Introduction
- Introduce yourself to the patient and offer the patient a chaperone, as necessary
- Wash your hands
- Briefly explain to the patient what the examination involves
- Ask the patient to expose both upper limbs to include the shoulder
- Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.
Inspection
With the patient standing:
- Ask the patient to relax, with shoulders adducted and elbows extended
- Inspect the elbow from anterior, lateral, posterior, and medial aspects
- Look for skin changes, scars, swellings, nodules
- Compare with contralateral elbow, looking for asymmetry
- Assess for the carrying angle of the elbow
Palpation
- Check temperature, feeling both sides
- Feel muscle bulk of biceps, triceps, forearm muscles
- Feel for bony and joint tenderness, starting anterior, working laterally to posterior, then medially around back to anterior elbow
- Biceps tendon → extensor muscle bulk → radial head → lateral epicondyle → olecranon → medial epicondyle → flexor muscle bulk
Movement
- Ideally, assess elbow movement from the starting position of:
- Arms supinated, abducted to 90° at the shoulder
- Assess flexion and extension – range should be 0 – 140°
- Up to 10° hyperextension is acceptable; more than this would suggest hypermobility or previous bony injury
- Assess pronation and supination with elbows flexed to 90 and shoulders adducted (“elbows tucked in”)
- Patient can be thumbs up or hold a pen in a fist; normal range would be approximately 90 supination and just less than 90 of pronation
- Gross evaluation of power (grading to MRC scale)
Special Tests
Lateral Epicondylitis test
If lateral epicondylitis test (also known as tennis elbow) is suspected, the patient may present with pain around the common extensor origin
- Extend the elbow and pronate fully
- With one digit, place light pressure over the common extensor origin
- Ask the patient to extend their wrist and fingers against resistance from your other hand
- If pain is elicited at common extensor origin on resisted extension, test is positive
Medial Epicondylitis test
If medial epicondylitis test (also known as golfer’s elbow) is suspected, the patient may present with pain around the common flexor origin
- Slightly flex the elbow and supinate fully
- Support the elbow, and place light pressure over the common flexor origin with one finger
- Ask the patient to flex their wrist and fingers against resistance from your other hand
- If pain is elicited at common flexor origin on resisted flexion, test is positive; passive extension of wrist and elbow may elicit pain at common flexor origin
Complete the Examination
Thank the patient and allow them to redress. Remember, if you have forgotten something important, you can go back and complete this.
State to the examiner that to complete your examination you would also like to examine the joint above (the shoulder) and below (the wrist), as well as the contralateral elbow, and review any relevant imaging available.