Elbow Exam

Physical Examinations III

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Overview

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

The elbow is a hinged joint that involves the articulation of 3 bones: the humerus, radius, and ulna. It is a much more stable joint than the shoulder, and because of that, the elbow has less range of motion. The elbow and its structures are prone to significant injuries, particularly with repetitive motion. Lateral and medial epicondylitis (also called tennis elbow and golfer's elbow) are two common diagnoses and often occur as a result of occupational activities.

When examining the elbow, it is important to remove enough clothing so that the entire shoulder and elbow can be inspected. It is important to compare the injured elbow to the uninvolved side. A systematic evaluation of the elbow includes inspection, palpation, range of motion (ROM) testing, and special tests, including maneuvers to evaluate ligamentous stability and stretch tests to accentuate pain caused by epicondylitis.

Cite this Video

JoVE Science Education Database. Physical Examinations III. Elbow Exam. JoVE, Cambridge, MA, (2017).

Procedure

1. Inspection

  1. When inspecting the elbow, compare to the uninvolved side while looking for swelling, redness, warmth, and carrying angle.
  2. If swelling is present, determine if it is in the bursa or in the joint. Swelling in the elbow joint will appear anteriorly at the brachial fossa. The most common site for swelling in the elbow is posterior, in the olecranon bursa.
  3. Note if redness or warmth is present; these may suggest olecranon bursitis or infection.
  4. Compare the size of the elbows, looking for atrophy. Remember that it is common to see adaptive hypertrophy of the dominant elbow in a thrower.
  5. Note the carrying angle, which is formed by the upper and lower arm in the anatomic position. It is normally 5-10° in males and 10-15° in females. This angle can be altered by prior supracondylar fracture or infection.

2. Palpation

Palpation is extremely helpful in pinpointing the source of elbow pain. It is helpful to generally localize elbow pain to anterior, posterior, medial, or lateral.

Palpate the following important structures in each of these areas:

  1. Anterior elbow
    1. Biceps tendon: Palpate for a tight cord in the medial aspect of the anterior elbow (best felt with the elbow bent to 90°).
    2. Brachial artery: Feel for the pulsation just medial to the biceps tendon.
    3. Palpate for tenderness over the median nerve located medially to the brachial artery.
    4. Palpate for tenderness over the anterior joint capsule.
  2. Posterior elbow
    1. Triceps: Palpate along the posterior upper arm to the tip of the olecranon process.
    2. Olecranon process: Palpate the prominent bump at posterior elbow.
    3. Olecranon fossa: Feel the depression just superior to the olecranon process.
    4. Olecranon bursa: Palpate posteriorly to the proximal ulna; this can only be felt if inflamed and swollen.
  3. Medial elbow
    1. Medial epicondyle: Palpate the bony prominence at the medial elbow.
    2. Wrist flexor and pronator muscles: Feel for the tendons at the medial epicondyle.
    3. Medial collateral ligament (MCL): Palpate from medial epicondyle to the olecranon. The MCL lies deep to flexor-pronator muscles.
    4. Ulnar nerve: Palpate from medial epicondyle to the olecranon process just above the MCL of the elbow. Tapping over the nerve may cause uncomfortable sensations when inflamed (Tinel's sign).
  4. Lateral elbow
    1. Lateral epicondyle: Feel the bony prominence on the lateral elbow.
    2. Extensor and supinator muscles: Palpate the tendons attached at the lateral epicondyle.
    3. Radial head: Palpate at the lateral elbow, best felt while supinating and pronating the wrist.
    4. Radialcapitellar joint: Palpate just proximal to the radial head.
    5. Palpate four fingerbreadths distal to the lateral epicondyle for tenderness: Pain in this area is associated with compression of posterior interosseous nerve.

3. Range of Motion (ROM)

The ROM at the elbow should be evaluated by comparing between the two sides. A lack of motion suggests stiffness (due to injury or arthritis) or a mechanical block within the joint (due to a loose body). Normal ROM is shown in parentheses. Check for the following motions:

  1. Extension (0°): Ask the patient to extend the elbow so the arm is straight. Keep in mind it is common to see slight flexion contracture in a thrower.
  2. Flexion (150°): Ask the patient to flex the elbow by trying to touch the hand to the shoulder.
  3. Pronation (70°): With the patient's elbow bent to 90° and the thumb pointing up, ask the patient to turn the hand so the palm is facing down toward the floor.
  4. Supination (90°): With the patient's elbow bent to 90° and the thumb pointing up, ask the patient to turn the hand so the palm is facing upward (as if trying to hold soup in the palm).

4. Strength Testing

Strength testing is done by checking resisted movements described above. Pain with these resisted motions is commonly due to tendonitis or epicondylitis. Strength should be evaluated in the following motions:

  1. Supination of forearm (see above): Resistance will aggravate lateral epicondylitis (supinator tendons attach at lateral epicondyle).
  2. Pronation of forearm (see above): Resistance will aggravate medial epicondylitis (pronators tendons attach at medial epicondyle).
  3. Extension of wrist: With the patient's wrist straight and the palm facing down, move the patient's hand in an upward direction. Resistance will aggravate pain of lateral epicondylitis (wrist extensors attach at lateral epicondyle).
  4. Flexion of wrist: With the patient's wrist straight and the palm facing down, move the patient's hand in a downward direction. Resistance will aggravate pain of medial epicondylitis (wrist flexors attach at medial epicondyle).
  5. Resisted long finger extension: With the patient's wrist straight and the palm facing down, move the patient's middle finger in an upward direction. Resistance will aggravate the pain of lateral epicondylitis.
  6. Elbow flexion (see above): Resistance will test biceps strength, and pain suggests tendonitis.
  7. Elbow extension (see above): Resistance will test tests triceps strength, and pain suggests tendonitis.

