Overview of Elbow Assessment

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Original Editor - Shala Cunningham Top Contributors - Jess Bell

Introduction

Musculoskeletal conditions of the elbow can have a significant physical and socioeconomic impact on both individuals and communities. Elbow pain can be caused by many structures, including the bone, tendons, ligaments, bursa, and nerves. It is, therefore, important that rehabilitation providers have a comprehensive understanding of the anatomy of the elbow and the objective assessment of the elbow. This page provides an overview of the elbow evaluation. To review elbow anatomy, please see Functional Anatomy of the Elbow.

Subjective Assessment

The mnemonic L-M-N-O-P-Q-R-S-T is used to cover the key aspects you should consider when taking a patient’s history.

L: location of symptoms and level of functional impairment

The location of symptoms can help you start to develop hypothetical diagnoses, based on which tissues are in the area.

Anterior elbow:

• biceps tendinopathy / tendonitis
• pronator syndrome
• anterior capsule strain
• torn brachialis

Lateral elbow:

• lateral elbow tendinopathy (also known as lateral epicondylalgia, lateral epicondylitis, tennis elbow)
• radial tunnel syndrome
• radiocapitellar chondromalacia

Medial elbow

• medial elbow tendinopathy (also known as medial epicondylalgia, medial epicondylitis, golfer’s elbow)
• ulnar collateral ligament strain
• ulnar nerve entrapment

Posterior elbow:

• Triceps tendinopathy / tendinosis / tendinitis
• olecranon impingement
• olecranon bursitis

Given the high burden of elbow pain, it is important to ascertain how a patient’s pain is affecting their ability to perform activities of daily living, as well as work-, school-, and sport-related tasks and other relevant functional activities.

M: medical factors (medications) and mechanism of injury

We need to find out what medications the patient is taking (including those prescribed by physicians or other healthcare providers or supplements) and what co-morbidities they may have. We also want to determine when and how the injury occurred (was there a specific trauma, overuse, etc)

Red flags: insidious onset, symptoms related to cardiovascular activity (i.e. exertion), and a history of cardiovascular disease.

N: neurological symptoms

Neurological symptoms include numbness, tingling, paraesthesias, sharp, burning pain that radiates down the arm.

When neurological symptoms are present, we need to determine if they are constant or intermittent and if they follow a dermatomal or peripheral nerve pattern. It is important to determine if symptoms are related to neck, shoulder or elbow positions or movements.

O: occupation, including limitations

It is important to determine if there are any work- or activity-related factors that are relevant:

• is there a possibility of overuse?
• does the patient perform any repetitive tasks?
• are they an overhead athlete?

P: palliating and provocating symptoms

Find out what increases or worsens symptoms. It’s also important to determine how long it takes for symptoms to calm down or decrease once aggravated.

Red flags: constant, unrelenting symptoms.

Q: quality of symptoms / pain

Find out if symptoms are:

• sharp
• dull
• stabbing
• aching
• electric shock-like

Is there any numbness, tingling, or a feeling of weakness / clumsiness?

R: radiation of symptoms

Questions to consider for radiating symptoms are:

• where do the symptoms radiate to?
• are radiating symptoms provoked by activities or position?
• how long do radiating symptoms last?

Red flag: radiating symptoms down multiple dermatomes (remember to check peripheral nerve sensory patterns if more than one dermatome appears to be affected).

S: severity of symptoms

It can be helpful to use scales such as the Visual Analogue Scale or the Numeric Pain Rating Scale, but also consider how symptoms affect function and activities. Does the patient have to modify or stop activities due to symptoms?

Red flag: sudden onset of severe pain without incident or accident.

T: timing of symptoms

Find out the timing of symptoms in a 24-hour period and in relation to activity:

• pain that tends to occur only after activity (not with activity) is more likely to be chronic
• pain that occurs with activity is more likely to be subacute
• pain that occurs before, during and after an activity is more likely to be acute

Systems review

• Ask about constitutional symptoms (fatigue, shortness of breath)
• Ask about cardiovascular risk factors and symptoms (angina)

Self-Assessment Questionnaires for Elbow Pain

• Disabilities of the Arm, Shoulder, and Hand (DASH)
• Quick DASH

Objective Assessment

The following sections discuss the general assessment of the elbow.

Observation

It is important to look at the whole upper quarter (neck, shoulder, elbow, wrist and hand). Observe both sides to allow for a comparison. Key points at the elbow:

• observe the carrying angle in extension
  • average ranges given for carrying angles in the literature vary, but in females, the carrying angle is around 5-16 degrees and, in men, around 5-14 degrees
  • the carrying angle tends to be higher in the dominant hand MANANDHAR https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9226732/
• look for any asymmetries, soft tissue changes, scars or swelling

• swelling local to the posterior tip: consider olecranon bursitis
• diminished tip of olecranon: consider dislocation or fracture
• altered carrying angle: consider non-union or mal-union of the humerus
• nodules: consider rheumatoid arthritis
• synovitis: consider rheumatoid arthritis

Palpation

Key palpation points at the elbow are as follows:

• medial elbow:
  • medial supracondylar line
  • medial epicondyle
  • ulnar nerve groove
  • ulnar nerve
  • common flexor tendon and pronator teres
• lateral elbow:
  • common extensor tendon
  • lateral supracondylar ridge
  • lateral epicondyle
  • radial head
• muscles:
  • biceps
  • brachialis
  • brachioradialis
  • common flexor tendon
  • common extensor tendon
  • triceps