Start at the supracondylar ridge and palpate down the ridge to the lateral epicondyle, common extensor origin and lateral collateral ligament (LCL). At this point the extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL) muscles can be assessed by resisted wrist extension in neutral and radial deviation. Point tenderness over the ECRB indicates tennis elbow (lateral epicondylitis).

Continue by palpating the radiocapitellar joint line, where tenderness may indicate articular injury or osteochondritis dissecans. Look for the infracondylar sulcus between the lateral condyle and the radial head. Palpation in this area will reveal boggy swelling if there is synovial hypertrophy due to rheumatoid arthritis or fluctuation if there is fluid in the joint.

Following this, palpate the radial head and check for congruency with the capitellum. Ask the patient to pronate and supinate to check that the radial head is well oriented to the capitellum and that there is no dislocation. Also check for pain or crepitus, as this will signify a recent injury, radial head fracture or degenerative change in that joint.

Anterior Palpation

The anterior structures from lateral to medial are the biceps tendon (together with the lacertus fibrosus), the brachial artery and median nerve (mnemonic: TAN). Look for biceps tendon insertion rupture (proximal bulge) or long head of biceps rupture (distal bulge), which is more common. Occasionally, anterior myositis ossificans may be palpated after elbow dislocation.

Medial Palpation

Feel for tenderness over the medial epicondyle and common flexor origin which indicates medial epicondylitis (golfer’s elbow) whereas tenderness over the pronator teres indicates pronator syndrome. In pronator syndrome percussion of the median nerve at the elbow results in tingling distally. Provocation tests for this syndrome include resisted middle finger flexion at the proximal interphalangeal joint, pain on resisted pronation and resisted elbow flexion.

The ulnar nerve should also be palpated and is easily felt behind the medial epicondyle. Check the position of the ulnar nerve during flexion and extension movements of the elbow to ascertain if there is subluxation of the nerve, as up to 10% of patients have an anterior subluxing ulnar nerve, which is a recognized cause of medial elbow pain. Be sure to know the common sites of compression of the ulnar nerve in this area. They are from proximal to distal.

Posterior Palpation

Palpate the bony prominences of the triad which includes the tip of the olecranon process and the medial and lateral epicondyles, which should form a straight line with the elbow extended. With the elbow flexed to 90°, these landmarks should form an isosceles triangle. Any disruption of this arrangement signifies previous bony injury.

Elbow Joint Movements

The other step in the elbow examination is moving the joint and check for range of motion, elbow flexion (140°) and extension (0°) can most easily be demonstrated in the coronal plane at 90° of shoulder abduction, comparing both sides.

Elbow Exam Special Tests

The last step in elbow examination is performing special tests for specific pathology of the elbow. There are a number of elbow orthopedic tests that can be used to elicit various conditions as detailed below:

Lateral epicondylitis (‘tennis elbow’):

With the wrist in neutral, resisted wrist dorsiflexion results in localized pain over the lateral epicondyle. Pain may also occur if the test is done with the wrist in extension and radial deviation and on resisted extension of the middle finger. Another provocative test includes pain at the lateral epicondyle on passive volar flexion of the wrist with elbow extension and pronation. Pinch grip is also found to be weak and painful. Resolution of the pain with an injection of local anaesthetic at the attachment of ECRB will confirm the diagnosis by eliminating symptoms.

Lateral epicondylitis should not be confused with PIN syndrome, which is compression of the posterior interosseous nerve at one of the following sites:

• Arcade of Frohse (most common location)
• Fibrous bands anterior to radial head (least common location)
• Radial recurrent vessels (leash of Henry)
• Tendinous origin of ECRB.

See Also: Lateral Epicondylitis

Medial epicondylitis (‘golfer’s elbow’)

This is characterized by tenderness at the common flexor origin. There is pain on resisted palmar flexion of the wrist.

Medial epicondylitis should not be confused with pronator syndrome, which is a compressive neuropathy of the median nerve at one of the following sites:

• between the two heads of the pronator teres muscle (commonest cause)
• compression of the nerve from the fibrous arch of the flexor digitorum superficialis
• compression at the thickening of the bicipital aponeurosis.

See Also: Golfer’s Elbow Test

Instability

Both valgus and varus testing are performed with the elbow in full extension and several degrees of flexion to about 30° to unlock the olecranon from the olecranon fossa.

Lateral pivot-shift test for posterolateral instability: Posterolateral rotatory instability is diagnosed by the lateral pivot-shift test of the elbow.

See Also: Elbow Special Tests

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Zwerus EL, Somford MP, Maissan F, Heisen J, Eygendaal D, van den Bekerom MP. Physical examination of the elbow, what is the evidence? A systematic literature review. Br J Sports Med. 2018 Oct;52(19):1253-1260. doi: 10.1136/bjsports-2016-096712. Epub 2017 Mar 1. PMID: 28249855.
3. Smith MV, Lamplot JD, Wright RW, Brophy RH. Comprehensive Review of the Elbow Physical Examination. J Am Acad Orthop Surg. 2018 Oct 1;26(19):678-687. doi: 10.5435/JAAOS-D-16-00622. PMID: 30095513.
4. MacDermid JC, Michlovitz SL. Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther. 2006 Apr-Jun;19(2):82-97. doi: 10.1197/j.jht.2006.02.018. PMID: 16713858.