Elbow Joint

Objective Evaluation

Postural examination [1]

When doing a posture analysis of the elbow the therapist should look for symmetry of the affected side as compared to the unaffected side. Observe carrying angle of the elbow, normal carrying angle is between 10-15 degrees. Carrying angle decreases as the elbow flexes so also note if the elbow is held in flexion or extension. A decreased carrying angle may be caused by damage or fracture to the epiphyseal plate. Supination and pronation can also be observed and may be easier identified by looking at the positioning of the wrist, normal positioning is slight pronation.

Gait Evaluation [2]

During gait observe how the patient holds their arm, close to the body may indicate they are in pain and attempting to protecting the elbow. Note if they are carrying an object with the affected arm and how they carry it to see the level of function. For example, if they cary a purse in the cradle of their elbow instead of by the handle it may indicate that they have trouble gripping the purse and could be an sign of lateral epicondylitis.

Palpation [3]

Palpate the major muscles and muscle groups around the elbow feel for point tenderness, muscle tightness, abnormal tone, swelling, warmth etc. also be sure to observe for any signs of bruising. Also note reproduction of any comparable sign.

  • Biceps
  • Triceps
  • Brachioradialis
  • Common Flexor Origin (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum profundus, and flexor carpi ulnaris) these muscles are hard to differentiate and share a common origin at the medial epicondyle.
  • Common Extensor Origin (extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) these muscles are hard to differentiate and share a common origin at the lateral epicondyle.

Palpate the bony prominences of the elbownote any tenderness.

  • Olecranon process- swelling around this area may indicate olecranon bursitis [1]
  • Medial epicondyle- tenderness may indcate medial epicondylitis
  • Lateral epicondyle- tenderness may indicate lateral epicondylitis
  • Groove for the ulnar nerve
  • Radial head- tenderness may indicate lateral epicondylitis
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(Image from http://www.theodora.com/anatomy/images/image1231.gif) (Image from http://www.theodora.com/anatomy/images/image1232.gif)

Clearing The Joints Above and Below [1]

  • Shoulder: Clear the shoulder in flexion, abduction and with the hand behind the back to assess extension, internal rotation and adduction. Have the patient raise their arms up in flexion and then lower back down to anatomical position, assess pain with active movement. Have the patient repeat this movement and this time stabilize the scapula with one hand and gently apply overpressure to the joint into flexion, note any pain with this movement. Repeat this process with the patient moving their arms into full abduction then applying overpressure, be sure the patient returns to anatomical position between movements and assess for pain each time. When observing shoulder motions take note of the plane of motion the patient uses and if it is appropriate, also observe if the patient appears to have full range. Lastly have the patient place their hand behind their back, observe how far they are able to place their hand, if they “throw it” into position, if they “crawl” their hand up the back, or if its a smooth quality movement. Note any pain with active motion, if there is no pain apply overpressure by stabilizing the upper arm and bringing the arm into extension first, then add adduction and internal rotation, again note any pain. This motion assesses the function of the rotator cuff.


To finish clearing the shoulder you must check power tests for flexion, extension, abduction, internal and external rotation. To do this have the patient short sit and raise their arm 90 degrees of flexion, first apply a downward pressure on the arm while stabilizing the shoulder, this checks flexion power (a), then switch to an upward force to check extension(b). Move on to abduction with the patients arm at 90 degrees abduction and apply a downward force to check the abduction power(c). Lastly for internal and external rotation have the patient hold their elbow at their side with the forearm flexed at 90 degrees, apply pressure to the outside of the wrist to check external rotation(d), and apply pressure to the inside to check internal rotation(e). During the power tests the patient should be able to resist your pressure.
a)flickr:8221002324 b)flickr:8219921289
c)flickr:8219921545 dflickr:8221002486
e)flickr:8221002586

  • Wrist: Clear the wrist in flexion and extension. While supporting the patients forearm have the patient extend the wrist. Note any pain on active extension, if there is no pain apply overpressure to the wrist putting it in greater extension. Be sure to apply the overpressure at the palmar aspect of the hand and not to the digits so that you are only assessing the wrist joint. Repeat this process asking the patient to go into active flexion, if there is no pain apply overpressure to the wrist flexion.

