The following is a system of examination for the elbow, but is not exhaustive
Look for evidence of swelling, previous scars, nodules. An effusion of the elbow is most easily seen in the posterolateral recess behind the radial head. Nodules on the extensor surface of the olecranon may indicate rheumatoid arthritis or gout. Swelling over the point of the elbow may indicate an olecranon bursitis. After injury look at the medial aspect of the elbow, bruising around the medial epicondyle may indicate an injury to the medial ligament or common flexor origin. Bruising more distally in the medial forearm is often seen after a distal biceps rupture. Look to see if the ulnar nerve subluxates during elbow flexion.
Feel the elbow with one finger starting on the lateral side of the elbow with the elbow bent at 90degrees, move your finger down the lateral ridge to the most prominent part of the lateral epicondyle. Move your finger 0.5cm distally to feel for tenderness at the origin of ECRB that may indicate tennis elbow. Move your finger another 0.5cm distally to feel for tenderness along the radiocapitellar joint line that may indicate osteoarthritis or a plica. Then move your finger posteriorly to and around the lateral side of the olecranon to examine for tenderness in the posterolateral recess or posteromedial recess indicative of posterior impingement.
Then feel the ulnar nerve behind the medial epicondyle for instability or tenderness. Gently tap over the nerve, if this produces tingling in to the little finger this is suggestive of cubital tunnel syndrome. Then feel over the medial epicondyle for tenderness associated with golfer’s elbow. 1cm anterior and lateral to the medial epicondyle lies the medial ligament that can be palpated for tenderness.
It is more difficult to obtain any specific diagnosis from feeling over the front of the elbow but tenderness here may be associated with a bicipital bursitis, distal biceps tendinopathy, or joint pathology.
Ask the patient to move the elbow with the arm held out the side. Start with the arms as straight as possible with the palms facing upwards. By convention of the arm and forearm are in a straight line this is zero degrees. Some patients, mainly females, will be able to extend their elbows beyond zero degrees, up to 15 degrees. This is reported as a negative value by convention. Then ask the patient to bend the elbows as far as possible and measure the angle that the arm and forearm make. There is a large range of ‘normal’ elbow flexion, often determined by the size of the biceps, but most patients can flex to 140 degrees. You are looking for asymmetry. The angles should be measured with a goniometer to ensure accuracy. A sudden loss of range in both directions is indicative of fluid in the elbow. Sudden loss of extension only may be caused by a loose body. Gradual loss of range of movement occurs in arthritis.
Next ask the patient to fully straighten the elbows by their sides with the palms facing forwards. Measure the angle between the arm and forearm, known as the carrying angle. This is normally measures around 11 degrees. Be aware that in the presence of a flexion contracture of the elbow the carrying angle cannot be measured reliably. An increased or decreases carrying angle may indicate a previous elbow injury such as a supracondylar fracture of the humerus. If the patient has a marked valgus deformity this may predispose to the development of an ulnar nerve lesion.
As the patient to hold the elbow flexed at 90 degrees and with the elbows tucked in by their sides to rotate the forearm from palm up to palm down. Loss of range of movement compared to the opposite side indicates a problem within the forearm from joint between the radial head and lesser sigmoid notch of the ulna to the distal radio-ulnar joint.
Mill’s sign – performed by passively flexing the wrist with the elbow bent. The examiner slowly brings the elbow into extension which will elicit pain in a positive test.
Maudsley’s sign – ask the patient to keep the elbow, wrist and fingers straight with the palm facing down while pressure is applied by the examiner over the distal end of the middle finger metacarpal. This will produce pain in a positive test.
Pronator Teres Provocation – the patient holds the elbow bent by their side with the palm facing down. The examiner tries to turn the palm to face upwards while the patient resists. This will produce pain in a positive test.
Distal Biceps Tendinopathy
O’Driscoll’s Hook Test – With the shoulder abducted to 90 degrees the patient is asked to look at their palm in front of their face. The examiner then brings a finger from lateral to medial to ‘hook’ the distal biceps tendon. The tendon can then be stretched in isolation. This will produce pain in a positive test. If the distal biceps cannot be ‘hooked’ then the patient may have a distal biceps tendon rupture.
