This document provides an overview of assessing the elbow, including: 1) Descriptions of the elbow joint anatomy and common injuries or complaints. 2) Details on subjective and objective examination techniques like inspection, palpation, range of motion testing, special tests, and neurological assessment. 3) Explanations of specific tests for common conditions like tennis elbow, golfer's elbow, ulnar nerve entrapment, and ligament injuries.

1. Assessment of the Elbow
Dr Sreeraj S R, Ph.D.

2. Sreeraj S R
About Elbow
▷ Hinge joint
1. Humero ulnar,
2. Radiohumeral
3. Sup. Radioulnar)
▷ Common - childhood injuries
▷ Easily prone for stiffness
▷ Pain and symptoms localized in or around elbow.
▷ May present with neurological symptoms local or
distant to elbow.

3. Sreeraj S R
▷ Ulnohumeral (Trochlear) Joint
○ Resting position: 70° elbow flexion, 10° supination
○ Close packed position: Extension with supination
○ Capsular pattern: Flexion, extension
▷ Radiohumeral Joint
○ Resting position: Full extension and full supination
○ Close packed position: Elbow flexed to 90°, forearm supinated to 5°
○ Capsular pattern: Flexion, extension, supination, pronation
▷ Superior Radioulnar Joint
○ Resting position: 35° supination, 70° elbow flexion
○ Close packed position: 5° supination
○ Capsular pattern: Equal limitation of supination and pronation
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4. Sreeraj S R
Common Complaints
▷ Pain
▷ Swelling
▷ Stiffness
▷ Deformity
▷ Instability
▷ Paraesthaesias / neuro. manifestations
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5. 5

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Osteokinematics of the Elbow
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9. Sreeraj S R
Arthrokinematics for Elbow
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10. Elbow pain management algorithm.
Javed M et al, 2015

11. Sreeraj S R
Assessment of the Elbow
▷ Introduce yourself
▷ Consent for history taking and physical examinations
▷ Patient history and pain history
▷ Observation
▷ Palpation
▷ Special tests
▷ Reflexes and cutaneous distribution
▷ Diagnostic imaging
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12. Subjective Assessment
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13. Sreeraj S R
Get Ready
▷ Introduction (name, grade)
▷ Explain assessment procedure
▷ Verbal consent
▷ Chaperone as appropriate
▷ Wash hands with alcohol/gel
▷ Patient to be sitting and adequately exposed.
▷ Listen to chief complaint from patient/go through case file
“Chaperone” a person who acts as a witness during a medical examination or procedure.

14. Sreeraj S R
Patient History
▷ Name, Age, Occupation
▷ What was the mechanism of injury?
▷ How long had the problem?
▷ Does the static or intermittent?
▷ Are there any activities that increase or decrease the pain?
▷ Does pulling (traction), twisting (torque), or pushing (compression) alter the pain?
▷ Are there any positions that relieve the pain?
▷ Is there any deformity, bruising, wasting, or muscle spasm?
▷ Are any movements impaired?
▷ What is the patient unable to do functionally?
▷ What is the patient’s usual activity or pastime?
▷ Have any of these activities been altered or increased in the past month?
▷ Does the patient complain of any abnormal nerve distribution pain?
▷ Does the patient have a history of previous overuse injury or trauma?
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15. Sreeraj S R
Pain History
▷ Location
▷ Type
▷ Onset
▷ AF/RF
▷ Diurnal variations
▷ Timeline
▷ Mechanism of the injury- In the case of a traumatic event
▷ Presence of numbness or tingling?
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16. Sreeraj S R
Muscle Pain Referral Patterns
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Brachioradialis Biceps brachii Flexor carpi radialis Flexor carpi ulnaris
Extensor carpi ulnaris Extensor carpi radialis longus Extensor carpi radialis brevis
Gulick D. 2009

17. Observation
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▷ Posture
▷ Carrying angle
▷ Fixed flexion deformity
▷ Swellings
▷ Ecchymosis
▷ Deformities
▷ Muscle wasting
▷ Rheumatic nodules
▷ Gouty tophi
▷ Bursitis
▷ Skin changes
▷ Psoriatic plaques
▷ Scars
▷ Symmetry.
Observe