  • Cervical Spine

To clear the cervical spine have the patient go into active neck extension, if there is no pain apply overpressure while supporting the shoulders. Next ask the patient to go into right and left rotations, again if there is no pain at the patients full range apply overpressure. Lastly check the patients lower cervical quadrants. The quadrants are checked by asking the patient to extend the neck, rotate towards one side (R quadrant rotates towards the right side) and then side bend towards that same side rotating further as if looking in the corner of the room behind their shoulder. Do this for both sides and give overpressure if the patient is able to achieve the position without pain.

Range of Motion Testing [3]

For quick screens of the elbow range of motion have the patient go into flexion placing both hands on shoulders(a) to assess extension have the patient extend their arms fully out of this position(b). Do quick screens bilaterally and simultaneously to assess if there is a difference between sides that you must further investigate. For supination(c) and pronation(d) have the patient place their elbows at their sides and transition from palms to the ceiling (supination) to palms facing the floor (pronation). To assess radial deviation(e) and ulnar deviation(f) support the patients forearm either with your hand or on a table and radial and ulnar deviation.
a)flickr:8189199816 b) flickr:8189199898 c)flickr:8188119079 d)flickr:8188119129
e)flickr:8188152337 f)flickr:8188152423

Normal Range of Motion [4]

  • Elbow Flexion: 160 degrees
  • Elbow Extension: 0 degrees
  • Supination: 80 degrees
  • Pronation: 90 degrees
  • Radial/ Unlar deviation: 20/30 degrees

Resisted Isometric Muscle Testing [1]

  • Elbow Flexion: Have the patient seated with elbow at their sides and flexed to 90 degrees. Apply an extension force on the elbow and ask the patient to resist your force.
flickr:8189200728
  • Elbow Extension:Have the patient seated with elbow at their sides and flexed to 90 degrees. Apply a flexion force on the elbow and ask the patient to resist your force.
flickr:8189200514
  • Supination: With the patients hand in neutral grip their hand around the thenar eminence and apply a pronation force, ask the patient to resist your force.
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  • Pronation:With the patients hand in neutral grip their hand around the thenar eminence and apply a supination force, ask the patient to resist your force.
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  • Forearm Flexors: Have the patient actively flex their wrist, with your hand apply an extension force to the patients palm and ask them to resist your force.
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  • Forearm Extensors:Have the patient actively extend their wrist, with your hand apply an flexion force to the patients palm and ask them to resist your force.
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  • Grip Strength: Cross your arms and grasp the patients hands as if you were to shake both hands at once. Have the patient squeeze your hands as hard as possible. Note any differences between hand strength. You can also have the patient squeeze your three middle digits and note their strength.

Dermatome Testing [1]

Locate the center of each dermatome around the elbow joint for testing. In relation to the elbow joint the surrounding dermatomes are:

  • C5 lateral arm superior to the lateral epicondyle
  • C6 anterior-lateral arm just inferior to the lateral epicondyle
  • T1 medial arm just inferior to the medial epicondyle
  • T2 medial arm just superior to the medial epicondyle
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(Inmage from http://medical.cdn.patient.co.uk/images/i71_l.jpg )

Myotome Testing [1]

At the elbow the two myotomes to screen are C6- elbow flexion, and C7- elbow extension. In a seated position have the patient keep their elbow at their side with the elbow flexed to 90 degrees and the forearm supinated. When performing the break tests make sure the patient is supported at the shoulder and does not compensate. Apply inferior force to the distal forearm and ask the patient to bend their elbow against your resistance, this checks the C6 myotome. Apply a superior force to the distal forearm by placing your hand under the forearm, ask the patient to straighten their elbow into your resistance, this checks the C7 myotome.

Reflex testing [1]

Biceps (C5-C6): The patient is short sitting and is relaxed. The examiner holds the weight of the arm and places their thumb over the biceps tendon and the taps the thumb with the reflex hammer to elicit the reflex. A positive reflex is when the bicep contracts drawing the lower arm upwards.
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(Image from http://www.waybuilder.net/sweethaven/MedTech/Neurology/fig0206.jpg)
Triceps (C7-C8): The patient is short sitting and is relaxed. The examiner holds the weight of the arm, such that it is in a 90° angle with the hand toward the floor, and taps the triceps tendon with the reflex hammer to elicit the reflex. A positive reflex is when will cause the arm to extend at the elbow and swing away from the body.
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(Image from http://www.waybuilder.net/sweethaven/MedTech/Neurology/fig0207.jpg)
Reflex grading
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(Image from http://o.quizlet.com/i/pAGf0as0rBCPn3UXRgbuMw_m.jpg)

Upper Limb Tension Tests [1]

