Physical Examination of Elbow

Follows the IP-PASS examination methodology

Inspection

• Skin
  • Color: erythema, ecchymosis, white, black
  • Trophic changes (altered hair growth, sweat production)
• Scars
• Swelling
• Muscle tone
• Atrophy, hypertrophy
• Deformity: asymmetry, rotation, amputation

Palpation

• Palpate for
  • Effusion
  • Clicking
  • Snapping
  • Crepitus
  • Tenderness
  • Temperature
  • Masses
• Areas of Emphasis
  • Recommend you divide the elbow into four quadrants
  • Lateral:
    • Lateral Epicondyle of Humerus
  • Medial:
    • Ulnar Collateral Ligament
    • Medial Epicondyle of Humerus
  • Anterior:
    • Radial Head of Radius
    • Tendon of Biceps Brachii
  • Posterior
    • Olecranon Bursa

Range of Motion

• Forearm
  • Pronation: 75-80
  • Supination: 80-85
• Elbow
  • Flexion: 150-160
  • Extension: 0
• Humerus and Shoulder
  • Abduction: 180 degrees
  • Adduction: 50 degrees
  • Forward flexion: 180 degrees
  • Extension: 50 degrees
  • External Rotation: 90 degrees
  • Internal rotation: 90 degrees

Strength

• Supination: Supinator, Brachioradialis, Biceps Brachii
• Pronation: Pronator Teres, Pronator Quadratus
• Elbow Flexion: Biceps Brachii, Brachioradialis, Brachialis
• Elbow Extension: Triceps Brachii

Neurovascular

• Motor Nerves:
  • Musculocutaneous Nerve: Elbow flexion, supination
  • Radial Nerve: Elbow extension, elbow flexion, supination (wrist extension, wrist adduction, wrist abduction)
  • Median Nerve: Pronation (wrist flexion, wrist abduction)

• Light touch
  • Lateral: Lateral cutaneous nerve of forearm (branch of Musculocutaneous Nerve)
  • Posterior: Posterior cutaneous nerve of forearm (branch of Radial Nerve)
  • Medial: Medial cutaneous nerve of forearm (branch of Ulnar Nerve)
• Dermatomes: C5-T1
  • Deltoid (C5)
  • Thumb (C6, median n)
  • Posterior 1st web space (C6, radial n)
  • Middle finger (C7, median n)
  • Little finger (C8, ulnar n)
  • Proximal medial forearm (T1)

• Deep Tendon Reflexes (C5-C7)
  • Biceps (C5, C6)
  • Brachioradialis (C6)
  • Triceps (C7)

• Myotomes: C5-T1
  • C5: shoulder abduction
  • C6: Elbow flexion Wrist extension
  • C7: Elbow extension
  • C8: Finger flexion
  • T1: Finger abduction

• Vascular
  • Radial pulse
  • Ulnar pulse

• Motor strength
  • Elbow Flexion in full supination primary brachialis and biceps (C5 and C6) in 90 degrees supination (thumb pointing to the ceiling) primarily brachioradialis (C6)

  • Elbow Extension triceps (C7)

  • Wrist Pronation flexor-pronator mass (C7, C8)

  • Wrist Supination primarily biceps (C6)

  • Wrist Extension ECRL, ECRB, ECU (C6-C8)

  • Wrist Flexion FCR, FCU (C6-C8)

  • Finger and thumb extension EDC, EPL (C7, C8)

  • Finger and thumb flexion FDS, FDP, FPL (C7, C8)

  • All small intrinsic movements of hand lumbricals, interossei (T1)

  • Clinical pearls
    • cubital tunnel syndrome – weak pinch from loss of thumb adduction (as much as 70% of pinch strength is lost). Froment sign compensatory thumb IP flexion by FPL (AIN) during key pinch compensates for the loss of MCP flexion by adductor pollicis (ulna n.)

    • PIN syndrome – finger metacarpal extension weakness wrist extension weakness inability to extend wrist in neutral or ulnar deviation the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent ECU (PIN)

    • AIN syndrome positive OK sign (test FDP and FPL) patient unable to make OK sign pronator quadratus weakness shown with weak resisted pronation with elbow maximally flexed

• Sensory
  • The sensation of medial antebrachial cutaneous, lateral antebrachial cutaneous, posterior antebrachial cutaneous, ulnar, median, superficial radial