19. Sreeraj S R
Carrying Angle
▷ Expose the area and Look for;
▷ Normal carrying angle.
o In males, a normal angle is 5 to 10 degrees;
o In females, a normal angle is 10 to 15 degrees
▷ If the carrying angle is;
o > 15°, it is cubitus valgus;
o < 5° to 10°, it is cubitus varus
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Axis of forearm
Carrying
angle
Gulick D. 2009

20. Sreeraj S R
Carrying Angle
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Gunstock deformity
Cubitus varus
Cubitus valgus

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Olecranon Bursitis Tuberculosis of Elbow

22. Sreeraj S R
Triangle sign
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1. Isosceles triangle in 900
elbow flexion
2. Elbow fully extended; the three points
normally form a straight line.
If there is a disruption
of bone or cartilage,
the distance between
the apex and the base
decreases and the
isosceles triangle no
longer exists.

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Deformities
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24. Palpation
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▷ Temperature changes
▷ Bony tenderness at;
○ Lateral and Medial Epicondyles
○ Olecranon Process
○ Radial Head
▷ Joint line tenderness
▷ Nodules
▷ Boggy swelling.

26. Sreeraj S R
Palpation
▷ Wrist Extensor Muscles
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Gulick D. 2009
ECRL & B
ED
ECU

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Palpation
▷ Wrist Flexor Muscles
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Gulick D. 2009
Pronator teres
FCR
PL
FCU

28. EXAMINATION
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29. Sreeraj S R
Active Movements
▷ Flexion of the elbow (140° to 150°)
▷ Extension of the elbow (0° to 10°)
▷ Supination of the forearm (90°)
▷ Pronation of the forearm (80° to 90°)
▷ If, in the history, the patient has complained that combined movements,
repetitive movements, or sustained positions cause pain, these specific
movements should be included in the active movement assessment.

30. Sreeraj S R
Passive Movements
▷ Passive Movements and Normal End Feel
○ Elbow flexion (tissue approximation)
○ Elbow extension (bone-to-bone)
○ Forearm supination (tissue stretch)
○ Forearm pronation (tissue stretch)
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31. Sreeraj S R
Resisted Isometric Movements
▷ Elbow flexion
▷ Elbow extension
▷ Supination
▷ Pronation
▷ Wrist flexion
▷ Wrist extension
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32. Sreeraj S R
Resisted Isometric Movements
▷ Stresses contractile tissues
▷ Isometric contraction of specific muscles
▷ "Neutral" joint position - don't allow joint motion
• Possible Responses & Reasons
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Type of response Possible tissues involved
Strong and pain free : No lesion of the contractile unit
Strong and painful : First- or second-degree local lesion
Weak and painful : Major lesion of a muscle, tendon OR a fracture
Weak and pain free : A third-degree strain, complete avulsion #, peripheral nerve or nerve root
involvement.

33. Sreeraj S R
Functional Assessment
▷ Liverpool elbow score
▷ American Shoulder and Elbow Surgeons-E (ASES-E)
▷ The Disability of Arm, Shoulder and Hand (DASH) & Quick-DASH
▷ Mayo elbow performance index
▷ Oxford elbow score
▷ Patient-Rated Tennis elbow evaluation
▷ Barthel Index
▷ Lawton - Brody Instrumental Activities of Daily Living Scale
(I.A.D.L.)
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34. Special Tests
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35. Sreeraj S R
TENNIS ELBOW
▷ Commonly known as tennis elbow
▷ Occurs in mostly 30-50 years age group
▷ Due to degeneration of the tendon fibres over the lateral
epicondyle which are involved in wrist extension
▷ severe burning pain on outside of elbow
▷ Pain worse on gripping or lifting objects and with direct pressure
over lateral epicondyle
▷ Pain may radiate down forearm

36. Sreeraj S R
Cozen’s test
▷ The patient’s elbow is stabilized by
the examiner’s thumb, which rests on
the patient’s lat. epicondyle.
▷ The patient is then asked to make a
fist, pronate the forearm, and radially
deviate and extent the wrist while the
examiner apply resistance.
▷ A positive sign is sudden severe pain
in the area.
▷ Tests ECRL & ECRB

37. Sreeraj S R
Mill’s test
▷ While palpating lat.
epicondyle, the examiner
passively pronate the
patient’s forearm, flexes the
wrist fully and extends the
elbow.
▷ A positive test is indicated
by pain over the area.
▷ Tests ECRL & ECRB

