This document provides an overview of an examination of the elbow, including: 1. Anatomical structures are discussed such as bones, ligaments, muscles and nerves. 2. The ideal clinical examination is outlined including obtaining history, inspection, palpation, range of motion testing, and neurological assessment. 3. Specific tests and maneuvers are described to evaluate various conditions like tennis elbow, ulnar nerve entrapment, and ligament injuries.

1. Elbow Examination
RSM Musculoskeletal Examination Masterclass:
Abbas Rashid
Consultant Elbow & Shoulder Surgeon

2. Remit
Surgical Anatomy
Osteoarticular
Capsuloligamentous
Muscles
Neurological

3. Remit
Surgical Anatomy
Osteoarticular
Capsuloligamentous
Muscles
Neurological
Idealised
clinical examination

17. Proximal
Ulna
Diaphyseal
Angle

28. aMCL
• constant valgus load
• Resisted by aMCL
• isometric through ROM
• Valgus load
1. MCL
2. anterior capsule
3. RCj
• tensile strength
261+71N

30. LUCL
• Resists varus load
- flexion:
Trochlea (75%)
- Extension
LuCL (46%)
• PLRI
• tensile strength
233_116N

34. Bursae

37. FABS MRI

40. Flexion/Extension
• Dominant=non-dominant
- Age, sex, muscularity
• Anterior offset of distal humerus
• Uniaxial hinge
• Carrying angle 11-14deg
• Axis: abducted by 50% of CA
Pronation/Supination
• 80deg pronation
• 90degree supination

41. Pronation/Supination
• Axis: radial head to ulnar head
• RH: Proximal migration of radius
with pronation
• OA: grip & grind
• Missed Essex-Lopresti Injury

59. History
Personal Vignette
• Age
• Hand Dominance
• Occupation
• Sports/Recreation/Hobbies
• PMH: obstetric, Trauma, RA
Symptoms
1. Pain
2. Stiffness
3. Clicking/Clunking/Grinding
4. Infection
5. Neurological

60. History
Personal Vignette
• Age
• Hand Dominance
• Occupation
• Sports/Recreation/Hobbies
• PMH: obstetric, Trauma, RA
Symptoms
1. Pain
2. Stiffness
3. Clicking/Clunking/Grinding
4. Infection
5. Neurological
ANY FUNCTIONAL LIMITATION?

61. Pain
• Which compartment?
Lateral
- tennis elbow
- radial tunnel syndrome
- RC OA
- PLRI
Medial
- ulnar neuritis
- subluxing nerve/snapping triceps
- golfers elbow
- UH OA
Posterior
- triceps tendinopathy/tear/bursitis
- VEO
- oelcranon fossa osteophytes
- olecranon bursitis
Anterior
- biceps tendinopathy/tear/bursitis
- coronoid osteophyte
- pronator syndrome

62. Pain
• Which compartment?
• During vs. Terminal motion?
• Worse in am or pm?
• Inciting activity?
• During motion = OA
• Terminal motion = impingement
• Anterior
- cornoid (eg.boxers)
• Posterior
- olecranon (eg. Pitchers)

63. Pain
• Which compartment?
• During vs. Terminal motion?
• Worse in am or pm?
• Inciting activity?
• AM
- gets better as day goes on
= inflammatory
• PM
- worse at end of day
= mechanical/OA

64. Instability
• Previous trauma?
• Macro vs. micro?
• Frequency?
- Pitchers/overhead athletes =
attenuation of aMCL
• Inciting injury?
Position of forearm at impact
• Sup, axial load, valgus stress
LUCL + RH +/- coronoid
= Terible Triad/PLRI
• Pro, axial load, varus stress
LUCL + AMF coronoid +/- pMCL
= Valgus PMRI

65. Instability
• Previous trauma?
• Macro vs. micro?
• Frequency?
- Pitchers/overhead athletes =
attenuation of aMCL
• Inciting injury?
• Previous dislocation
- CEO + LUCL + aMCL + CFPO
3/4 in-tact = conservative tx
• Repetitive
- attritional
- RA
- attrition aMCL + posterior impingement
= VEO (eg. Pitching athletes)

66. Infection
• Previous skin breach
• Underlying medical conditions
- Diabetes
- RA

67. Stiffness
• Previous injury or surgery
• Flex-Ext vs. Pro-Sup
• Impact
• +/- Secondary shoulder pain

68. Neurological
• Parasthesia or Dysasthesia
• Distribution

69. Inspection
• Carrying angle
• Posture
• Scars

70. Inspection
• Muscle bulk • Swelling vs. Nodules

71. Palpation
Lateral
• Radial Tunnel
• Mobile Wad
• Radial Head
• Lateral Epicondyle/ECRB
• Posterior Capitellum
• LUCL
• soft spot