5. Stretch Tests

These tests will aggravate pain caused by medial or lateral epicondylitis by pulling at the epicondyle.

  1. Stretch the wrist into flexion or pronation (described above); this pulls at the lateral epicondyle and aggravates the pain of lateral epicondylitis.
  2. Stretch the wrist into extension or supination (described above); this pulls at the medial epicondyle and aggravates the pain of medial epicondylitis.

6. Collateral Ligament Testing

The collateral ligaments of the elbow should be evaluated for pain and/or laxity. The medial collateral ligament is injured much more commonly than the lateral.

Two tests are used to evaluate these ligaments:

  1. Varus/valgus stress
    1. Passively rotate the patient's shoulder outward (full external rotation), and flex the elbow to 30° to unlock the olecranon from the olecranon fossa.
    2. Place one palm over the patient's lateral elbow and push medially with your other hand (valgus stress is applied to assess the medial collateral ligament).
    3. Perform varus stress test to assess the lateral collateral ligament by placing your palm over the patient's medial elbow and pushing in a lateral direction.
    4. Check for pain and/or laxity.
    5. Grade the severity of ligament injury.
      Grade I (ligament stretched): Pain with no laxity.
      Grade II (partial tear): Pain with minimal laxity. Soft endpoint.
      Grade III (complete tear): Pain with no good endpoint.
  2. Milking maneuver: Bend the affected elbow to 90° and full supination with thumb extended. Reach opposite arm under involved elbow and grasp thumb. Pulling laterally on thumb creates valgus stress at the medial collateral ligament of the affected elbow.

The elbow joint enables mobility of the upper extremities and allows precise control of the hand's position in space.

The anatomy of the elbow is complex. It is a hinged joint formed by articulations between three bones: humerus, radius, and ulna. It is stabilized by the lateral and medial collateral ligament complexes.

The muscles involved in elbow movement are classified as per their function. The flexor group includes biceps brachii, brachilais, and brachioradialis. Extension is a function of posterior muscles-triceps brachii and anconeus. Pronation involves brachoradilais and pronator teres. Lastly, supination engages biceps brachii, brachoradilais, and supinator muscles.

In addition, the bony prominences of the distal humerus-called the lateral and medical epicondyle-form the attachment sites for muscles involves in wrist and hand movement. Lateral epicondyle is where the extensors attach and medial epicondyle is the attachment site for the flexor muscles. Inflammation surrounding these epicondyles, or epicondylitis, is one of the common reasons of elbow pain. Lateral epicondylitis is frequently seen in tennis players, giving this condition a colloquial name - the "tennis elbow". Similarly, medial epicondylitis is commonly seen in golfers, and therefore known as the "golfer's elbow".

The source of the elbow pain can be identified based on the patient history and careful physical examination, and here, we will review the steps of this exam in detail.

Systematic elbow examination starts with inspection and palpation. Before starting the exam wash your hands thoroughly. For inspection, ask the patient to sit on the exam table and request them to remove enough clothing so that the entire shoulder and elbow are exposed.

First assess the size of the elbows and look for atrophy and swelling, and check for redness or warmth. The joint swelling may appear anteriorly at the brachial fossa, but the more common site is in posterior region, in the olecranon bursa. Next, assess the carrying angle, which is formed by the upper arm and the forearm in the anatomic position. The carrying angle is normally 5-10° in males and 10-15° in females, and can be altered by prior trauma or infection.

Now move onto palpation, which is helpful in localizing the pain to the anterior, posterior, medial, or lateral region. Starting at the anterior elbow, first find the biceps tendon in the cubital fossa, which feels like a tight cord. From there move a bit medially to assess for tenderness over the median nerve. And palpate over the anterior joint capsule, which can be a source of pain when inflamed.

After that assess the posterior elbow. Start by palpating the triceps muscle along the posterior upper arm. Move downwards until you reach the prominent bump at posterior elbow called the olecranon process of the ulna. From there move your fingers superiorly to locate the olecranon fossa, which is felt as a small depression. Also examine the area posterior to the proximal ulna-the "olecranon bursa", which can only be felt if inflamed or swollen.

Next, assess the medial side. First, palpate the medial epicondyle on the distal humerus. Then, feel the tendons in the same location that belong to the wrist flexor and pronator muscles. Subsequently, palpate from the medial epicondyle to the olecranon to assess the MCL, which lies deeper than the flexor and pronator muscles. Lastly, just above the MCL, palpate the ulnar nerve, which follows the same path as the MCL. Tapping over this nerve may cause uncomfortable sensation when inflamed. This is known as the "Tinel's Sign".

Finally, examine the lateral aspect of the elbow. Start by palpating the lateral epicondyle, followed by the tendons of the extensor and supinator muscles, which are attached to the lateral epicondyle. Just beyond the epicondyle you can find the radial head, and while supinating and pronating the wrist you can feel the radial head and the articulation at the radial-capitellar joint. Finally, feel for tenderness in the area four fingerbreadths distal to the lateral epicondyle. Pain in this region suggests compression of the posterior interosseous nerve.

