The document describes how to examine a patient's elbow through inspection, palpation, and assessing range of motion. Key points include: 1. Inspection notes the carrying angle of the elbow and any swelling, bony prominences, or scarring. 2. Palpation identifies bony landmarks like the epicondyles and feels for effusions in the triangular space between landmarks. 3. Range of motion is measured for flexion, extension, pronation and supination using a goniometer positioned at anatomical reference points. Normal elbow motion is noted.

1. Cubital Tunnel Syndrome

2. CLINICAL EXAMINATION

3. INSPECTION
• The patient should be standing, with shoulders slightly
braced back, to display the elbow.
• When the forearm is in full extension and supination, there
will be a physiological valgus ("carrying angle") of 9-14°; in
women, the angle will be 2-3° greater
• This angle has been found to be 10-15° greater in the
dominant arm of throwing athletes
• This angle allows the elbow to be tucked into the waist
depression above the iliac crest; it increases when a
heavy object is being lifted
• Any increase in, or loss of, this physiological angle is
indicative either of major elbow instability or of malunion.
• However, the angle varies from valgus in extension to
varus in flexion, and its measurement is not of any
practical importance.

4. Inspection
• Sometimes, on the side of the elbow, bulging
in the para-olecranon groove will be seen;
such a swelling is produced by an effusion or
by synovial tissue proliferation
• On the back, prominence of the olecranon is
a sign of posterior subluxation of the elbow,
a feature commonly found in RA .
• Rheumatoid nodules are extremely
common
• Bursitis is also a frequently encountered
pathology, especially in RA patients.
• Skin atrophy at steroid injection sites, or
scars from previous surgery.

5. Figure 8
The physiological valgus (“carrying angle”) of the
elbow is increased when a load is being carried.
Normally, the angle is between 9 and 14° when the
elbow is extended and the forearm is supinated.

6. PALPATION
• Palpation starts at the posterior aspect,
with the patient standing with his or her
shoulder braced backwards.
• The three palpation landmarks - the two
epicondyles and the apex of the olecranon
- form an equilateral triangle when the
elbow is flexed 90°, and a straight line
when the elbow is in extension (Figs. 9,
10).

7. PALPATION
Figures 9, 10
Three bony landmarks - the medial epicondyle, the lateral
epicondyle, and the apex of the olecranon - form an
equilateral triangle when the elbow is flexed 90°, and a
straight line when the elbow is in extension

8. PALPATION
• Since the elbow is a very superficial joint, it can
be readily palpated from behind and from the
sides.
• The posterior aspect has the olecranon mid-way
between the medial and the lateral condyle.
• Slight elbow flexion will bring the olecranon out
of the olecranon fossa, in which it lodges in
extension; in this position, the proximal portion of
the fossa on either side of the triceps tendon
may be palpated (Fig. 11)

9. • Figure 11 Flexing the elbow allows
palpation of the olecranon fossa on
either side of the triceps tendon.
• Figure 12 Anatomical landmarks
on the lateral aspect of the elbow:
The lateral epicondyle continues
proximally in the supracondylar
ridge.
• Two 2cms distally, the main
landmark is formed by the radial
head.
PALPATION

10. • The olecranon bursa is not in communication with
the synovial cavity.
• This is why the elbow may be mobilized in
bursitis, and why even massive bursitis will not be
tender.
• In chronic bursitis, a boggy globular mass may be
palpated; the overlying skin will be thickened. Flat,
hard nodules may be felt under the palpating
fingertips.
• In infected bursitis, the skin will be tight and
shiny; streaks of lymphangitis will be commonly
seen; while in 25% of the cases, the axillary
lymph nodes will be enlarged.
• On the lateral side, the main landmarks are the
lateral epicondyle proximally and the radial head
distally.

11. • The supracondylar ridge is also very accessible to
palpation; its chief value is that of a landmark for
surgical approaches (Fig. 12).
• Sometimes, palpation may be carried out all the
way up to the deltoid tuberosity.
• The radial head is palpated with the examiner’s
thumb, while the other hand is used to pronate and
supinate the forearm (Fig. 13).
• The head is about 2 cm distal to the lateral
epicondyle
• Inside the triangle formed by the bony
prominences of the lateral epicondyle, the radial
head and the olecranon, the joint itself is palpated,
to detect even very minor effusions or low-grade
synovitis (Fig. 14(

12. Figure 13
• Anatomical landmarks on the lateral aspect of the elbow:
• The radial head is palpated with the thumb, while the
examiner’s other hand is used to pronate and supinate the
forearm
.Figure 14
• The elbow joint may be palpated inside a triangle formed by
the bony prominences of the lateral epicondyle, the radial
head, and the olecranon.
• This palpation will reveal even minor effusions or mild
synovitis.
• Puncture for joint aspiration is performed inside this triangle.
• Similarly, an arthroscopy portal may be placed there
(posterolateral portal(
PALPATION

13. • Figure 15 Palpation and
testing of brachioradialis,
a forearm flexor.
• Figure 16 Palpation and
testing of the wrist
extensors
PALPATION

14. PALPATION
• From the medial side, the joint is not very accessible to palpation, and the
small amount of synovial tissue on the medial border of the olecranon
makes joint palpation difficult
• Palpation of the ridge that provides insertion for the intermuscular septum is
useful mainly as a guide for surgical approaches. Also, the supracondylar
lymph nodes may be palpated at this site (Fig. 17).
• Over, and slightly anterior to, the supracondylar ridge, a bony excrescence
may be palpated; this outgrowth may irritate the median nerve
• This supracondylar process is present in 1-3% of the population, and is
seen at a distance of 5-7 cm above the joint line
• Behind the septum, the ulnar nerve may be palpated; in patients with a very
mobile nerve, it may be seen to roll on the medial condyle(10) (Fig. 18).
• Ulnar nerve instability is more easily tested with the arm in slight abduction
and external rotation, with the elbow flexed between 20 and 70°.