72. Palpation
Posterior
• Olecranon
- colinear with ME/LE extension
• Fossa
- PM osteophyte
• Triceps insertion
• PM/PL UH joint

73. Palpation
Medial
• ME
• CFO [under tension]
• MCL
• ulnar nerve

74. Palpation
Anterior
• Coronoid tip
• Radial Tunnel
• Distal Biceps
• Brachial artery

75. Motion
• Goniometer
- humeral and ulna shaft ref
- SD for error = 3.7 deg
• 0-140 flexion
- >flexion if <19y/o
- Hyperextention
• Functional arc = 30-130

76. Motion
• goniometer at dorsal DRUJ
• 75 supination
- Terminal 15 through carpus
• 90 pronoation
• Functional arc 50-50
• Avoid cheating from shoulder
• Endpoints soft or hard

77. Neurological
• Cervical roots C5-T1
• Brachial plexus
• Peripheral nerves
• Extension=70% flexion
• Pronation=85% of supination
• Non-dominant =90%dominant

78. PIN/Radial Nerve
1. Fibrous bands @ RCJ
2. Leash of Henry
3. Medial edge ECRB
4. Arcade of Frohse
5. Distal edge Supinator
Radial Tunnel Syndrome
• Pain syndrome
• Tender over Supinator Arch
- 3cm distal 2 cm medial to LE
• Resisted Supination
• Passive pronation + wrist flexion
PIN Palsy
• Motor syndrome
• Cannot extend MCPJs
• Can extend IPJs (NOT thumb)
• Can only extend wrist in radial dev.
• Wrist tenodesis effect
- cf extensor rupture

79. Ulnar Nerve
Cubital Tunnel Syndrome
• 1st dorsal interoseeous wasting
• Ring + ring finger clawing
• Subluxing nerve over ME
• Reduced sensation medial digits
• Resisted index finger abduction
• Elbow Flexion (75%)
• Elbow flexion + Pressure (93%)
• Tinels Sign over Cubital Tunnel (71%)
• Froments + Wartenbergs Signs

80. Medial Nerve
1. Supracondylar process
2. Ligament of Struthers
3. Lacertus Fibrosus
4. Heads of PT
5. FDS aponeurotic arch
Pronator Syndrome
• Reduced sensation with
repetetive rotation of forearm
• Includes palmar cutaneous
branch
• Fatigue of forearm muscles
• Tinels positive in proximal
forearm NOT at wrist
• Resisted flexion of long and ring
fingers may cause forearm pain
• Resisted elbow flexion + forearm
• Nb-coexisting golfers elbwo

81. Tennis Elbow
• Lateral elbow pain
- Picking up coffee cup
- pulling covers while in bed
• 50% tennis players
• ECRB degeneration
• Tender over ECRB origin
• chair lift test: 3 finger pinch

82. • Maudsleys Test: Resisted wrist +
middle finger extension with
elbow extended
• Cozens Test: resisted wrist
extension in radial deviation
• Mills Test: passively extend elbow
with wrist flexed and forearm
pronated

83. Golfers elbow
• Pain of anteromedial aspect of
elbow
• Unlar neuritis in 50% cases
• Tender CFPO
• Resisted wrist felxion and
forearm supinated and elbow
extended
• Passive wrist extension with
elbow extended and forearm
supinated

84. LUCL
• Varus stress test
• Chair sign
• Table top relocation
• Lateral pivot shift test
- in OR

85. Radiocapitellar OA
• Lateral elbow pain
• Crepitus
• Rotation>flexion
• Tender over RCj
• Grip & Grind Test
- proximal migration of radius

86. MCL
• Valgus stress test
• Moving valgus stress test
• Milking manouvre
Valgus Extention Overload Syndrome
• Tender PM olexcranon
• Pain on forced extention
• Valgus extention overload test

87. Distal Biceps Tendon
• Anteromedial ecchymosis
• High riding
• No rise and fall with rotation
• Weak/pain resisted elbow flexion
and forearm supination
• Tender biciptal tuberosity
• O’Driscoll Hook Test

88. Distal Triceps
• Pain on resisted elbow extension
• Posterior ecchymoses
• Defect proximal to olecranon tip
• No extension against gravity
• Viegas: Elbow extension when
triceps squeezed [modification of
Thompson Test].

89. Plicae
• Anterolateral
- palpate RCJ
- pronate forearm
- Passively bring from 90 to flexion
- valgus load
• Posterolateral
- palpate RCJ
- supinate forearm
- passively move from 15 to
extension
- valgus load

90. Medial Snapping
• Place thumb on PM epicondyle
• Passively move from extension to
flexion
1. Ulnar nerve @ 90deg
2. medial head triceps @ 115 deg
• Only sensory symptoms

91. Questions??

92. …not about this guy!

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