38. Sreeraj S R
Tennis Elbow test/
Maudsley's Lateral Epicondylitis Test
▷ Patient sitting with forearm rested
on a plinth.
▷ Forearm pronated.
▷ The examiner resists extension of
the third digit of the hand distal to
the proximal IP joint, stressing the
ED muscle and tendon.
▷ A positive test indicated by pain
over the area

39. Sreeraj S R
The Chair Test
▷ Ask the patient to
attempt to lift a chair
with elbow straight
and shoulders flexed
to 60°
▷ Difficulty to perform
and complain of pain
over lat. aspect is a
positive sign

40. Sreeraj S R
Thomson’s test
▷ Ask the patient to clench the
fist, dorsiflex the wrist and
extend the elbow.
▷ Tester does a forceful palmar
flexion against patient’s
resistance
▷ Pain over the area is a
positive sign

41. Sreeraj S R
Golfer’s Elbow
▷ Also known as Medial
epicondylitis
▷ Similar to Tennis elbow
▷ Most common in men 20-50 years
▷ Pain over medial elbow, may
radiate down inner forearm
▷ Pain worse when make fist/shake
hands

42. Sreeraj S R
Golfer’s elbow test
▷ Flex the elbow, supinate
the hand, and then
extend the elbow.
▷ Pain over the med.
epicondyle is a positive
sign.

43. Sreeraj S R
Olecranon Bursitis
▷ Infection/inflammation of
bursa
▷ Causes-
1. Trauma
2. Prolonged pressure
3. Infection
4. Medical conditions e.g.
rheumatoid arthritis/gout

44. Sreeraj S R
Medial Ligamentous Injuries
▷ MCL/ UCL/ ”Little Leaguer’s Elbow”
▷ Usually injured due to valgus trauma
(acute) or repetitive overhead
throwing activities (chronic)
▷ Valgus stress test
○ Elbow flexed 25-30 degrees.
Abduction or valgus force is
applied to the distal forearm
while the ligament is palpated
○ The examiner feels the ligament
tense when stress is applied

45. Sreeraj S R
Lateral Ligamentous Injuries
▷ If LCL damaged, varus opening present with
stress
▷ Varus laxity increases with annular ligament
injury due to separation of head of radius
from ulna
▷ Varus stress test –
○ Elbow flexed 25-30° and stabilized
with the examiner’s hand.
○ An adduction force is applied by the
examiner to the distal forearm.
○ The examiner feels the ligament tense
when stress is applied

46. Sreeraj S R
Posterolateral Instability
▷ Posterolateral Rotatory Instability (PLRI)
of the elbow instability is common in
cases of ulna/radius displacement.
▷ Posterolateral Rotary Apprehension
Test/ The Lateral Pivot-Shift
o Patient lies supine with arm to be tested
overhead.
o Grasp patient’s wrist & extend elbow.
o A mild supination force applied to forearm at
wrist.
o Patient's elbow is then flexed while a valgus
stress and compression applied to elbow.
o If there is PL instability a look of apprehension
will become evident as the elbow moved to
flexion.

47. Sreeraj S R
Cubital Tunnel Syndrome
▷ Tinel Sign:
▷ The area of ulnar nerve in the
groove between olecranon process
and med. epicondyle is tapped.
▷ A + ve sign is indicated by tingling
sensation in ulnar distribution distal
to the point of compression.
▷ This indicates point of
regeneration of sensory fibers.
▷ The most distal point at which
abnormal sensation felt represents
the limit of nerve regeneration.

48. Sreeraj S R
Scratch Collapse Test
▷ For evaluation of carpal and cubital tunnel syndrome
▷ The patient faces the examiner in sitting position with arms adducted, elbows
flexed, and hands outstretched with wrists at neutral.
▷ The examiner asks the patient to externally rotate both the shoulders.
▷ The examiner resist the external rotation movement by placing the hands over the
lateral aspect of the forearm and give an inward force.
▷ The patient is instructed to resist the force applied by the examiner.
▷ Next, the examiner “scratches” or swipes with fingertips over the area of nerve
compression.
▷ The procedure mentioned above is immediately repeated.
▷ Brief temporary loss of the patient’s external resistance tone is considered a
positive scratch collapse test
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49. Sreeraj S R
Scratch Collapse Test
▷ Basis of the Test
▷ Painful cutaneous stimulus has
been noted to cause a period of
inhibition in tonic voluntary
muscle activity.
▷ It is generally thought to be an
inhibitory spinal reflex that may
play a protective role in
facilitating withdrawal of a limb
from potentially harmful stimuli
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50. Sreeraj S R
Wartenberg’s Sign
▷ Sitting with hands on table.
▷ The examiner passively spreads fingers apart and asks
patient to bring them together.
▷ Inability to bring little finger close indicates Ulnar
neuropathy.