Next, we will demonstrate how to test the range of motion for the elbow. This should be evaluated by comparing between the two sides, and lack of motion may suggest a mechanical block, or stiffness due to injury or arthritis.

Start by assessing extension. Instruct the patient to fully straighten the arm. Normally the angle at full extension is 0°, since elbow is a hinged joint. Next, ask the patient to flex the arm and try to touch the hand to the shoulder. Normally, the flexion range is about 150°.

For the next test, that is pronation, instruct the patient to bend their elbows to 90° with their thumbs pointing upwards and then turn their hands inward so their palms are facing down. The normal pronation range is about 80°- 90°. Finally, to test supination, have the patient rotate their hands so that the palms face upward. The upper limit for this movement is about 90°.

Now, move on to evaluating the strength of muscles involved in the aforementioned range of motion movements. Pain with the following resisted motions is commonly due to tendonitis or epicondylitis.

Begin by instructing the patient to rotate their forearm inward as before, while you provide resistance. This maneuver assesses the pronator muscles, and it is painful in presence of medial epicondylitis, since the pronator tendons attach on medial epicondyle. Next, ask the patient to turn their forearm outward against your resistance, which tests the supinator muscles. This would aggravate pain in lateral epicondylitis due to the attachment of the supinator tendons to the lateral epicondyle.

For the following tests, instruct the patient to have their wrist straight and the palm facing down. Now, ask them to first move the hand in an upward direction against your resistance. This assesses the wrist extensor muscles that attach to the lateral epicondyle. Therefore, presence of pain suggests lateral epicondylitis. Similarly, moving the hand in downward direction against resistance examines the wrist flexors that attach to the medial epicondyle. Therefore, this maneuver aggravates the pain related to medial epicondylitis. Then ask the patient to move just their middle finger in upward direction, while you push down. This test the muscle that extends the long finger extensor and again aggravates the elbow pain caused by lateral epicondylitis. Lastly, to test the biceps and triceps, ask the patient to flex and extend their elbow against your resistance. Pain during these motions suggests tendonitis.

Finally, let's review a few special tests performed to diagnose the common elbow disorders. First group of these are known as the Stretch Tests. Take the patient's hand and passively flex and pronate the wrist. This will aggravate the pain related to lateral epicondylitis. Next, passively stretch the patient's wrist into extension followed by supination. This will aggravate the pain of medial epicondylitis.

The final few maneuvers of this exam assess the pain and laxity of the medial and lateral collateral ligaments - the MCL and LCL. The MCL is injured much more commonly than the LCL. Grade the severity of ligament injury according to the table provided in the accompanying manuscript.

First, passively rotate the patient's shoulder outward, place your palm over the lateral elbow and fingers around the joint line and apply Valgus stress to assess the MCL. To test the LCL, place your palm over the medial elbow and fingers on the lateral side, and apply Varus stress.

For the last assessment, ask the patient to bend one elbow to 90° and fully supinate the hand with the thumb extended. Now ask them to use the opposite arm to grasp thumb from under the elbow, and pull it laterally. This test is called the "Milking maneuver", and is perfomed to test the MCL by creating a valgus stress. This concludes the comprehensive evaluation of the elbow joint.

You've just watched JoVE's video on the elbow examination. Here, we demonstrated the essential steps of elbow assessment and also gave examples of how the physical findings can help the clinician to reach a diagnosis. We started with the inspection and palpation of the key elbow structures, followed by testing of range of motion first actively and then against resistance. Finally, we explained how to perform a few special maneuvers to assess stability of the collateral ligaments. As always, thanks for watching!

The elbow joint enables mobility of the upper extremities and allows precise control of the hand's position in space.

The anatomy of the elbow is complex. It is a hinged joint formed by articulations between three bones: humerus, radius, and ulna. It is stabilized by the lateral and medial collateral ligament complexes.

The muscles involved in elbow movement are classified as per their function. The flexor group includes biceps brachii, brachilais, and brachioradialis. Extension is a function of posterior muscles-triceps brachii and anconeus. Pronation involves brachoradilais and pronator teres. Lastly, supination engages biceps brachii, brachoradilais, and supinator muscles.

In addition, the bony prominences of the distal humerus-called the lateral and medical epicondyle-form the attachment sites for muscles involves in wrist and hand movement. Lateral epicondyle is where the extensors attach and medial epicondyle is the attachment site for the flexor muscles. Inflammation surrounding these epicondyles, or epicondylitis, is one of the common reasons of elbow pain. Lateral epicondylitis is frequently seen in tennis players, giving this condition a colloquial name - the "tennis elbow". Similarly, medial epicondylitis is commonly seen in golfers, and therefore known as the "golfer's elbow".

The source of the elbow pain can be identified based on the patient history and careful physical examination, and here, we will review the steps of this exam in detail.

Systematic elbow examination starts with inspection and palpation. Before starting the exam wash your hands thoroughly. For inspection, ask the patient to sit on the exam table and request them to remove enough clothing so that the entire shoulder and elbow are exposed.

