Elbow Clinical Examination

Courtesy: Nader Paksima and NewYOrkOrtho

Clinical Examination of the Elbow

Overview

A systematic elbow examination performed after taking the history. The examination proceeds through:

Observation – Range of motion  -Palpation/landmarks – Muscle testing – Nerve examination – Stability testing – Specific provocative tests.

1. Observation

Both elbows should be fully exposed and compared simultaneously.

Look for:

• Asymmetry
• Swelling
• Ecchymosis
• Redness/signs of infection
• Olecranon bursal swelling
• Abnormal antecubital contour
• Vascular abnormalities

2. Range of Motion

Assess both:

Active ROM

Movement performed by the patient.

Passive ROM

Movement obtained by the examiner.

A difference between active and passive ROM is important. when a tendon-related problem limits motion:

Passive ROM is typically greater than active ROM.

Quick Screening of Active Motion

ask the patient to:

• Raise both arms overhead
• Place hands behind the neck
• Place hands behind the back
• Extend both arms
• Flex both elbows

Both sides are observed together for:

• Ease of movement
• Speed
• Catching
• Restriction

A brief shoulder examination is included because shoulder pathology may be responsible for symptoms attributed to the elbow.

3. Elbow Flexion–Extension

• 0° = full extension
• Flexion approximately 135°

ROM is recorded with extension first and flexion second.

Example

10–120°

means:

• 10° extension deficit
• Flexion to 120°

Hyperextension

record hyperextension using a plus sign.

For example:

+10–135°

= 10° hyperextension to 135° flexion.

4. Forearm Rotation

Do not forget that elbow examination includes forearm rotation.

Assess:

• Supination
• Pronation

The patient holds both arms forward and turns:

• Palms upward – supination
• Palms downward – pronation

most people have approximately:

80–85° in either direction.

Comparison with the opposite side is important.

5. Goniometer

A goniometer should be used when accurate ROM measurement is required.

For elbow flexion-extension, its hinge is aligned with the axis/hinge of elbow motion.

forearm rotation is more difficult to measure consistently; therefore, use a consistent technique and compare both sides.

6. Palpation — Lateral Side

Important lateral landmarks include:

• Olecranon
• Lateral epicondyle
• Radiocapitellar joint/radial head
• Anconeus
• Supracondylar ridge
• Mobile wad

Olecranon

The triceps inserts onto the olecranon.

Swelling/fluid over the olecranon may indicate:

Olecranon bursitis

Lateral Epicondyle

Tenderness directly around the lateral epicondyle may occur with:

Lateral epicondylitis / tennis elbow

Radial Head / Radiocapitellar Joint

The radial head can be localized by palpating while the patient performs:

Pronation and supination

feel the radial head moving beneath the thumb.

7. Anconeus

The anconeus is described as a triangular muscle in the posterolateral elbow region.

his region as an important landmark when accessing the elbow joint for:

• Aspiration
• Injection

The relevant three bony points form a triangle corresponding to the anconeus region.

8. Mobile Wad

mobile wad  including:

• Brachioradialis
• ECRL
• ECRB

It can be palpated and made prominent with a resisted hammer-curl type maneuver with the forearm neutral.

9. Lateral Epicondylitis vs Radial Tunnel Pain

This is an important clinical distinction.

Lateral epicondylitis

Pain/tenderness:

At the lateral epicondyle

Radial tunnel

Pain:

Approximately 3 cm distal to the lateral epicondyle, around the mobile-wad/supinator region.

the radial nerve passes through this region near the supinator, where radial tunnel syndrome may occur.

Exam Pearl

Pain on lateral epicondyle – lateral epicondylitis

Pain ~3 cm distal – think radial tunnel

10. Muscle Testing

Elbow Extension

Test the:

Triceps

against resistance.

Elbow Flexion

Several muscles contribute:

• Biceps
• Brachialis
• Brachioradialis

11. Radial Nerve

the radial nerve passing from the posterior to the anterior compartment of the arm and then between:

• Brachioradialis
• Brachialis

It can be palpated approximately:

10 cm proximal to the lateral epicondyle

where it may feel like a structure rolling beneath the examiner’s thumb.

12. Medial Elbow Examination

Important medial structures:

• Olecranon
• Medial epicondyle
• Cubital tunnel
• Ulnar nerve
• Flexor-pronator mass

The ulnar nerve lies in the cubital tunnel between the medial epicondyle and olecranon region.

13. Medial Epicondylitis vs Ulnar Nerve Pain

Medial epicondylitis

Pain is:

Anterior to the medial epicondyle

Ulnar nerve pathology

Pain is:

Posterior to the medial epicondyle

The flexor-pronator mass is activated by making a fist and performing wrist flexion with ulnar deviation.

14. Ulnar Nerve Examination

1. Tinel Test

Tap over the ulnar nerve in the cubital tunnel.

