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 individuals. Many structures, including bones, tendons, ligaments, bursae, and nerves, can cause elbow pain. Therefore, rehabilitation providers must have a comprehensive understanding of elbow anatomy and the subjective and objective assessment of the elbow.

Subjective Assessment

The mnemonic L-M-N-O-P-Q-R-S-T highlights the key areas to cover in a patient history.

L: location of symptoms and level of functional impairment

The location of symptoms can help you develop hypothetical diagnoses based on which tissues are in the area. You should also ascertain how a patient’s pain is affecting their ability to perform activities of daily living and other work-, school-, and sport-related tasks.

M: medical factors (medications) and mechanism of injury

We need to find out what medications a patient is taking (including supplements) and what co-morbidities they may have. We also want to determine when and how the injury occurred (specific trauma, overuse, etc)

Red flags: insidious onset, symptoms related to cardiovascular activity, and a history of cardiovascular disease.

N: neurological symptoms

Neurological symptoms include numbness, tingling, paraesthesias, sharp or 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

Are there 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 and how long it takes for symptoms to decrease once aggravated.

Red flags: constant, unrelenting symptoms.

Q: quality of symptoms / pain

Find out if symptoms are sharp, dull, stabbing, aching, or electric shock-like and if there is any numbness, tingling, or a feeling of weakness / clumsiness.

R: radiation of symptoms

Questions to ask relating to radiating symptoms:

• 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

Scales such as the Visual Analogue Scale or the Numeric Pain Rating Scale can be used, 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.

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

Observation

Remember 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
• look for any asymmetries, soft tissue changes, scars or swelling

Palpation

Key palpation points at the elbow are listed in Table 1.

Table 1. Key palpation points for the elbow

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

It is important to assess active and passive range of motion, including with over-pressure. For more information on the range of motion assessment, please see: Assessing Range of Motion.

Table 2 shows normative values for elbow range of motion and typical end feels. Please note that elbow range of motion is influenced by several factors, including age, biological sex and body mass index (BMI) and that figures for normal range of motion vary in the literature. You can often use the unaffected side as a comparison for the affected side.

Table 2. Elbow range of motion and end feel

Movement	Range of motion	Typical end feel
Flexion	0-145 degrees (active) 0-160 degrees (passive) figures given in the literature vary from 130-154 degrees	Soft
Extension	0-15 degrees (hyperextension) values given in the literature range between -6 and 11 degrees	Hard
Pronation	80 degrees values given in the literature range from 75-85 degrees	Firm
Supination	80 degrees values given in the literature range from 80-104 degrees	Firm

Zwerus et al. note that passive range of motion is typically 3-5 degrees more than active range of motion.

Resisted Testing

Assess the strength of the elbow flexors (biceps brachii, brachialis, brachioradialis) and extensors (triceps brachii, anconeus). For more information on the strength assessment, please see Assessing Muscle Strength.

Neurovascular Testing

Look for changes in nail quality, colour, temperature and blanching that could suggest neurovascular compromise.

• Brachial pulse: palpated proximal to the elbow, between the medial epicondyle of the humerus and the distal biceps tendon
• Radial pulse: palpated at the anterior wrist, proximal to the base of the thumb
• Modified Allen test: used to assess 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

Please watch the following videos if you would like to learn more about assessing the brachial and radial pulses and the modified Allen test.

Accessory Movements / Joint Mobility Testing

Table 3 identifies which accessory movements you can assess at the elbow.

Table 3. Accessory movements of the elbow.

Type of distraction	When to test / use
Humeroulnar distraction	Assessed when a patient has a general flexion / extension mobility limitation; can be used as an intervention to improve flexion / extension mobility Assessed when a patient has limited end-range extension or flexion; can be used to improve end-range extension / flexion
Radiohumeral distraction	Assessed when a patient has limited elbow extension and radial head mobility; can be used to improve general mobility and extension
Radiohumeral anterior (volar) and posterior (dorsal) glides	Assess anterior glide when a patient has limited supination; can be used to improve supination Assess posterior glide when a patient has limited pronation; can be used to improve pronation

Assessment for Common Elbow Pathologies

Cubital Tunnel Syndrome

Cubital tunnel syndrome is a “compression of the ulnar nerve as it courses through the cubital tunnel near the elbow”. It is the second most commonly diagnosed mononeuropathy (after carpal tunnel syndrome), affecting around 5.9% of the general population.

History:

• numbness and tingling in the ulnar nerve distribution distal to the elbow
• positional complaints
• trauma to the elbow region / repetitive elbow flexion tasks
• valgus stress

Observation: look for atrophy of the muscles supplied by the ulnar nerve (flexor carpi ulnaris, flexor digitorum profundus 4 and 5, hypothenar muscles, adductor pollicis, lumbricals four and five, dorsal and palmar interossei).

Palpation: look for tenderness at the ulnar groove.