First assess the size of the elbows and look for atrophy and swelling, and check for redness or warmth. The joint swelling may appear anteriorly at the brachial fossa, but the more common site is in posterior region, in the olecranon bursa. Next, assess the carrying angle, which is formed by the upper arm and the forearm in the anatomic position. The carrying angle is normally 5-10° in males and 10-15° in females, and can be altered by prior trauma or infection.

Now move onto palpation, which is helpful in localizing the pain to the anterior, posterior, medial, or lateral region. Starting at the anterior elbow, first find the biceps tendon in the cubital fossa, which feels like a tight cord. From there move a bit medially to assess for tenderness over the median nerve. And palpate over the anterior joint capsule, which can be a source of pain when inflamed.

After that assess the posterior elbow. Start by palpating the triceps muscle along the posterior upper arm. Move downwards until you reach the prominent bump at posterior elbow called the olecranon process of the ulna. From there move your fingers superiorly to locate the olecranon fossa, which is felt as a small depression. Also examine the area posterior to the proximal ulna-the "olecranon bursa", which can only be felt if inflamed or swollen.

Next, assess the medial side. First, palpate the medial epicondyle on the distal humerus. Then, feel the tendons in the same location that belong to the wrist flexor and pronator muscles. Subsequently, palpate from the medial epicondyle to the olecranon to assess the MCL, which lies deeper than the flexor and pronator muscles. Lastly, just above the MCL, palpate the ulnar nerve, which follows the same path as the MCL. Tapping over this nerve may cause uncomfortable sensation when inflamed. This is known as the "Tinel's Sign".

Finally, examine the lateral aspect of the elbow. Start by palpating the lateral epicondyle, followed by the tendons of the extensor and supinator muscles, which are attached to the lateral epicondyle. Just beyond the epicondyle you can find the radial head, and while supinating and pronating the wrist you can feel the radial head and the articulation at the radial-capitellar joint. Finally, feel for tenderness in the area four fingerbreadths distal to the lateral epicondyle. Pain in this region suggests compression of the posterior interosseous nerve.

Next, we will demonstrate how to test the range of motion for the elbow. This should be evaluated by comparing between the two sides, and lack of motion may suggest a mechanical block, or stiffness due to injury or arthritis.

Start by assessing extension. Instruct the patient to fully straighten the arm. Normally the angle at full extension is 0°, since elbow is a hinged joint. Next, ask the patient to flex the arm and try to touch the hand to the shoulder. Normally, the flexion range is about 150°.

For the next test, that is pronation, instruct the patient to bend their elbows to 90° with their thumbs pointing upwards and then turn their hands inward so their palms are facing down. The normal pronation range is about 80°- 90°. Finally, to test supination, have the patient rotate their hands so that the palms face upward. The upper limit for this movement is about 90°.

Now, move on to evaluating the strength of muscles involved in the aforementioned range of motion movements. Pain with the following resisted motions is commonly due to tendonitis or epicondylitis.

Begin by instructing the patient to rotate their forearm inward as before, while you provide resistance. This maneuver assesses the pronator muscles, and it is painful in presence of medial epicondylitis, since the pronator tendons attach on medial epicondyle. Next, ask the patient to turn their forearm outward against your resistance, which tests the supinator muscles. This would aggravate pain in lateral epicondylitis due to the attachment of the supinator tendons to the lateral epicondyle.

For the following tests, instruct the patient to have their wrist straight and the palm facing down. Now, ask them to first move the hand in an upward direction against your resistance. This assesses the wrist extensor muscles that attach to the lateral epicondyle. Therefore, presence of pain suggests lateral epicondylitis. Similarly, moving the hand in downward direction against resistance examines the wrist flexors that attach to the medial epicondyle. Therefore, this maneuver aggravates the pain related to medial epicondylitis. Then ask the patient to move just their middle finger in upward direction, while you push down. This test the muscle that extends the long finger extensor and again aggravates the elbow pain caused by lateral epicondylitis. Lastly, to test the biceps and triceps, ask the patient to flex and extend their elbow against your resistance. Pain during these motions suggests tendonitis.

Finally, let's review a few special tests performed to diagnose the common elbow disorders. First group of these are known as the Stretch Tests. Take the patient's hand and passively flex and pronate the wrist. This will aggravate the pain related to lateral epicondylitis. Next, passively stretch the patient's wrist into extension followed by supination. This will aggravate the pain of medial epicondylitis.

The final few maneuvers of this exam assess the pain and laxity of the medial and lateral collateral ligaments - the MCL and LCL. The MCL is injured much more commonly than the LCL. Grade the severity of ligament injury according to the table provided in the accompanying manuscript.

First, passively rotate the patient's shoulder outward, place your palm over the lateral elbow and fingers around the joint line and apply Valgus stress to assess the MCL. To test the LCL, place your palm over the medial elbow and fingers on the lateral side, and apply Varus stress.

For the last assessment, ask the patient to bend one elbow to 90° and fully supinate the hand with the thumb extended. Now ask them to use the opposite arm to grasp thumb from under the elbow, and pull it laterally. This test is called the "Milking maneuver", and is perfomed to test the MCL by creating a valgus stress. This concludes the comprehensive evaluation of the elbow joint.

You've just watched JoVE's video on the elbow examination. Here, we demonstrated the essential steps of elbow assessment and also gave examples of how the physical findings can help the clinician to reach a diagnosis. We started with the inspection and palpation of the key elbow structures, followed by testing of range of motion first actively and then against resistance. Finally, we explained how to perform a few special maneuvers to assess stability of the collateral ligaments. As always, thanks for watching!

