ELBOW EXAM

Inspection

SEADS

S = swelling	Epicondyles Olecranon process Para-olecranon grooves Olecranon bursa (can indicate bursitis, RA, gout)
E = erythema	Epicondyles Olecranon process Para-olecranon grooves Olecranon bursa (redness and heat may indicate sepsis)
A = atrophy	Assess for atrophy of the biceps, triceps, and forearm muscles
D = deformity	Assess for forearm contractures
S = skin changes	Note any rash, surgical scars, psoriasis, rheumatoid nodules, gouty tophi

• Carrying angle
  • Angle between the humerus and the forearm
    • Usually 10 degrees in men and up to 20 degrees in women 
  • Elbow is normally slightly valgus in anatomical position

Palpation

• Indicate to the patient that you will be palpating over different regions for pain or tenderness 
• Ask for patient permission prior to start 
• Palpate systematically in the following manner:
  • Posteriorly
    • Palpate the humerus and triceps
    • Feel the olecranon bursa for tenderness and nodules
    • Continue down the extensor side of the forearm
    • Appreciate the ulnar nerve by flexing and extending the elbow
    • Joint effusion
      • Palpate the para-olecranon grooves, especially the lateral recess
      • With your fingers in the grooves, flex and extend the elbow, feeling the bulges move could indicate an effusion
  • Medially
    • Feel the triceps and supratrochlear lymph nodes
    • Feel the medial epicondyle and the flexor tendons
      • Golfer’s elbow 
  • Anteriorly
    • Feel the biceps and move down to the biceps tendon
      • Check for swelling or tenderness
    • Medial to the biceps tendon, feel the brachial pulse
      • Can be easily found by moving straight down from the wrist
  • Laterally
    • Palpate the lateral epicondyle and common extensor tendon for tenderness
      • Tennis elbow
    • Feel the radial head by pronating and supinating the forearm
    • Feel for crepitus or swelling in the radio-humeral joint
  • Crepitus
    • Cup the elbow and flex/extend the forearm feeling for crepitus

Range of Motion

Perform active ROM first, followed by passive ROM only if active ROM is limited. These may be integrated at terminal range of movement.

• Active ROM (Often helpful to demonstrate and have patient copy your movements)
  • Flexion: 140-150^o
  • Extension: 0°
    • May see hyperextension, especially in young women 
  • Pronation and Supination: 90°
    • Make sure elbows are at the side and at 90 degrees to limit shoulder activity 

• Passive ROM (performed with each step above as needed)
  • Assess end-feel (firm, soft) 

Power Assessment 

This is best done by resisted isometric testing, with patient resisting examiner’s force. For flexion and extension, stabilize the elbow with one hand. 

• Flexion/Extension
  • Flexion strength: examiner pulls down on the patient’s forearm as patient flexes upward
  • Extension strength: examiner pushes up on the patient’s forearm as patient extends arm downward
• Supination/Pronation (arm at the side at 90 degrees, palm should be perpendicular to the floor)
  • Supination: examiner tries to point palm down
  • Pronation: examiner tries to point palm up 

Special Tests 

• Stability Testing
  • Flex the elbow to 20-30 degrees
  • To check the MCL, stabilize the elbow with one hand and apply a valgus force
  • To check the LCL, stabilize the elbow with one hand and apply a varus force
  • AP stability
    • Grasp the forearm with the elbow flexed at 90 degrees.
    • Push and pull on the humerus, you should see no movement. 

• Lateral epicondylitis (Tennis elbow)
  • Resisted wrist extension
    • Extend elbow and make a fist, cocking it backwards so knuckles are facing the patient
    • Push down on the wrist, pain at the lateral epicondyle would indicate inflammation
  • Passive stretch of common extensors 

• Medial epicondylitis (Golfer’s elbow)
  • Resisted wrist flexion
    • Maximally flex wrist so patient’s fingers are pointing to the floor
    • Pull on the fingers to bring them parallel and ask patient to resist movement (eliciting flexion)
    • Pain at the medial epicondyle indicates inflammation
  • Passive stretch of common flexors 

• Cubital Tunnel Syndrome
  • Checking for entrapment of the ulnar nerve in the cubital tunnel, would thus see parasthesia in the medial 1.5 fingers with a positive finding
    • Tinel’s Sign
      • Tap on the ulnar nerve by the medial epicondyle and ask the patient for any tingling or numbness in the medial 1.5 fingers
    • Elbow Flexion Test
      • Have patient maximally flex elbow with the wrist extended for a minute
      • If pain develops, this is a positive test