*ULTT1 (Median Nerve)- The patient is supine. The examiner is going to depress the scapula so that there is no scapular movement. The examiner will then abduct the shoulder to 110° and laterally rotate. Next the examiner will fully supinate the forearm and have the patient actively extend elbow, wrist and fingers. The examiner will then apply over pressure to the wrist and fingers. Lastly, patient will laterally flex the neck contralaterally if tingling goes down the arm have the patient come back to neutral or laterally flex the neck ipsilaterally, if this decreases or eliminates the tingling this is positive for neural tension on the median nerve. If the patient is limited in external rotation or is has recurrent shoulder dislocations do not do this test.
flickr:8221001808

*ULTT2 (Median Nerve)- The patient is supine lying diagonally. The examiner is going to depress the scapula so that there is no scapular movement. Next the examiner will extend elbow and forearm keeping the forearm in the anatomical position. The examiner will then laterally rotate the shoulder, supinate the forearm, extend the wrist, and abduct the shoulder. Lastly, patient will laterally flex the neck contralaterally if tingling goes down the arm have the patient come back to neutral or laterally flex the neck ipsilaterally, if this decreases or eliminates the tingling this is positive for neural tension on the median nerve.
flickr:8221001600

*ULTT3 (Radial Nerve)- The patient is supine lying diagonally. The examiner is going to depress the scapula so that there is no scapular movement. Next the examiner will extend elbow and forearm keeping the forearm in the anatomical position. The examiner will then medially rotate the shoulder, pronate the forearm, flex the wrist with ulnar deviation, and abduct the shoulder. Lastly, patient will laterally flex the neck contralaterally if tingling goes down the arm have the patient come back to neutral or laterally flex the neck ipsilaterally, if this decreases or eliminates the tingling this is positive for neural tension on the radial nerve.
flickr:8219920825

*ULTT4 (Ulnar Nerve)-The patient is supine. The examiner is going to flex the patient’s elbow and pronate the forearm. Next the examiner will extend the wrist adding ulnar deviation. The examiner will then laterally rotate and abduct the shoulder. Lastly, patient will laterally flex the neck contralaterally if tingling goes down the arm have the patient come back to neutral or laterally flex the neck ipsilaterally, if this decreases or eliminates the tingling this is positive for neural tension on the ulnar nerve.
flickr:8219921097

Neural tension tests [1]

Hoffmann’s Sign: The examiner holds the patient’s middle finger and briskly flicks the distal phalanx. A positive sign is when the interphalangeal joint of the thumb of the same hand flexes.

Passive Physiological Movements [3]

The following tests should be done passively. The examiner is looking to reproduce a comparable sign. The examiner would want to feel for R1, P1 and as needed R2, P2, L and B. The passive physiological examination can also be used as a treatment technique.

*Elbow Extension
The examiner should cradle and support the patient’s elbow while having their elbow on the anterior aspect of the shoulder to help stabilize. A force is then applied to the proximal wrist. The examiner should note when they feel resistance and location of pain.

*Elbow Extension with Adduction
The examiner should cradle and support the patient’s elbow while having their elbow on the anterior aspect of the shoulder to help stabilize. The examiner will rotate the patient’s humerus medially to get adduction at the forearm and elbow. The patient’s thump should point up. The examiner will then take the patient’s arm from 10° of flexion to full extension. The examiner should note when they feel resistance and location of pain.

*Elbow Extension with Abduction
The examiner should cradle and support the patient’s elbow while having their elbow on the anterior aspect of the shoulder to help stabilize. The examiner will rotate the patient’s humerus laterally to get abduction at the forearm and elbow. The patient’s thump should point down. The examiner will then take the patient’s arm from 10° of flexion to full extension. The examiner should note when they feel resistance and location of pain.

*Elbow Flexion
The patient’s elbow should be supported and stabilized by the examiner. The examiner will move the wrist towards the glenohumeral joint. The examiner should note when they feel resistance and location of pain.

*Elbow Flexion with Adduction
The patient’s elbow should be supported and stabilized by the examiner. The examiner will laterally rotate the humerus and then move the wrist towards the patient’s face. The examiner should note when they feel resistance and location of pain.

*Elbow Flexion with Abduction
The patient’s elbow should be supported and stabilized by the examiner. The examiner will medially rotate the humerus and then move the wristtowards the patient’s greater tubercle. The examiner should note when they feel resistance and location of pain.