Summary

Examination of the elbow is best done by following a stepwise approach with the patient in a sitting position. It is important to have the patient remove enough clothing so that that surface anatomy can be seen and compared to the uninvolved side. The exam should begin with inspection, looking for asymmetry between the involved and uninvolved elbow. Next, palpation of key structures is done, looking for tenderness, swelling or deformity.

This is followed by assessing ROM, first actively and then against resistance to assess strength. Pain with resisted motion suggests epicondylitis or tendonitis, while weakness may suggest a tear. Stability of the ulnar collateral ligament can be assessed by using the valgus stress test or the milking maneuver, while the lateral collateral ligament is assessed by the varus stress test.

1. Inspection

  1. When inspecting the elbow, compare to the uninvolved side while looking for swelling, redness, warmth, and carrying angle.
  2. If swelling is present, determine if it is in the bursa or in the joint. Swelling in the elbow joint will appear anteriorly at the brachial fossa. The most common site for swelling in the elbow is posterior, in the olecranon bursa.
  3. Note if redness or warmth is present; these may suggest olecranon bursitis or infection.
  4. Compare the size of the elbows, looking for atrophy. Remember that it is common to see adaptive hypertrophy of the dominant elbow in a thrower.
  5. Note the carrying angle, which is formed by the upper and lower arm in the anatomic position. It is normally 5-10° in males and 10-15° in females. This angle can be altered by prior supracondylar fracture or infection.

2. Palpation

Palpation is extremely helpful in pinpointing the source of elbow pain. It is helpful to generally localize elbow pain to anterior, posterior, medial, or lateral.

Palpate the following important structures in each of these areas:

  1. Anterior elbow
    1. Biceps tendon: Palpate for a tight cord in the medial aspect of the anterior elbow (best felt with the elbow bent to 90°).
    2. Brachial artery: Feel for the pulsation just medial to the biceps tendon.
    3. Palpate for tenderness over the median nerve located medially to the brachial artery.
    4. Palpate for tenderness over the anterior joint capsule.
  2. Posterior elbow
    1. Triceps: Palpate along the posterior upper arm to the tip of the olecranon process.
    2. Olecranon process: Palpate the prominent bump at posterior elbow.
    3. Olecranon fossa: Feel the depression just superior to the olecranon process.
    4. Olecranon bursa: Palpate posteriorly to the proximal ulna; this can only be felt if inflamed and swollen.
  3. Medial elbow
    1. Medial epicondyle: Palpate the bony prominence at the medial elbow.
    2. Wrist flexor and pronator muscles: Feel for the tendons at the medial epicondyle.
    3. Medial collateral ligament (MCL): Palpate from medial epicondyle to the olecranon. The MCL lies deep to flexor-pronator muscles.
    4. Ulnar nerve: Palpate from medial epicondyle to the olecranon process just above the MCL of the elbow. Tapping over the nerve may cause uncomfortable sensations when inflamed (Tinel's sign).
  4. Lateral elbow
    1. Lateral epicondyle: Feel the bony prominence on the lateral elbow.
    2. Extensor and supinator muscles: Palpate the tendons attached at the lateral epicondyle.
    3. Radial head: Palpate at the lateral elbow, best felt while supinating and pronating the wrist.
    4. Radialcapitellar joint: Palpate just proximal to the radial head.
    5. Palpate four fingerbreadths distal to the lateral epicondyle for tenderness: Pain in this area is associated with compression of posterior interosseous nerve.

3. Range of Motion (ROM)

The ROM at the elbow should be evaluated by comparing between the two sides. A lack of motion suggests stiffness (due to injury or arthritis) or a mechanical block within the joint (due to a loose body). Normal ROM is shown in parentheses. Check for the following motions:

  1. Extension (0°): Ask the patient to extend the elbow so the arm is straight. Keep in mind it is common to see slight flexion contracture in a thrower.
  2. Flexion (150°): Ask the patient to flex the elbow by trying to touch the hand to the shoulder.
  3. Pronation (70°): With the patient's elbow bent to 90° and the thumb pointing up, ask the patient to turn the hand so the palm is facing down toward the floor.
  4. Supination (90°): With the patient's elbow bent to 90° and the thumb pointing up, ask the patient to turn the hand so the palm is facing upward (as if trying to hold soup in the palm).

4. Strength Testing

Strength testing is done by checking resisted movements described above. Pain with these resisted motions is commonly due to tendonitis or epicondylitis. Strength should be evaluated in the following motions:

  1. Supination of forearm (see above): Resistance will aggravate lateral epicondylitis (supinator tendons attach at lateral epicondyle).
  2. Pronation of forearm (see above): Resistance will aggravate medial epicondylitis (pronators tendons attach at medial epicondyle).
  3. Extension of wrist: With the patient's wrist straight and the palm facing down, move the patient's hand in an upward direction. Resistance will aggravate pain of lateral epicondylitis (wrist extensors attach at lateral epicondyle).
  4. Flexion of wrist: With the patient's wrist straight and the palm facing down, move the patient's hand in a downward direction. Resistance will aggravate pain of medial epicondylitis (wrist flexors attach at medial epicondyle).
  5. Resisted long finger extension: With the patient's wrist straight and the palm facing down, move the patient's middle finger in an upward direction. Resistance will aggravate the pain of lateral epicondylitis.
  6. Elbow flexion (see above): Resistance will test biceps strength, and pain suggests tendonitis.
  7. Elbow extension (see above): Resistance will test tests triceps strength, and pain suggests tendonitis.