  • cubital tunnel syndrome – decreased 2-point discrimination over the small finger and ulnar half of ring finger decreased 2-point discrimination over the ulnar aspect of the dorsal hand may discriminate cubital tunnel from more distal entrapment (dorsal branch of ulnar nerve branches 5 cm proximal to wrist) 
  • pronator syndrome – sensory disturbances over the distribution of palmar cutaneous branch of the median nerve which arises 4 to 5 cm proximal to carpal tunnel 

    unlike in carpal tunnel syndrome which does not exhibit sensory disturbances over palmar cutaneous nerve distribution

• Vascular
  • Brachial artery palpable on the anterior aspect of the elbow, medial to the tendon of the biceps

  • Radial artery

  • Ulnar artery

• Provocative tests – stability
  • MCL injuries
    • milking maneuver – creates valgus stress by pulling on the patient’s thumb with the forearm supinated and elbow flexed at 90 degrees the patient may be supine or seated/standing a positive test is a subjective apprehension, instability, or pain at the MCL origin 87.5% sensitive with a negative predictive value of 100%

    • moving valgus stress test – place the elbow in the same position as the “milking maneuver” and apply valgus stress while the elbow is ranged through the full arc of flexion and extension shoulder should be fully externally rotated during the entire test positive test is a subjective apprehension, instability, or pain at the MCL origin between 70 and 120 degrees

      correlates in throwers to the location of early acceleration (70 degrees flexion), and the location of late cocking (120 degrees flexion) 100% sensitive and 75% specific

  • LCL injuries
    • lateral pivot-shift test – the patient lies supine with the affected arm overhead; with the shoulder fully externally rotated, the forearm is supinated and valgus stress is applied while bringing the elbow from full extension to flexion
      at 40 degrees flexion, the patient may feel pain and apprehension

      with increased flexion, triceps tension reduces the radial head and another clunk may be appreciated link appreciated at 40 degrees represents dislocated radiocapitellar joint often more reliable on an anesthetized patient

    • posterolateral rotatory drawer test – with the patient supine and elbow flexed to 40 degrees, the forearm is supinated and the examiner’s index finger is placed under the radial head and the thumb over it. application of an anterior-to-posterior force if performed over the lateral proximal forearm positive test is indicated by apprehension or presence of a skin dimple (indicating posterior subluxation of the radial head)

    • chair push-up test sitting on a chair, the patient attempts to perform a pushup while holding on to handles with a forearm supinated

      inability to do pushups or apprehension indicates a positive test.87.5% sensitivity (100% when combined with prone push-up test)

    • table-top relocation test 
    • 1st part: patient places the hand of the symptomatic elbow around the edge of the table and is asked to perform a press-up maneuver with the elbow pointing laterally and the forearm supinated

    • 2nd part: the same maneuver as 1st part but examiner places thumb over patient’s radial head during the maneuver relief of pain and apprehension indicates a positive test (as the examiner’s thumb should be preventing radial head subluxation)
    • 3rd part: same as 1st part without examiner’s thumb pain and apprehension during 1st and 3rd part with relief during 2nd part indicate posterolateral instability with an intra-articular radial head fracture, the pain would be present in all 3 parts. 3-part test pain and apprehension as the elbow is gradually flexed indicates a positive test

    • prone push-up test – patient unable to perform push-ups with forearm supinated 87.5% sensitivity (100% when combined with chair push-up test)

  • Valgus extension overload
    • pain with forced elbow extension valgus loading during terminal extension reproduces pain varus loading reduces pain

• Provocative tests – nerve
  • Cubital tunnel syndrome
    • Jeanne sign – compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch compensates for the loss of IP extension and thumb adduction by adductor pollicis (ulna n.)

    • Wartenberg sign – persistent small finger abduction and extension during attempted adduction secondary to weak intrinsic and unopposed action of EDM

    • Masse sign – palmar arch flattening and loss of ulnar hand elevation secondary to weak opponents digiti quinti and decreased small finger MCP flexion

    • Tinel sign – positive over the cubital tunnel with the elbow extended

    • elbow flexion test – positive when flexion of the elbow for > 60 seconds reproduces symptoms

  • Radial tunnel syndrome
    • resisted long finger extension test – reproduces pain at radial tunnel (weakness because of pain)

    • resisted supination test (with elbow and wrist in extension) – reproduces pain at radial tunnel (weakness because of pain)

    • passive pronation with wrist flexion reproduces pain at the radial tunnel

    • the passive stretch of the supinator muscle increases pressure inside the radial tunnel to 250mmHg (normal 50mmHg)

  • PIN syndrome
    • resisted supination will increase pain symptoms

    • normal tenodesis test tenodesis test is used to differentiate from the extensor tendon rupture

  • Pronator syndrome
    • positive Tinel sign in the proximal anterior forearm but no Tinel sign at the wrist