15. Figure 17
• Palpation of the medial aspect of the elbow.
• Above the medial epicondyle is the ridge on
which the intermuscular septum inserts.
• Two centimetres above the epicondyle is the
site used for lymph node palpation.
Figure 18
The ulnar nerve is palpated
behind the intermuscular
septum.
It may sometimes sublux or roll
on the epicondyle.
Ulnar nerve instability is more
readily demonstrated if the
elbow is flexed 60° and the
upper limb is abducted and
externally rotated.

16. PALPATION
• Anteriorly, the bulk of the flexor-pronator group restricts the
extent of joint palpation.
• The flexor-pronator muscles must be tested as a unit, by
asking the patient to perform wrist adduction and flexion
against resistance (Fig. 19).
• Next, each one of these muscles should be tested individually.
• The anterior aspect does not lend itself to palpation, since it is
tucked away behind the muscles.
• Laterally, brachioradialis will be felt; and in the middle, the
biceps tendon is readily accessible if the patient is made to flex
the forearm against resistance.
• Lacertus fibrosus is palpated medial to the biceps tendon; the
pulse of the brachial artery will be felt deep to this aponeurosis
(Fig. 20).
• Sometimes anterior protrusion cysts produced by herniated
synovial membrane may be felt.

17. Figure 19
Diagrammatic view of the pattern of
the flexor-pronator group: The thumb
represents pronator teres; the index,
flexor carpi radialis; the middle
finger, palmaris longus; and the ring
finger, flexor carpi ulnaris.
Figure 20
Palpation of the medial biceps
expansion (lacertus fibrosus), which
courses over the brachial vessels
and the median nerve.

18. MOBILITY
• The main function of the elbow is to bring the hand
to the mouth; this is why the investigation of the
elbow range of movement (ROM) is an important part
of the examination process.
• Any difference between passive and active mobility
is usually due to reflex inhibition from pain
• The end-feel - the feeling transmitted to the
examiner’s hands at the extreme range of passive
motion - must also be assessed (Table 1)
• If the feel is abnormal, there is usually something
wrong with the joint.

19. Table 1 Classification and description of end-feels
(modified from TS Ellenbecker & AJ Mattalino)(12a(
Bony Two hard surfaces meeting,
bone to bone (elbow
extension(
Capsular Leathery feel, further motion
available (forearm pronation
and supination(
Soft tissue approximation Soft tissue contact (elbow
flexion(
Spasm Muscle contraction limits
motion
Springy block Intra-articular block;
rebound is felt
Empty Movement causes pain, pain
limits movement

20. ELBOW JOINT
• The elbow is a complex joint with three different
articulations.
• The humeroulnar joint is a hinge joint, and
allows the forearm to flex and extend, and
provides stability.
• The radiohumeral and radioulnar joints allow for
flexion, extension and rotation of the radius on
the ulna, which in turn allows the forearm to
pronate and supinate.

21. RANGE OF MOTION
• Flex and extend, and supinate and
pronate.
• Normal elbow range of motion
• Extension: 0°
• Flexion: 150°
• Pronation: 70°
• Supination: 90°

22. Elbow Goniometry

23. Flexion
• Patient Instructions:
• Ask the patient to bend their elbow as far as
they can, try and touch their shoulder.

24. Starting Position
• Position: Supine, arm in the anatomical position with arm of the
patient is resting on the edge of the table.
• The fulcrum aligned with the lateral epicondyle of the humerus.
• The stationary arm is positioned along the midline of the humerus
• The moving arm is aligned with the radial styloid process.

25. Ending Position
• The arm is now flexed at the elbow, the goniometer
should still be aligned with the correct anatomical
landmarks as described below.
• Normal ROM is between 150-160º, the patient has 155º
of elbow flexion.

26. Pronation
• Patient Instructions:
• Have the patient turn their wrist down toward the ground.
• Starting Position:
• Patient sitting up with elbow bent 90 degrees and at patient’s
side, wrist in a handshake position.
• The fulcrum is placed just behind the ulnar styloid process.
• The moving arm and stationary arm are parallel with the anterior
midline of the humerus.

27. Ending Position
• The fulcrum should remain in the same position as above.
• The stationary arm will still be aligned parallel to the midline of
the humerus, the moving arm will lie across the dorsum of the
forearm just behind the ulnar and radial styloid processes.
• Normal ROM is 90-96º, the patient has 95º of pronation.

28. Supination
• Patient Instructions:
• Have the patient turn their palm up as if they are holding
something in the palm of their hand.
• Starting Position:
• Patient position is the same as for pronation.
• The goniometer is placed on the medial aspect of the forearm
with the fulcrum at the radioulnar joint.
• The arms are both aligned with the anterior midline of the
humerus.

29. Ending Position
• The moving arm will be resting on the medial forearm
at the radioulnar joint.
• The moving arm should remain parallel to the midline
of the humerus.
• Normal ROM is 81-93º, the patient has 90º of
Supination.

30. Normal ROM Reference
Values
Elbow Typical ROM
Flexion 150-160º
Extension 0
Pronation 90-96º
Supination 81-93º