5. Stretch Tests

These tests will aggravate pain caused by medial or lateral epicondylitis by pulling at the epicondyle.

  1. Stretch the wrist into flexion or pronation (described above); this pulls at the lateral epicondyle and aggravates the pain of lateral epicondylitis.
  2. Stretch the wrist into extension or supination (described above); this pulls at the medial epicondyle and aggravates the pain of medial epicondylitis.

6. Collateral Ligament Testing

The collateral ligaments of the elbow should be evaluated for pain and/or laxity. The medial collateral ligament is injured much more commonly than the lateral.

Two tests are used to evaluate these ligaments:

  1. Varus/valgus stress
    1. Passively rotate the patient's shoulder outward (full external rotation), and flex the elbow to 30° to unlock the olecranon from the olecranon fossa.
    2. Place one palm over the patient's lateral elbow and push medially with your other hand (valgus stress is applied to assess the medial collateral ligament).
    3. Perform varus stress test to assess the lateral collateral ligament by placing your palm over the patient's medial elbow and pushing in a lateral direction.
    4. Check for pain and/or laxity.
    5. Grade the severity of ligament injury.
      Grade I (ligament stretched): Pain with no laxity.
      Grade II (partial tear): Pain with minimal laxity. Soft endpoint.
      Grade III (complete tear): Pain with no good endpoint.
  2. Milking maneuver: Bend the affected elbow to 90° and full supination with thumb extended. Reach opposite arm under involved elbow and grasp thumb. Pulling laterally on thumb creates valgus stress at the medial collateral ligament of the affected elbow.

The elbow joint enables mobility of the upper extremities and allows precise control of the hand's position in space.

The anatomy of the elbow is complex. It is a hinged joint formed by articulations between three bones: humerus, radius, and ulna. It is stabilized by the lateral and medial collateral ligament complexes.

The muscles involved in elbow movement are classified as per their function. The flexor group includes biceps brachii, brachilais, and brachioradialis. Extension is a function of posterior muscles-triceps brachii and anconeus. Pronation involves brachoradilais and pronator teres. Lastly, supination engages biceps brachii, brachoradilais, and supinator muscles.

In addition, the bony prominences of the distal humerus-called the lateral and medical epicondyle-form the attachment sites for muscles involves in wrist and hand movement. Lateral epicondyle is where the extensors attach and medial epicondyle is the attachment site for the flexor muscles. Inflammation surrounding these epicondyles, or epicondylitis, is one of the common reasons of elbow pain. Lateral epicondylitis is frequently seen in tennis players, giving this condition a colloquial name - the "tennis elbow". Similarly, medial epicondylitis is commonly seen in golfers, and therefore known as the "golfer's elbow".

The source of the elbow pain can be identified based on the patient history and careful physical examination, and here, we will review the steps of this exam in detail.

Systematic elbow examination starts with inspection and palpation. Before starting the exam wash your hands thoroughly. For inspection, ask the patient to sit on the exam table and request them to remove enough clothing so that the entire shoulder and elbow are exposed.

First assess the size of the elbows and look for atrophy and swelling, and check for redness or warmth. The joint swelling may appear anteriorly at the brachial fossa, but the more common site is in posterior region, in the olecranon bursa. Next, assess the carrying angle, which is formed by the upper arm and the forearm in the anatomic position. The carrying angle is normally 5-10° in males and 10-15° in females, and can be altered by prior trauma or infection.

Now move onto palpation, which is helpful in localizing the pain to the anterior, posterior, medial, or lateral region. Starting at the anterior elbow, first find the biceps tendon in the cubital fossa, which feels like a tight cord. From there move a bit medially to assess for tenderness over the median nerve. And palpate over the anterior joint capsule, which can be a source of pain when inflamed.

After that assess the posterior elbow. Start by palpating the triceps muscle along the posterior upper arm. Move downwards until you reach the prominent bump at posterior elbow called the olecranon process of the ulna. From there move your fingers superiorly to locate the olecranon fossa, which is felt as a small depression. Also examine the area posterior to the proximal ulna-the "olecranon bursa", which can only be felt if inflamed or swollen.

Next, assess the medial side. First, palpate the medial epicondyle on the distal humerus. Then, feel the tendons in the same location that belong to the wrist flexor and pronator muscles. Subsequently, palpate from the medial epicondyle to the olecranon to assess the MCL, which lies deeper than the flexor and pronator muscles. Lastly, just above the MCL, palpate the ulnar nerve, which follows the same path as the MCL. Tapping over this nerve may cause uncomfortable sensation when inflamed. This is known as the "Tinel's Sign".

Finally, examine the lateral aspect of the elbow. Start by palpating the lateral epicondyle, followed by the tendons of the extensor and supinator muscles, which are attached to the lateral epicondyle. Just beyond the epicondyle you can find the radial head, and while supinating and pronating the wrist you can feel the radial head and the articulation at the radial-capitellar joint. Finally, feel for tenderness in the area four fingerbreadths distal to the lateral epicondyle. Pain in this region suggests compression of the posterior interosseous nerve.

