Section editor: Mr Fazal Ali 

Segment author: Mr Madhavan Papanna 

Document history:  15/09/2019

Version 1 

History

-Age/Sex/hand 

-Dominance/Occupation/General Health

- Age will give an hint to the likelihood  of certain pathology correlating to the patients symptoms.  

For Example:

- Osteochondritis dissecans may be the underlying cause of elbow locking in young patients, whereas in elderly patients with same symptoms it  is more likely to be due to the loose bodies formation from degenerative OA.

Rheumatoid arthritis, occurrence is more common in women and  elbow may be the first affected joint at presentation.

-Enquiry into hand dominance should be made, since a disorder of the dominant elbow may affect work, inability to participate in sporting activity or ADL.

General Health

   Medical co-morbidities

   Generalized musculoskeletal disorder

   Hemophilia/Osteochondromatosis

   Sporting activities

   Occupation

Presenting Symptoms

Pain: Nature/Location/Frequency/Aggravating and relieving factors/Radiation

Stiffness:It may be due to several causes, but more commonly due to trauma, osteoarthritis and inflammatory  arthropathies. Loose bodies in the elbow joint can cause intermittent locking and reduced ROM.

• Expose and stand the patient 

• Look 

• Move

• Feel

• Provocative tests 

• Instability tests

• General Inspection

Muscle wasting, Dysmorphic Features, Popeye sign ,Posture, Scar and Skin (Fig 1)

Figure 1 1.Inspection of the elbow from front and side followed by medial and posteriorly.From the front carrying angle is noted

• Axial alignment

- Look from the front assessing the carrying angle, Gunstock deformity

- Inspect from the sides and then  posteriorly and never forget to  look medially especially for scars.

- Active followed by Passive movements

Flexion and Extension

- Ask patient to extend both elbows with shoulder abducted and then 

Figure 2 and Figure 3.Flexion and Extension compared with arm abducted

Pronation and Supination

-  Ask patient to put elbows to their side and test for pronation and supination (Fig 4 and Fig 5).This movement can be quantified by either asking them to  hold a pencil in the hand or point their thumb upwards and compare each side.

• Functional Range of movements

- Flexion - Extension 

   30 -130⁰ 

- Pronation and Supination : 50⁰  each from neutral

Figure 4 and Figure 5.Pronation and supination movements can be easily assessed with the elbow held against the sides to minimize compensation from the shoulders

Palpate painful bit last Lateral to medial : examiner should put one finger on the medial epicondyle, one finger on the lateral epicondyle and one  onthe tip of the olecranon process.

     Lateral 

    - Palpation should be systematic, involving the lateral supra condylar ridge, lateral epicondyle, common extensor origin, radio-capitellar joint, radial head and lateral collateral Ligament.The extensor carpi radialis brevis and longus muscle can be assessed by resisted wrist extension in neutral and radial deviation, respectively

Differential diagnosis of lateral  

       elbow pain and swelling

-Tennis elbow

-Radio-capitellar OA

-Osteochondritis dissecans

-Congenital or traumatic radial head 

  dislocation

-PLRI

Medial 

- Tenderness over medial eicondyle and common extensor origin, will indicate medial epicondylitis.The ulnar nerve should be palpating and it can be easily felt behind the medial  epicondyle. It is important to identify the position of the ulnar nerve during flexion and extension of  the elbow and feel for a  subluxing ulnar nerve. If the ulnar nerve is subluxing,it may give rise to medial elbow pain. 

Differential diagnosis of Medial elbow pain

Cubital tunnel syndrome

Golfer's elbow

Pronator syndrome

Anterior

Examination of the arm may reveal a retracted biceps muscle bulge  appearing more proximally in the arm as opposed to distal muscle bulge with long head of biceps rupture. The structures palpated anteriorly from lateral to medial aspect include brachioradialis, the biceps tendon, brachial artery and the median nerve.The hook test will demonstrate the integrity of the distal biceps tendon at the anterior aspect of the elbow.(Fig 6)

Figure 6. Distal biceps tendon rupture can be demonstrated with 'HOOK TEST'.Ask the patient to actively supinate the forearm against resistance and hook around the biceps insertion from the lateral side.

Posteriorly

- Feel for symmetry of the elbow by feeling these bony prominences. In extension normally these 3 bony prominences form a straight line and in 90⁰degrees of flexion form an isosceles triangle. (Fig 7 and Fig 8) Any abnormality of the above bony landmark arrangement is indicative of previous bony injury.

Figure 7 and Figure 8.The bony relationship of the tip of the olecranon process to the medial and lateral epicondyle with elbow flexed to 90⁰ forms a isosceles triangle and with the elbow extended these bony land marks form a straight line

 - Provocative tests are performed if the patient has medial or lateral tenderness.

Golfer's elbow

- If patient has medial tenderness then provocative test for golfer's elbow is performed. The test is performed by asking the patient to flex the wrist and prevent the examiner from straightening it. (Fig 9).

Positive test results in increasing pain in the region of the medial epicondyle (common flexor origin).

Figure 9.Provocation test for medial epicondylitis

Tennis Elbow

- If subject has lateral tenderness, ask the patient to extend the wrist against the resistance (Fig 10). Positive test results in increasing pain in the region of the Lateral epicondyle (common extensor origin) and is indicative of lateral epicondylitis.

Figure 10.Provocative test for lateral epicondylitis

-Instability tests are for the medial collateral (valgus) and lateral collateral (varus) ligament.

Medial collateral ligament

-To assess valgus stability, the examiner  should externally rotate the shoulder to lock it and then  by flexing theelbow 

Figure 11.Valgus instability testing.Valgus stress is applied across the elbow with the humerus in full external rotation.

Lateral collateral ligament

-Test for lateral collateral ligament is performed by internally rotating the shoulder to lock it, flexing the elbow to approximatoly 30⁰  to unlock the olecranon   from its fossa and  then apply varus stress to the elbow (Fig 12).

Figure 12.Varus instability testing. Varus stress is applied across the elbow with the humerus in full internal  rotation.

Postero Lateral Rotatory Instability(PLRI)

- PLRI results from the insufficiency of the lateral ulnar collateral ligament. The most sensitive test for LUCL insufficiency is the Pivot Shift Test.

- The Lateral Pivot shift test, is performed on a supine patient: The shoulder is flexed overhead. The elbow is fully extended and an axial force is applied to the supinated forearm. At the same time valgus force is applied to the elbow.

- As the elbow is flexed to 45⁰ the radial head subluxates and creates a postero-lateral prominence with a dimple in the skin proximal to it. Increasing the flexion beyond this causes reduction of the radial head and the skin dimple disappears.

Apprehension Sign

-  A patient is asked to rise from the chair using their arms to push them into standing position is reluctant to do so because this manoeuvre (axial load, valgus force and supination of the forearm)reproduces symptoms of PLRI instability (Fig 13).

Figure 13.Apprehension test.The patient is reluctant to extend the elbow fully when rising from the chair and pushing up his arms. 

Finally Don't Forget

- Shoulder/Wrist/Cervical spine and Neurovascular Examination