1. Palpation

Assess for:

• Tenderness
• Irritability

1. Elbow Flexion Test

• Hyperflex the elbow.
• Hold for approximately 30 seconds.
• Compare both sides.

Positive if it reproduces:

Numbness/tingling in the ring and little fingers

This suggests ulnar nerve irritation.

15. Ulnar Nerve Subluxation

Place a finger lightly over the medial epicondylar/ulnar nerve region while moving the elbow:

Flexion – Extension

The nerve may:

• Subluxate anteriorly over the medial epicondyle
• Snap
• Relocate during movement

This may be painful when symptomatic.

16. Elbow Stability

Assess:

• Valgus stability
• Varus stability

Valgus Stress Test

The transcript identifies the ulnar collateral ligament as the important medial stabilizer.

30° of elbow flexion

rather than full extension.

Apply valgus stress and compare with the opposite elbow.

Tests

Valgus stress – UCL

Varus Stress Test

Apply stress in the opposite direction to assess the lateral ligament complex.

Lateral ulnar collateral ligament (LUCL)

and notes that “radial collateral ligament” may be used in discussion.

Tests

Varus stress – lateral collateral ligament complex

17. Chair Dip Test

The patient places both hands on chair rails and pushes the body upward as if performing a dip.

office maneuver to demonstrate instability associated with the:

Lateral ulnar collateral ligament

18. Pivot-Shift Test of Elbow

The speaker mentions the pivot-shift test for:

LUCL instability

it is best performed under anesthesia with the patient supine.

19. Lateral Epicondylitis Provocative Testing

Resisted Wrist Extension

• Ask patient to extend the wrist.
• Examiner pushes down against resistance.
• Simultaneously palpate the lateral epicondyle.

Activation of the ECRB/wrist extensors reproducing lateral epicondylar pain supports:

Lateral epicondylitis

Resisted Middle-Finger Extension

Apply resistance to middle-finger extension.

this test is supposed to be more specific for:

Radial tunnel syndrome

However, he notes from his own experience that it can also be positive in lateral epicondylitis.

High-Yield Examination Table

Region / pathology	Key finding or test
Olecranon bursitis	Posterior olecranon swelling
Lateral epicondylitis	Lateral epicondyle tenderness
Radial tunnel	Pain ~3 cm distal to lateral epicondyle
Radiocapitellar joint	Palpate radial head during rotation
Triceps	Resisted elbow extension
Biceps/brachialis/brachioradialis	Resisted elbow flexion
Medial epicondylitis	Pain anterior to medial epicondyle
Ulnar nerve pathology	Pain posterior to medial epicondyle
Cubital tunnel	Tinel + elbow flexion test
Ulnar nerve instability	Palpate during flexion-extension
UCL	Valgus stress
Lateral ligament complex/LUCL	Varus stress
LUCL instability	Chair dip / pivot-shift
Lateral epicondylitis	Resisted wrist extension
Radial tunnel	Resisted middle-finger extension discussed

Practical Examination Sequence

History

Observation

• Compare both elbows
• Swelling, bruising, redness, bursitis, deformity

ROM

• Active then passive
• Flexion/extension
• Pronation/supination
• Compare sides

Palpation

• Olecranon
• Epicondyles
• Radial head
• Anconeus
• Mobile wad
• Cubital tunnel

Muscles

• Flexors
• Extensors
• Flexor-pronator mass
• Mobile wad

Nerves

• Radial nerve
• Ulnar nerve
• Tinel
• Elbow flexion test
• Ulnar nerve subluxation

Stability

• Valgus
• Varus
• Chair dip
• Pivot shift when indicated

Specific provocative tests

• Resisted wrist extension
• Resisted middle-finger extension

Key Take-Home Points

• Elbow examination should be systematic and bilateral.
• Always assess both active and passive ROM.
• Elbow ROM is recorded extension first, flexion second.
• Forearm pronation/supination forms an important component of elbow examination.
• Lateral epicondyle tenderness – lateral epicondylitis, whereas radial tunnel pain is described about 3 cm distal.
• Medial epicondylitis pain is anterior to the medial epicondyle; ulnar nerve pain is posterior.
• Cubital tunnel evaluation includes Tinel test, elbow flexion test and assessment for ulnar nerve subluxation.
• Valgus stress – UCL/medial stability.
• Varus stress – lateral ligament complex.
• The speaker uses the chair dip and pivot-shift maneuvers when assessing LUCL-related instability.
• Clinical findings should be interpreted by combining landmark palpation, muscle testing, nerve examination and stability testing.

Exam Pearls

Lateral epicondyle = Tennis elbow

~3 cm distal to lateral epicondyle = Radial tunnel

Medial epicondyle: anterior pain = medial epicondylitis; posterior pain = ulnar nerve

Cubital tunnel = Tinel + elbow flexion test

Valgus stress = UCL

Varus stress = lateral ligament complex

Active ROM < passive ROM = think muscle/tendon-related limitation in the speaker’s framework