Elbow Examination

Original Editor - Jason Brandi and Krista Dayton as part of the Temple University EBP Project

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Subjective

Clinical Presentation

Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.

Subjective History

• Exact location of pain
• Timeline-When are the patients reported symptoms at their worst?
• Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis. For atraumatic injuries, specific symptoms can be highly useful in determining a diagnosis.
     For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.
• Presence of numbness or tingling?
• Medications?
• Past Medical History
• Diagnostic Testing/Imaging?

• Region Specific Historical Question: These questions will help guide the examination. For example:

Please refer to the User's Guide to the Musculoskeletal Examination for further information.²
1. Do your symptoms change (better or worse) with any movements of the neck or shoulder?
    
2. Does your elbow ever “slip out” or feel unstable?
    
3. Does the pain change with gripping activities?
    
4. Do you ever experience numbness of tingling in the hand?
   
5. Was the elbow hyper extended during the time of injury?
    
6. Do you relate the symptoms to a throwing activity?
    

• Environmental and Personal Factors
During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury. Table 1 outlines these issues.

Table 1. Patient Factors that can affect healing and return of function after elbow injury

Diabetes • Immunosuppression • Infection • Multiple site injuries • Tobacco use • Excessive alcohol intake • Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability)

Self-Report Outcome Measures

• DASH (Quick Dash)
• Patient-Specific Functional Scale
• PREE and ASES: Patient-rated elbow evaluation (PREE) and American Shoulder and Elbow Society evaluation(ASES) are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.
• P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.
  

• SF-36: SF-36 is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the SF-36 is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.

Special Questions

• Red and Yellow Flags- Conditions that may require referral to appropriate health care provider. 

Red Flags

•Infection/Inflammation •Malignancy •Fracture/Dislocation (Positive Elbow Extension Test) • Inflammatory Arthritides •Abnormal Vitals •Abnormal Vascular/Neurological Exam •Heterotopic Ossification (Post-Surgical Consideration) •Inappropriate progress from treatment made after surgery

Yellow Flags

-Psychosocial factors -Passive coping -Fear Avoidance Beliefs

Investigations

• Radiological Considerations
     The information from the history should be correlated with imaging findings of the elbow when available.

                                                                   

Illustration adapted from [Frick, 2006]

Image 1: Anteroposterior (a) and lateral (b) radiographs of a normal elbow demonstrate the normal articulations of the elbow.

Objective

Observation

• General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms.
• Thoracic and cervical spine including kyphosis and forward head
• Scapula
• Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.
• Swelling/ecchymosis/deformities/muscle wasting
• Triangle Sign

Functional Tests

The goal in performing functional test is to obtain and quantify an asterisk sign to assess and reassess after intervention is performed.

1.  Determination of an asterisk sign-(What activity increases symptoms?)
2.  Pain-Free Grip Strength
3.  Push-off Test: The push off test can be used to quantify a person’s ability to bear weight through the upper           extremity. This can help identify functional/occupational limitations. (ICC=0.31-0.97).
4. Functional Impairment Test-Hand, Neck, Shoulder Arm (FIT-HaNSA): Standardized physical test. Assesses gross activities of the upper extremity. Validation in elbow conditions has not yet been completed. 
   

Palpation

• Medial/lateral epicondyle
• Olecranon and olecranon fossa
• Radial head
• Ulnar Collateral Ligament (UCL) of the elbow
• Soft tissue in upper arm and forearm/wrist for pain provocation, heat, swelling
  

                                                                             

Image 2: Anterior Elbow                Image 3: Lateral Elbow                             Image 4: Medial Epicondyle

Bicep tendon Marked                        Circle represents lateral epicondyle             Dot represents medial epicondyle

Neurologic Assessment

• Reflexes: C5-C7
• Myotomes: C5-T1
• Dermatomes: C5-T1

Movement Testing

• Active Range Of Motion(AROM)/Passive Range Of Motion(PROM) with or without overpressure
     o Elbow
          Flexion
          Extension
               - Positive Elbow Extension Test may indicate fracture and referral.
          Forearm pronation/supination
     o Wrist
          Flexion
          Extension
     o Cervical, Shoulder and Elbow Range of Motion with or without overpressure
          Posterior-anterior glide assessment on cervical/thoracic spine for distal symptoms reproduction as well.

• Resistive testing
     o Elbow flexion/extension
     o Forearm pronation/supination
     o Wrist flexion/extension
     o Pain-free grip strength
     o Thumb
     o Fingers

• Accessory motion testing
     o Humeroulnar traction
     o Humeroradial traction
     o Proximal/distal radioulnar Anterior/Posterior and Posterior/Anterior glides

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Special Tests (broken up by possible diagnosis)

Cubital Tunnel Syndrome:

• Elbow Flexion Test
• Tinnel's Sign
• Ulnar Nerve Compression Test

Lateral Epicondylalgia:

• Passive elbow extension, pronation, wrist flexion (Mill's Test)
• Resisted wrist extension with radial deviation (Cozen's Test)
• Resisted middle finger extension (Maudley's Test)

Ligamentous Tests:

• Varus Stress Test
• Valgus Stress Test
• Moving Valgus Stress Test

Neurodynamic Tests

Median nerve bias: Upper Limb Neurodynamic Test 1

• Radial nerve bias:  Upper Limb Neurodynamic Test 2b
• Ulnar nerve bias:  Upper Limb Neurodynamic Test 3
  

References

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