    • provocative symptoms with wrist flexion as would be seen in CTS

    • tests for specific sites of entrapment – resisted elbow flexion with forearm supination (compression at bicipital aponeurosis) resisted forearm pronation with the elbow extended (compression at two heads of pronator teres) resisted contraction of FDS to middle finger (compression at FDS fibrous arch)

  • AIN syndrome
    • distinguish from FPL attritional rupture (seen in rheumatoid) by passively flexing and extending the wrist to confirm tenodesis effect in intact tendon if tendons are intact, passive wrist extension brings the thumb IP joint and index finger DIP joint into a relatively flexed position

• Provocative tests – tendon
  • Triceps tendon rupture
    • modified Thompson squeeze test – patient lies prone with the elbow at the end of the table and forearm hanging down triceps muscle is firmly squeezed inability to extend the elbow against gravity suggests complete disruption of triceps proper and lateral expansion

  • Distal biceps tendon rupture
    • Hook test – performed by asking the patient to actively flex the elbow to 90° and to fully supinate the forearmzcx examiner then uses the index finger to hook the lateral edge of the biceps tendon with an intact / partially torn tendon, the finger can be inserted 1 cm beneath the tendon false-positive – partial tear, intact lacertus fibrosis, underlying brachialis tendon sensitivity, and specificity 100%

    • Ruland biceps squeeze test (akin to the Thompson/Simmonds test for Achilles rupture) – elbow held in 60-80° of flexion with the forearm slightly pronated. one hand stabilizes the elbow while the other hand squeezes across the distal biceps muscle belly. a positive test is a failure to observe supination of the patient’s forearm or wrist. sensitivity 96%

    • biceps crease interval (BCI) – measurement of the distance between palpable and anatomic biceps insertion the patient elbow is brought from flexion to extension with the forearm supinated and the main crease in the antecubital fossa is marked (crease) next, the location where the distal biceps tendon turns most sharply toward the antecubital fossa is marked (cusp) the distance between the crease and the cusp is the BCI values > 6 cm or 1.2x the value of contralateral arm are positive for biceps tendon rupture 92% sensitivity, 100% specificity

    • passive forearm pronation test – the observation that the biceps muscle belly moves proximally with forearm supination and distally with forearm pronation (actively and passively) performing the hook test, passive forearm pronation test, and BCI test in sequence results in 100% sensitivity and 100% specificity for complete biceps tendon rupture loss of more supination than flexion strength

  • Lateral epicondylitis
    • the following maneuvers exacerbate pain at the lateral epicondyle resisted wrist extension with the elbow fully extended and pronated resisted extension of the middle finger (Maudsley Test) selectively recruits fibers of the ECRB maximal flexion of the wrist passive wrist flexion in pronation causes pain at the elbow

    • chair Test – with the elbow fully extended, forearm pronated, and shoulder forward flexed, the patient is asked to lift a chair lateral elbow pain is positive for lateral epicondylitis.

  • Medial epicondylitis
    • pain with resisted forearm pronation and wrist flexion no instability or apprehension with valgus stress or milking maneuver used to differentiate from MCL injuries.

Special Tests

• Lateral Epicondylitis
  • Cozens Test
  • Mills Test
  • Maudsleys Test
  • Chair Test
• Medial Epicondylitis
  • Golfers Elbow Test
  • Resisted Wrist Flexion Pronation Test
• Distal Biceps Tendon Rupture
  • Hook Test
  • Biceps Squeeze Test
• Triceps Tendon Injury
  • Arm Bar Test
  • Triceps Squeeze Test
• Ulnar Collateral Ligament Injury
  • Elbow Valgus Stress Test
  • Moving Valgus Stress Test (Elbow)
  • Milking Maneuver
• Radial Collateral Ligament Injury (LCL)
  • Elbow Varus Stress Test
  • Lateral Pivot Shift Test
  • Table Top Relocation Test
  • Pushup Apprehension Test
  • Chair Apprehension Test
  • Rotatory Drawer Test
• Cubital Tunnel Syndrome
  • Tinels Test
  • Elbow Flexion Compression Test
  • Scratch Collapse Test
• Posteromedial Rotatory Instability
  • Gravity Varus Stress Test
  • Hyper pronation Test
  • Chair Test
  • Pushup Apprehension Test
• Little League Elbow
  • Elbow Valgus Stress Test
• Radial Tunnel Syndrome
  • Maudsley’s Test
  • Resisted Active Forearm Extension Test
• Panners Disease
  • Plica Impingement Test
  • Active Radiocapitellar Compression Test