Active and passive range of motion:

• possible symptoms in full flexion
• look for symptom reproduction during passive range of motion

Manual muscle testing: likely no symptoms, but look for weakness in the muscles supplied by the ulnar nerve (listed above in observation).

Accessory movement testing: should be within normal limits.

Special tests

Pressure provocation test:

• flex the patient's elbow to approximately 20 degrees
• apply and hold pressure just proximal to the cubital tunnel for a maximum of 60 seconds, stopping sooner if / when the patient has symptoms along the ulnar nerve distribution
• positive test = the patient gets symptoms along the ulnar nerve distribution
• negative test = compression is held for 60 seconds, and the patient has no symptoms

Elbow flexion test:

• flex the patient's elbow, and apply overpressure (i.e. at maximum passive flexion of the elbow)
• hold this position for a maximum of 60 seconds, stopping sooner if / when the patient complains of symptoms along the ulnar nerve distribution
• positive test = reproduction of symptoms
• negative test = no reproduction of symptoms in 60 seconds

Combined pressure and flexion test:

• a combination of the above two tests
• apply pressure to the ulnar nerve just proximal to the cubital tunnel with the elbow in 20 degrees of flexion
• maintain this pressure and add in elbow flexion
• positive test = reproduction of symptoms
• negative test = no reproduction of symptoms after 60 seconds

Tinel's sign:

• the examiner taps on the ulnar nerve proximal to the cubital tunnel with their fingers (or lightly with a reflex hammer) four to six times
• positive test = reproduction of symptoms along the ulnar nerve distribution
• negative test = no reproduction of symptoms

Table 4 shows the sensitivity, specificity and likelihood ratios of these tests. Please note that different sources provide different values for sensitivity, specificity and likelihood ratios. These figures are based on research by Novak et al.

Table 4. Sensitivity, specificity and likelihood ratios of special tests for cubital tunnel syndrome.

Test	Sensitivity	Specificity	Positive likelihood ratio (+LR)	Negative likelihood ratio (-LR)
Pressure provocative test	0.89	0.98	44.5	0.11
Elbow flexion test	0.75	0.99	75	0.25
Combined pressure and flexion test	0.98	0.95	19.6	0.02
Tinel's test	0.70	0.98	35	0.31

 

Medial Collateral Ligament (MCL) Tear

“Elbow medial collateral ligament sprain occurs when the elbow is subjected to a valgus force exceeding the tensile properties of the medial collateral ligament (MCL). This is an injury seen more often in throwing athletes.”

History:

• trauma with valgus stress or repetitive stress (e.g. throwing)
• in acute injuries, patients may describe hearing a “pop”
• in chronic injuries, patients may have noticed that their accuracy / velocity when throwing has decreased
• pain along the medial elbow
• swelling
• bruising
• if there is a complete rupture, patients will complain of instability

Observation: check for swelling and possible bruising at the medial elbow.

Palpation: check for tenderness along the medial elbow.

Active and passive range of motion: likely within normal limits.

Accessory movements:

• excessive medial glide of the ulnar with or without pain is likely, although this test is not commonly performed
• usually, no changes noted on distraction

Special Tests

Moving valgus stress test:

• “currently accepted as the gold-standard clinical test”, but patient tolerance has to be considered when selecting this test
• place the patient’s shoulder in 90 degrees of abduction and position their elbow in full flexion
• apply a valgus stress at the shoulder while externally rotating the shoulder
• maintain this valgus stress and extend the patient’s elbow
• positive test = pain or increased mobility compared to the other side

Valgus stress test:

• apply valgus stress along the lateral elbow towards the midline
• performed at 30, 60, 70 and 90 degrees of elbow flexion

As shown in Table 5, the moving valgus stress test has better positive and negative likelihood ratios than the valgus stress test.

Table 5. Likelihood ratios of moving valgus stress test and valgus stress test.

Test	Positive likelihood ratio	Negative likelihood ratio
Moving valgus stress test	4.0	0.04
Valgus stress test	1.3	0.81

Lateral Elbow Tendinopathy

Lateral elbow tendinopathy (also known as lateral epicondylalgia, lateral epicondylitis and tennis elbow) is one of the most common causes of elbow pain and dysfunction, with a population prevalence of 1-3%. Its peak incidence is in individuals aged 40-50 years. "Although the condition is self‐limiting it is associated with considerable morbidity."

History:

• pain along the lateral elbow, which is usually caused by repetitive elbow or wrist movements
• pain with gripping activities (e.g. shaking hands, turning a door knob, holding a coffee cup)

Observation:

• patients may be hesitant to shake hands
• they may be wearing a brace

Palpation: tenderness along the lateral epicondyle and common extensor tendon / muscles.

Active and passive range of motion:

• pain with flexion of the wrist with extension of the elbow (active and passive)
• pain with active extension of the wrist

Resisted range of motion:

• pain with resisted wrist extension
• pain with resisted middle finger extension

Accessory movements: usually within normal limits.