Triceps provocation – Ask the seated patient to bring their arm above their head with the elbow bent at 90degrees. While the examiner tries to push the arm down the patient resists. This will produce pain in a positive test. Isolated tenderness at the triceps insertion may indicate an enthesophyte fracture.
Biceps Tendon rupture
O’Driscolls Hook Test – see above
Biceps squeeze test – ask the seated patient to sit with the forearm relaxed across their lap. The examiner squeezes the biceps and examines for passive forearm supination. If there is no movement the patient may have a biceps tendon rupture.
Pop-eye sign – proximal retraction of the biceps muscle belly
Passive rotation – with passive rotation of the forearm with the elbow flexed to 90degrees the biceps muscle belly should be seen to move.
Resisted elbow flexion – strength may well be preserved even with a complete rupture, but the patient will fatigue more rapidly.
Resisted supination – the patient is asked to hold the hand palm upwards with the elbow bent by their side at 90degrees while the examiner tries to turn to palm down. This will be weaker with a biceps rupture.
Lateral ligament incompetence
Varus instability – with the humerus in full internal rotation and the elbow flexed to 30degrees a varus force is applied to the elbow while inspecting the lateral joint line.
Bench press test – the patient is asked to attempt a press-up on the edge of a desk with the arm in pronation, if they can do this but are then unable to perform the same test with the forearm in supination this is indicative of postero-lateral rotatory instability. The examiner can then place a thumb on the back of the radial head maintaining the reduced position of the radial head and the test is repeated.
Push up test – as above but performed with the patient seated. The patient is asked to push themselves up with their hands on the arm rests of the chair. Firstly with forearm pronation then supination.
Pivot shift test – this test should be reserved for the anaesthetised patient. The forearm is placed in supination and flexion and a valgus and axial load is applied as the elbow is straightened. The radial head will be seen to dislocate.
Medial ligament injury
Valgus instability – with the humerus in full external rotation and the elbow flexed to 30degrees a valgus force is applied to the elbow while palpating the medial joint line.
Passive Milking manoeuvre – with the shoulder abducted to 90 degrees and elbow flexed to 90degrees the examiner grasps the patients thumb and applies a valgus force.
Moving valgus stress test – A valgus force is applied as the elbow is moved from full flexion to full extension passively by the examiner. Pain at around 90 to 70degrees indicates pathology of the medial ligament.
Ulnar nerve examination
Froment’s sign – ask the patient to grip a piece of paper between both thumbs and index finger, in the “key-pinch” position. The examiner then tries to pull the piece of paper away. In a positive test the patient will have to flex the interphalangeal joint of the thumb, recruiting the median nerve innervated flexor pollicis longus, because of the weak ulnar nerve innervated muscles.
Apley’s sign – The patient is asked to spread their fingers wide and to push their little fingers hard against each other. In a positive test the anduction of the little finger of the hand with an ulnar nerve lesion will be overcome by the uninjured hand. Note that the dominant hand may be stronger than the non-dominant hand.
Reverse Apley’s sign – as above but using the index finger
Wartenberg’s sign – the little finger is held in abduction due to the eccentric pull of extensor digiti minimi.
Tinel’s sign – gentle percussion over the ulnar nerve at the elbow sends a shooting pain or tingling into the ulnar innervated fingers in the hand.
Flexion test – the patient extends the wrist and flexes the elbow. A positive test reproduces the symptoms in the hand.
Pressure test – direct pressure is applied over the ulnar nerve in the cubital tunnel to reproduce symptoms.
Flexion-pressure test – a combination of the two tests above. It is said that this increases the sensitivity of the test.
Other special tests
Spinner’s sign for snapping triceps – the patient is asked to push against the examiners hand as the examiner passively flexes the elbow while looking at the medial side of the elbow. This will reproduce the patients symptoms of painful snapping of the tendon in the medial border of triceps. At the same time first the nerve and then the tendon will be seen to subluxate over the medial epicondyle.