*Supination and Pronation
The patient’s arm will be supported by the table. The patient’s elbow should be at 90° of flexion. The examiner will then use either a “wing-nut” grip or “interthenar-styloid” grip at the distal radial and ulna and rotate moving the arm into supination and pronation. The examiner should note when they feel resistance and location of pain.

Passive Accessory Movements [3]

The following tests should be done passively with the least amount of force, this is, the lowest grade of movement. The examiner is looking to reproduce a comparable sign. The examiner would want to feel for R1, P1 and as needed R2, P2, L and B. The passive accessory examination can also be used as a treatment technique.

*Antero-Posterior on Ulna:The patient is supine. The examiner will place thumbs over top of the ulna and using their body will put an antero-posterior force. This action often forces flexion. The examiner should note when they feel resistance and location of pain.
flickr:8188118923

*Postero-Anterior on Olecranon: The patient is prone. The examiner will place thumbs over top of the olecranon process and using their body will put a postero-anterior force. This action often forces extension. The examiner should note when they feel resistance and location of pain.
flickr:8189200172

*Superior Radio-Ulnar Postero-Anterior: The patient is supine with their elbow at 90° of flexion. Facing the patient’s head the examiner will place their thumbs over the radial head and using their body will apply pressure toward the patient’s body. The examiner should note when they feel resistance and location of pain.
flickr:8188118861

*Superior Radio-Ulnar Antero-Posterior:The patient is supine with their elbow at 90° of flexion. Facing the patient’s feet the examiner will place their thumbs over the radial head and using their body will apply pressure away from the patient’s body. The examiner should note when they feel resistance and location of pain.
flickr:8188119369

Ligament testing [1]

For the tests below, the patient should be relaxed. The examiner will test the unaffected side first and then the affected so they have something to compare it to. The examiner should apply their force gently and increase gradually until an end feel is established or to the point of pain. A normal ligamentous end feel should be a sudden stop. A soft or empty end feel is indicative of an injury.

*Varus stress test
Structure Tested: Radial Ligament
Patient Position: Patient can be in a supine position or a short sit depends on where the patient is more relaxed
Test Procedure: The examiner stabilizes the distal ulna and radius with one hand and with the other hand you push laterally against the humerus. This test is done with the elbow in 30° and then again in 0°.
Test Results: A positive test would be when the examiner sees gapping or if the patient feels pain.

*Valgus stress test
Structure Tested: Ulnar Collateral Ligament
Patient Position: Patient can be in a supine position or a short sit depends on where the patient is more relaxed
Test Procedure: The examiner stabilizes the distal ulna and radius with one hand and with the other hand you push medially against the humerus. This test is done with the elbow in 30° and then again in 0°.
Test Results: A positive test would be when the examiner sees gapping or if the patient feels pain.

The following video demonstrates both the Varus and the Valgus stress tests:

Special tests [1]

*Tinels Test
Structure Tested: Ulnar nerve
Patient Position: Patient can be in a supine position or a short sit depends on where the patient is more relaxed.
Test Procedure: The patient’s arm is flexed to about 20°. The examiner taps in the groove between the olecranon and the medial epicondyle.
Test Results: Tingling down the ulnar nerve distribution in the forearm and hand there could be a neuroma within the ulnar nerve.

*Maudsley’s Test
Structure Tested: Lateral epicondyle
Patient Position: The patient should be short sitting.
Test Procedure: The examiner has the patient extend their elbow completely and has the patient extend their middle finger. The examiner then resists the middle finger extension.
Test Results: If their pain is reproduced the test is positive for lateral epicondylitis.

*Golfer’s Elbow Test
Structure tested: medial epicondyle
Patient Position: Patient can be in a supine position or a short sit depends on where the patient is more relaxed.
Test Procedure: The examiner palpates the patient’s medial epicondyle and passively supinates the arm, and extends the elbow, wrist and fingers.
Test Results: If there is pain over the medial epicondyle of the humerus it is positive for medial epicondylitis.

Bibliography
1. Magee DJ. Orthopedic physical assessment. Missouri: Saunders Elsevier; 2008.
2. Craig J. Elbow, Wrist and Hand. Fall 2012 Lectures. 2012;Week 12.
3. Banks K.; Hengeveld E. Maitland's Clinical Companion. Edinburgh NY: Churchll Livingstone/Elsevier; 2009.
4. Reese N.; Bandy W. Joint Range of Motion and Muscle Length Testing. St Louis MS: Saunders Elsevier;2002.

Christine and Annie

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