Elbow Examination

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Subjective

Clinical Presentation

Pain and symptoms localized in or around elbow. May present with neurological symptoms local or distant to elbow.

Subjective History

• Exact location of pain
• Timeline-When are the patients reported symptoms at their worst?
• Mechanism of the injury- In the case of a traumatic event, the mechanism of injury helps guide the diagnosis. For atraumatic injuries, specific symptoms can be highly useful in determining a diagnosis.
     For example: patient reported numbness and/or tingling in the 5th digit may suggest ulnar neuropathy.
• Presence of numbness or tingling?
• Medications?
• Past Medical History
• Diagnostic Testing/Imaging?

• Region Specific Historical Question: These questions will help guide the examination. For example:
1. Do your symptoms change (better or worse) with any movements of the neck or shoulder?
     “Yes” the cervical spine and shoulder region should be screened.
2. Does your elbow ever “slip out” or feel unstable?
     “Yes”, elbow instability could be indicated
3. Does the pain change with gripping activities?
     “Yes” could indicate possible lateral or medial epicondylagia.
4. Do you ever experience numbness of tingling in the hand?
     “Yes” could indicate possible pronator teres or cubital tunnel syndrome.
5. Was the elbow hyper extended during the time of injury?
     “Yes” could indicate fracture of ligamentous/capsular damage.
6. Do you relate the symptoms to a throwing activity?
     “Yes” could indicate medial instability.

• Environmental and Personal Factors
During the initial examination, environmental and personal factors should be addressed. These issues could affect healing and return of function after an elbow injury. Table 1 outlines these issues.

Table 1. Patient Factors that can affect healing and return of function after elbow injury

Diabetes • Immunosuppression • Infection • Multiple site injuries • Tobacco use • Excessive alcohol intake • Complications following injury or surgery(joint stiffness, heterotopic ossification, infection, joint instability)

Self-Report Outcome Measures

• DASH (Quick Dash)
• Patient-Specific Functional Scale
• PREE and ASES: Patient-rated elbow evaluation (PREE) and American Shoulder and Elbow Society evaluation(ASES) are two similar scales that allow the patient to self-report their pain and disability related to their elbow pathology. The conceptual difference between the two scales is minimal and the correlation between the two scales usually exceeds 0.90.
• P4: P4 is a 4-item pain intensity measure. The P4 asks patients to rate pain in the morning, afternoon, evening, and with activity over the past 2 days. The P4 can be particularly useful as the elbow is greatly impacted by movement and time of day.
  

• SF-36: SF-36 is a generic health form. It is appropriate to address broad areas of health. For individuals with elbow dysfunction, the SF-36 is not a good tool to evaluate change in the clinic for patients with elbow disorders because it is not responsive and specific to the symptoms that the patient is reporting with. This measure can also be very time consuming and difficult to use.

Special Questions

• Red and Yellow Flags

Red Flags

•Infection/Inflammation •Malignancy •Fracture/Dislocation (Positive Elbow Extension Test) • Inflammatory Arthritides •Abnormal Vitals •Abnormal Vascular/Neurological Exam •Heterotopic Ossification (Post-Surgical Consideration) •Inappropriate progress from treatment made after surgery

Yellow Flags

-Psychosocial factors -Passive coping -Fear Avoidance Beliefs

Investigations

• Radiological Considerations
     The information from the history should be correlated with imaging findings of the elbow when available.¹

                                                                   Fig. 1

Illustration adapted from [Frick, 2006]

Fig. 1 . Anteroposterior (a) and lateral (b) radiographs of a normal elbow demonstrate the normal articulations of the elbow.

Objective

Observation

• General posture of the upper quarter: Proximal factors should be considered which could predispose the patient to elbow symptoms.
• Thoracic and cervical spine including kyphosis and forward head
• Scapular Considerations
• Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women.
• Swelling/ecchymosis/deformities/muscle wasting
• Triangle Sign

Palpation

• Medial/lateral epicondyle
• Olecranon and olecranon fossa
• Radial head
• Ulnar Collateral Ligament (UCL) of the elbow
• Soft tissue in upper arm and forearm/wrist for pain provocation, heat, swelling
  

Neurologic Assessment

• Reflexes: C5-C7
• Myotomes: C5-T1
• Dermatomes: C5-T1

Movement Testing

• AROM, PROM, and Overpressure
• Passive Intervertebral Motion
• Muscle Strength
  

Special Tests (broken up by possible diagnosis)

Cubital Tunnel Syndrome:

• Elbow Flexion Test
• Tinnel's Sign
• Ulnar Nerve Compression Test

Lateral Epicondylalgia:

• Passive elbow extension, pronation, wrist flexion (Mill's Test)
• Resisted wrist extension with radial deviation (Cozen's Test)
• Resisted middle finger extension (Maudley's Test)

Ligamentous Tests:

• Varus Stress Test
• Valgus Stress Test
• Moving Valgus Stress Test

Neurodynamic Tests

• Median nerve bias: Upper Limb Neurodynamic Test 1
• Radial nerve bias:  Upper Limb Neurodynamic Test 2b
• Ulnar nerve bias:  Upper Limb Neurodynamic Test 3

References

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