Next, we will demonstrate how to test the range of motion for the elbow. This should be evaluated by comparing between the two sides, and lack of motion may suggest a mechanical block, or stiffness due to injury or arthritis.

Start by assessing extension. Instruct the patient to fully straighten the arm. Normally the angle at full extension is 0°, since elbow is a hinged joint. Next, ask the patient to flex the arm and try to touch the hand to the shoulder. Normally, the flexion range is about 150°.

For the next test, that is pronation, instruct the patient to bend their elbows to 90° with their thumbs pointing upwards and then turn their hands inward so their palms are facing down. The normal pronation range is about 80°- 90°. Finally, to test supination, have the patient rotate their hands so that the palms face upward. The upper limit for this movement is about 90°.

Now, move on to evaluating the strength of muscles involved in the aforementioned range of motion movements. Pain with the following resisted motions is commonly due to tendonitis or epicondylitis.

Begin by instructing the patient to rotate their forearm inward as before, while you provide resistance. This maneuver assesses the pronator muscles, and it is painful in presence of medial epicondylitis, since the pronator tendons attach on medial epicondyle. Next, ask the patient to turn their forearm outward against your resistance, which tests the supinator muscles. This would aggravate pain in lateral epicondylitis due to the attachment of the supinator tendons to the lateral epicondyle.

For the following tests, instruct the patient to have their wrist straight and the palm facing down. Now, ask them to first move the hand in an upward direction against your resistance. This assesses the wrist extensor muscles that attach to the lateral epicondyle. Therefore, presence of pain suggests lateral epicondylitis. Similarly, moving the hand in downward direction against resistance examines the wrist flexors that attach to the medial epicondyle. Therefore, this maneuver aggravates the pain related to medial epicondylitis. Then ask the patient to move just their middle finger in upward direction, while you push down. This test the muscle that extends the long finger extensor and again aggravates the elbow pain caused by lateral epicondylitis. Lastly, to test the biceps and triceps, ask the patient to flex and extend their elbow against your resistance. Pain during these motions suggests tendonitis.

Finally, let's review a few special tests performed to diagnose the common elbow disorders. First group of these are known as the Stretch Tests. Take the patient's hand and passively flex and pronate the wrist. This will aggravate the pain related to lateral epicondylitis. Next, passively stretch the patient's wrist into extension followed by supination. This will aggravate the pain of medial epicondylitis.

The final few maneuvers of this exam assess the pain and laxity of the medial and lateral collateral ligaments - the MCL and LCL. The MCL is injured much more commonly than the LCL. Grade the severity of ligament injury according to the table provided in the accompanying manuscript.

First, passively rotate the patient's shoulder outward, place your palm over the lateral elbow and fingers around the joint line and apply Valgus stress to assess the MCL. To test the LCL, place your palm over the medial elbow and fingers on the lateral side, and apply Varus stress.

For the last assessment, ask the patient to bend one elbow to 90° and fully supinate the hand with the thumb extended. Now ask them to use the opposite arm to grasp thumb from under the elbow, and pull it laterally. This test is called the "Milking maneuver", and is perfomed to test the MCL by creating a valgus stress. This concludes the comprehensive evaluation of the elbow joint.

You've just watched JoVE's video on the elbow examination. Here, we demonstrated the essential steps of elbow assessment and also gave examples of how the physical findings can help the clinician to reach a diagnosis. We started with the inspection and palpation of the key elbow structures, followed by testing of range of motion first actively and then against resistance. Finally, we explained how to perform a few special maneuvers to assess stability of the collateral ligaments. As always, thanks for watching!

The elbow joint enables mobility of the upper extremities and allows precise control of the hand's position in space.

The anatomy of the elbow is complex. It is a hinged joint formed by articulations between three bones: humerus, radius, and ulna. It is stabilized by the lateral and medial collateral ligament complexes.

The muscles involved in elbow movement are classified as per their function. The flexor group includes biceps brachii, brachilais, and brachioradialis. Extension is a function of posterior muscles-triceps brachii and anconeus. Pronation involves brachoradilais and pronator teres. Lastly, supination engages biceps brachii, brachoradilais, and supinator muscles.

In addition, the bony prominences of the distal humerus-called the lateral and medical epicondyle-form the attachment sites for muscles involves in wrist and hand movement. Lateral epicondyle is where the extensors attach and medial epicondyle is the attachment site for the flexor muscles. Inflammation surrounding these epicondyles, or epicondylitis, is one of the common reasons of elbow pain. Lateral epicondylitis is frequently seen in tennis players, giving this condition a colloquial name - the "tennis elbow". Similarly, medial epicondylitis is commonly seen in golfers, and therefore known as the "golfer's elbow".

The source of the elbow pain can be identified based on the patient history and careful physical examination, and here, we will review the steps of this exam in detail.

Systematic elbow examination starts with inspection and palpation. Before starting the exam wash your hands thoroughly. For inspection, ask the patient to sit on the exam table and request them to remove enough clothing so that the entire shoulder and elbow are exposed.

First assess the size of the elbows and look for atrophy and swelling, and check for redness or warmth. The joint swelling may appear anteriorly at the brachial fossa, but the more common site is in posterior region, in the olecranon bursa. Next, assess the carrying angle, which is formed by the upper arm and the forearm in the anatomic position. The carrying angle is normally 5-10° in males and 10-15° in females, and can be altered by prior trauma or infection.