51. Sreeraj S R
Elbow Flexion Test
▷ Patient is asked to fully flex elbow
with extension of the wrist and
shoulder girdle abduction and
depression and hold it for 3 to 5
minutes.
▷ A positive test is indicated by
tingling or parasthesia in ulnar nerve
distribution
▷ The test is confirmatory for cubital
tunnel syndrome

52. Sreeraj S R
Ulnar nerve injuries
▷ Loss of sensation as
shown
▷ Motor supply to small
muscles of hand except
thenar muscle and 1st two
lumbricals
▷ Produces decreased grip
strength

53. Sreeraj S R
Median Nerve Injury
▷ Occasionally damaged
in supracondylar
fractures
▷ More commonly in
wrist lacerations
▷ Produces loss of
sensation as shown
▷ High injuries produce
decreased strength in
wrist flexion, loss of
ulna deviation and
thumb opposition

54. Sreeraj S R
Median Nerve Injury
▷ Test For Pronator Teres Syndrome:
▷ Patient sits with elbow flexed to 90°.
▷ Examiner strongly resists pronation as
the elbow is extended.
▷ A positive test is indicated by tingling
or parasthesia in median nerve
distribution.
▷ Also called humerus supracondylar
process syndrome

55. Sreeraj S R
Pinch Grip Test
▷ Patient is asked to pinch the tips of
index and thumb together.
▷ If patient is unable to pinch tip to
tip and have a pulp to pulp pinch it
is indicative of injury to ant.
interosseous nerve, branch of
median nerve.

56. Sreeraj S R
Ant. Intr. Nerve
▷ Can be entrapped as it
passes between the two
heads of pronator teres
muscle
▷ known as ant. intr. nerve
syndrome or Kilho-Nevin
syndrome
▷ Pinch deformity

57. Sreeraj S R
Radial Nerve
▷ Injury can be due to trauma or compression in between the two
heads of supinator in the arcade or canal of Frohse
▷ Can also be a radial tunnel syndrome
▷ Compression of superficial branch of radial nerve as it passes
under the tendon of brachioradialis.
▷ Only sensory changes and patient complaints of nocturnal pain
along the dorsum of wrist, thumb and web space
▷ Known as Cheiralgia parasthetica or Wartenberg’s disease

58. Sreeraj S R
Dermatomes
▷ C5 – lateral arm
▷ C6 – lateral forearm, thumb and index finger
▷ C7 – posterior forearm and middle finger
▷ C8 – medial forearm, ring and little fingers
▷ T1 – medial arm
▷ Except T2 all other dermatomes extend distally to
forearm and hand

59. Sreeraj S R
Myotomes
▷ C5 – shoulder abduction
▷ C6 – elbow flexion, wrist extension
▷ C7 – elbow extension, wrist flexion
▷ C8 – finger flexion/grip strength
▷ T1 – finger abduction/adduction

60. Sreeraj S R
Cutaneous distribution
▷ Pain may be referred to the elbow
and surrounding tissues from neck,
often mimicking Tennis Elbow,
shoulder or wrist.

61. Sreeraj S R
REFLEXES
▷ Biceps (C5,C6)
▷ Brachioradialis (C5-C6)
▷ Triceps (C7- C8)

62. Sreeraj S R
Cervical radiculopathy
▷ Affecting C6 will involve biceps, brachioradialis,
supinator and part of triceps.
▷ The triceps reflex is the one usually most affected.
▷ Any sensory loss affects the thumb and index finger.
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63. Sreeraj S R
References
1. Gulick D. Ortho Notes : Clinical Examination Pocket Guide. 2nd
ed. F.A. Davis; 2009:84-98.
2. Magee DJ. Orthopedic Physical Assessment. 6th ed. Saunders;
2014: 388-428.
3. Buckup K, Buckup J. Clinical Tests for the Musculoskeletal
System: Examinations, Signs, Phenomena. 2008. 3rd ed.,
Stuttgart, Thieme, 2016, pp. 138–154.
4. Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to
assessment and management in primary care. Br J Gen Pract.
2015;65(640):610-612. doi:10.3399/bjgp15X687625
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