Special Tests

Muscle tests:

• pain on palpation
• pain on stretch of the common extensors
• pain with resisted wrist extension

Grip strength with dynamometer (if available):

• compare sides
• likely painful and limited on the affected side

Mill’s test:

• the patient’s arm is positioned in elbow flexion
• the examiner palpates the patient’s lateral epicondyle and then passively pronates the patient’s forearm, flexes their wrist, and extends their elbow (shown in the optional video below)
• positive test = reproduction of concordant symptoms, pain over lateral epicondyle of humerus

Cozen’s test:

• the examiner places their thumb at the patient’s lateral epicondyle
• the patient’s elbow is flexed and pronated, with their wrist extended and in radial deviation
• the examiner resists wrist extension / radial deviation
• positive test = reproduction of concordant symptoms, sudden severe pain at the lateral epicondyle of the humerus

Karanasios et al. note that Cozen's test has a sensitivity of 91%. "Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET [lateral elbow tendinopathy] but are poorly investigated."

Medial Elbow Tendinopathy

Medial elbow tendinopathy (also known as medial epicondylitis, medial epicondylopathy, golfer's elbow) is less common than lateral elbow tendinopathy. It is "caused by repetitive strain from activities that involve frequent loaded gripping, forearm pronation, and/or wrist flexion."

History:

• pain in the medial elbow with wrist flexion and supination
• pain with activities, such as using a screwdriver, hammering and any squeezing activity (e.g. holding a golf club or a baseball bat)

Observation: patients may be hesitant to shake hands.

Palpation: tenderness along the medial epicondyle and common flexor tendon / muscles.

Active and passive range of motion: discomfort with elbow extension and with wrist extension (active and passive).

Resisted range of motion: pain with wrist flexion and forearm pronation.

Biceps Tendon Rupture

“Distal biceps tendon ruptures are mostly caused by a sudden extension force on the flexed elbow. Recent literature shows an increasing incidence, while the age of patients with a distal biceps rupture is decreasing."

History: the patient reports a specific incident, with an immediate decrease in elbow flexion strength. They might note they felt a "pop" at the time of injury.

Observation: you can observe the defect after a few days as the biceps muscle retracts.

Palpation:

• may be able to palpate a defect
• may have tenderness along the biceps

Active and passive range of motion: limited elbow flexion active range of motion, but full passive range of motion.

Resisted range of motion: weakness with resisted elbow flexion.

Special Tests

Biceps squeeze test:

• the patient is seated with their elbow flexed 60-80 degrees and their forearm in slight pronation (i.e. resting in their lap)
• the examiner squeezes the patient’s biceps firmly with both hands - one hand is along the muscle belly, and the other is at the distal myotendinous junction
• positive test = lack of forearm supination when the biceps is squeezed

Hook test:

• the examiner uses their index finger to palpate the biceps tendon in the antecubital fossa
• positive test = NO tendon

Passive forearm pronation test:

• the patient is seated with their elbow at 90 degrees of flexion
• the examiner passively moves the patient’s forearm from supination into pronation
• positive test = loss of visual and palpable movement of the bicep muscle belly

Biceps crease interval:

• the patient is seated with their elbow at 90 degrees of flexion
• the examiner fixates the patient’s wrist and places their finger on the patient’s antecubital fossa
• the examiner passively extends the patient’s elbow and supinates their forearm, and then measures the distance from the antecubital crease to the distal muscle belly
• positive test = distance more than 6cm

Zwerus et al. note that the "Hook test, PFP [passive forearm pronation test], BCI [biceps crease interval]/BCR [biceps crease ratio], biceps squeeze test, and supination-pronation test were investigated for individual use and showed a sensitivity ranging from 81% to 100% and a specificity from 50% to 100%." In their study, they found that the "combination of a positive Hook test and BCI serves best to accurately diagnose acute complete ruptures of the distal biceps tendon."

Elbow Fracture

Seven percent of all fractures are elbow fractures. Extra-articular fractures are more common in children, while articular fractures are more common in adults aged over 50 years. Elbow fractures in younger adults tend to be caused by high-energy injuries (e.g. motor vehicle crashes, sports, falls from a height), but in adults aged more than 80 years, they tend to be low-energy injuries (e.g. falls from a standing height).

Special Tests

These tests can be used to determine the need for radiography.

Four-way range of motion test:

• the patient is seated with their arm at their side and their elbow extended
• the patient is asked to actively:
  • extend to a full locked position
  • flex their elbow to 90 degrees
  • while flexed, pronate to their full range of motion
  • while flexed, supinate to their full range of motion

• positive test = decreased range of motion in any of the four manoeuvres
• positive likelihood ratio = 2.47; negative likelihood ratio = 0.02

Elbow extension test:

• the patient is seated with their arms supinated
• the patient is asked to actively flex their shoulders to 90 degrees
• the patient then extends their elbow
• positive test = decreased range of motion in the involved elbow
• positive likelihood ratio = 1.88; negative likelihood ratio = 0.06