Now move onto palpation, which is helpful in localizing the pain to the anterior, posterior, medial, or lateral region. Starting at the anterior elbow, first find the biceps tendon in the cubital fossa, which feels like a tight cord. From there move a bit medially to assess for tenderness over the median nerve. And palpate over the anterior joint capsule, which can be a source of pain when inflamed.

After that assess the posterior elbow. Start by palpating the triceps muscle along the posterior upper arm. Move downwards until you reach the prominent bump at posterior elbow called the olecranon process of the ulna. From there move your fingers superiorly to locate the olecranon fossa, which is felt as a small depression. Also examine the area posterior to the proximal ulna-the "olecranon bursa", which can only be felt if inflamed or swollen.

Next, assess the medial side. First, palpate the medial epicondyle on the distal humerus. Then, feel the tendons in the same location that belong to the wrist flexor and pronator muscles. Subsequently, palpate from the medial epicondyle to the olecranon to assess the MCL, which lies deeper than the flexor and pronator muscles. Lastly, just above the MCL, palpate the ulnar nerve, which follows the same path as the MCL. Tapping over this nerve may cause uncomfortable sensation when inflamed. This is known as the "Tinel's Sign".

Finally, examine the lateral aspect of the elbow. Start by palpating the lateral epicondyle, followed by the tendons of the extensor and supinator muscles, which are attached to the lateral epicondyle. Just beyond the epicondyle you can find the radial head, and while supinating and pronating the wrist you can feel the radial head and the articulation at the radial-capitellar joint. Finally, feel for tenderness in the area four fingerbreadths distal to the lateral epicondyle. Pain in this region suggests compression of the posterior interosseous nerve.

Next, we will demonstrate how to test the range of motion for the elbow. This should be evaluated by comparing between the two sides, and lack of motion may suggest a mechanical block, or stiffness due to injury or arthritis.

Start by assessing extension. Instruct the patient to fully straighten the arm. Normally the angle at full extension is 0°, since elbow is a hinged joint. Next, ask the patient to flex the arm and try to touch the hand to the shoulder. Normally, the flexion range is about 150°.

For the next test, that is pronation, instruct the patient to bend their elbows to 90° with their thumbs pointing upwards and then turn their hands inward so their palms are facing down. The normal pronation range is about 80°- 90°. Finally, to test supination, have the patient rotate their hands so that the palms face upward. The upper limit for this movement is about 90°.

Now, move on to evaluating the strength of muscles involved in the aforementioned range of motion movements. Pain with the following resisted motions is commonly due to tendonitis or epicondylitis.

Begin by instructing the patient to rotate their forearm inward as before, while you provide resistance. This maneuver assesses the pronator muscles, and it is painful in presence of medial epicondylitis, since the pronator tendons attach on medial epicondyle. Next, ask the patient to turn their forearm outward against your resistance, which tests the supinator muscles. This would aggravate pain in lateral epicondylitis due to the attachment of the supinator tendons to the lateral epicondyle.

For the following tests, instruct the patient to have their wrist straight and the palm facing down. Now, ask them to first move the hand in an upward direction against your resistance. This assesses the wrist extensor muscles that attach to the lateral epicondyle. Therefore, presence of pain suggests lateral epicondylitis. Similarly, moving the hand in downward direction against resistance examines the wrist flexors that attach to the medial epicondyle. Therefore, this maneuver aggravates the pain related to medial epicondylitis. Then ask the patient to move just their middle finger in upward direction, while you push down. This test the muscle that extends the long finger extensor and again aggravates the elbow pain caused by lateral epicondylitis. Lastly, to test the biceps and triceps, ask the patient to flex and extend their elbow against your resistance. Pain during these motions suggests tendonitis.

Finally, let's review a few special tests performed to diagnose the common elbow disorders. First group of these are known as the Stretch Tests. Take the patient's hand and passively flex and pronate the wrist. This will aggravate the pain related to lateral epicondylitis. Next, passively stretch the patient's wrist into extension followed by supination. This will aggravate the pain of medial epicondylitis.

The final few maneuvers of this exam assess the pain and laxity of the medial and lateral collateral ligaments - the MCL and LCL. The MCL is injured much more commonly than the LCL. Grade the severity of ligament injury according to the table provided in the accompanying manuscript.

First, passively rotate the patient's shoulder outward, place your palm over the lateral elbow and fingers around the joint line and apply Valgus stress to assess the MCL. To test the LCL, place your palm over the medial elbow and fingers on the lateral side, and apply Varus stress.

For the last assessment, ask the patient to bend one elbow to 90° and fully supinate the hand with the thumb extended. Now ask them to use the opposite arm to grasp thumb from under the elbow, and pull it laterally. This test is called the "Milking maneuver", and is perfomed to test the MCL by creating a valgus stress. This concludes the comprehensive evaluation of the elbow joint.

You've just watched JoVE's video on the elbow examination. Here, we demonstrated the essential steps of elbow assessment and also gave examples of how the physical findings can help the clinician to reach a diagnosis. We started with the inspection and palpation of the key elbow structures, followed by testing of range of motion first actively and then against resistance. Finally, we explained how to perform a few special maneuvers to assess stability of the collateral ligaments. As always, thanks for watching!

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