Overview of Elbow Assessment
Introduction[edit | edit source]
Musculoskeletal conditions of the elbow can have a significant physical and socioeconomic impact on both individuals and communities.[1][2] Elbow pain can be caused by many structures, including the bone, tendons, ligaments, bursa, and nerves.[3] 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[edit | edit source]
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,[1] 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,[4] 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[edit | edit source]
Objective Assessment[edit | edit source]
The following sections discuss the general assessment of the elbow.
Observation[edit | edit source]
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,[5][6] but in females, the carrying angle is around 5-16 degrees and, in men, around 5-14 degrees[7]
- 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[edit | edit source]
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
Please watch the following video if you would like to learn more about elbow palpation.
Range of Motion[edit | edit source]
It is important to assess active and passive range of motion and with over-pressure applied. For more information on the range of motion assessment, please see: Assessing Range of Motion.
Table 1 shows normative values for elbow range of motion and typical end feels. Please note that elbow range of motion is influenced by a number of factors, including age, biological sex and body mass index (BMI) and that figures for normal range of motion vary in the literature. You can generally use the unaffected side as a comparison for the affected side.[9]
| Movement | Range of motion | Typical end feel |
|---|---|---|
| Flexion |
|
Soft |
| Extension |
|
Hard |
| Pronation |
|
Firm |
| Supination |
|
Firm |
Please note that passive range of motion is typically 3-5 degrees more than active range of motion. Any restriction in elbow range of motion can increase load on the shoulder and wrist.[9]
Daily activities can be achieved with:[9]
- restriction of 30 degrees of elbow extension
- minimum of 130 degrees of elbow flexion, in combination with 50 degrees of pronation and supination
Resisted Testing[edit | edit source]
The following muscles should be assessed. For more information on the strength assessment, please see Assessing Muscle Strength.
Flexion:
- biceps brachii
- brachialis
- brachioradialis
Extension:
- triceps brachii
- anconeus
Neurovascular Testing[edit | edit source]
Look for any changes in nail quality, colour, temperature and blanching that could suggest neurovascular compromise.
Brachial pulse: you can palpate the brachial pulse just proximal to the elbow, between the medial epicondyle of the humerus and the distal biceps tendon[11]
Radial pulse: you might also palpate the radial pulse at the anterior wrist, proximal to the base of the thumb[11]
Please watch the following video if you would like to learn more about assessing the brachial and radial posts.
Modified Allen test[edit | edit source]
The modified Allen test, which is shown in the optional video below, assesses the patency of the radial and ulnar arteries
- the examiner compresses the radial and ulnar arteries with their thumbs and asks the patient to clench their fist 3-5 times
- the patient then opens their fist, and their palm should have reduced colour (blanched)
- the examiner releases the compression on one artery and notes the time taken for the skin to return to its usual colour
- the test is then repeated, releasing the other artery first, so that you can note if there are differences between sides
References[edit | edit source]
- ↑ 1.0 1.1 Janela D, Costa F, Molinos M, Moulder RG, Lains J, Bento V, et al. Digital rehabilitation for elbow pain musculoskeletal conditions: a prospective longitudinal cohort study. Int J Environ Res Public Health. 2022 Jul 27;19(15):9198.
- ↑ Lucado AM, Day JM, Vincent JI, MacDermid JC, Fedorczyk J, Grewal R, Martin RL. Lateral elbow pain and muscle function impairments. J Orthop Sports Phys Ther. 2022 Dec;52(12):CPG1-CPG111.
- ↑ Chung HJ, Joo YB, Park JY, Lee WY. Differential diagnosis of elbow pain. Ewha Med J 2023;46(4):e13.
- ↑ Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to assessment and management in primary care. Br J Gen Pract. 2015 Nov;65(640):610-2.
- ↑ Manandhar B, Shrestha I, Shrestha R. Dominance of carrying angle in right-hand among dental students of a teaching hospital: a descriptive cross-sectional study. JNMA J Nepal Med Assoc. 2022 Mar 11;60(247):282-5.
- ↑ Chang CW, Wang YC, Chu CH. Increased carrying angle is a risk factor for nontraumatic ulnar neuropathy at the elbow. Clin Orthop Relat Res. 2008 Sep;466(9):2190-5.
- ↑ 7.0 7.1 Cunningham S. Overview of Elbow Assessment Course. Plus, 2024.
- ↑ Clinical Physio. Elbow Palpation | Clinical Physio Premium. Available from: http://www.youtube.com/watch?v=dZcbF0obRFc [last accessed 22/4/2024]
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Zwerus EL, Willigenburg NW, Scholtes VA, Somford MP, Eygendaal D, van den Bekerom MP. Normative values and affecting factors for the elbow range of motion. Shoulder Elbow. 2019 Jun;11(3):215-24.
- ↑ Physiopedia, Range of Motion Normative Values.
- ↑ 11.0 11.1 Zimmerman B, Williams D. Peripheral Pulse. [Updated 2023 Apr 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542175/
- ↑ Geeky Medics. How to Feel a Pulse | Radial & Brachial Pulses - OSCE Guide | UKMLA | CPSA. Available from: http://www.youtube.com/watch?v=CGNR4bbnbDA [last accessed 22/4/24]
