ELBOW EXAMINATION

ELBOW
JOINT
ULNOHUMERA RADIOHUME SUPERIOR
L JOINT RAL RADIOULNAR
JOINT JOINT
• The elbow complex make up a compound synovial joint.
• The articulations made up of
- Ulnohumeral joint
- Radioulnar joint
- Superior radioulnar joint
• Combination of these three joints allows 2 degree of freedom
- Flexion-Extension
- Rotations
• Carrying angle/Cubital Valgus : Position of these joints makes
normal Valgus Angulation of 8 to 15 degree.
Ulnohumeral Joint/Trochlear joint:
• Uniaxial Hinge Joint
Resting position : 70 degree of elbow flexion
10 degree of supination
Neutral position : midway between supination & pronation
Close pack position : Extension with supination
Capsular pattern : Flexion, Extension
• In early flexion there is 5 degree of medial rotation
• In late flexion there is 5 degree of lateral rotation
The Radiohumeral Joint :
Uniaxial Hinge joint
Resting position : full extension and full supination
Close packed position: Elbow 90 degree flexed,
Forearm 5 degree supinated
Capsular pattern: Flexion, extension, supination, pronation
(Flexion more limited than extension)
Superior Radioulnar Joint:
• A uniaxial Pivot joint
Resting position: 35 degree supination,
70 degree elbow flexion
Close packed position: 5 degree supinated
Capsular pattern : equal limitation of supination & pronation
 HISTORY

1. Age of patient ? Occupation of patient?

- in children if there is pain followed by lack of supination
we can suspect dislocation of the head of the radius
- between 15 to 20 years of age chances of Osteochondritis
disseccans
- In middle age (35 yrs or more) we can suspect Tennis
Elbow (lateral epicondylitis) who has great deal with wrist
flexion- extension in occupation or activities.
2. Mechanism of Injury
- Fall on out-stretched hand (FOOSH) or fall on tip of elbow
- Catching oneself from falling or repetitive stress in sports
can create valgus stress on elbow joint causing medial side
traction injury and lateral side compression injury leading to
Radiohumeral joint injury
- An abnormal stress at medial epicondyle due to repetitive
stress from throwing causes little leagure’s elbow
- also causes osteochondral damage either on olecranon
process or on olecranon fossa
• A “pop” while throwing or doing any other activities followed by
pain and swelling on medial side of elbow may indicate Ulnar
Ligament sprain
• And a “pop” in the center followed by weakness of elbow flexion
may indicate biceps rupture

3. How long patient had the pain? Does condition come and go?
What are aggravating activities?
- Indicate seriousness of disease and
- how much it bothers patients
4. Details of present pain and other symptoms
• Site and boundaries of pain
• Whether the pain is radiating
• Does it ache?
• Worsens at night?
• If referred from cervical?
• Consider multiple joint diseases (e.g., RA, OA) if pain is in several
joints

5. Activities that increase or decrease the pain. Does pulling, twisting or

pressing alter the pain?
6. Relieving factors
- Usually patient holds the elbow to the side and wrist supported in
acute conditions

7. Any deformitiy, bruising, wasting or spasm.

8. Any movements impaired?

- If flexion-extension restricted joints involved are: Ulnohumeral
Radiohumeral
- If supination/pronation restricted : any one of five joints
radio humeral joint
Superior, middle, inferior radio-ulnar joints
ulnomeniscocarpal joint

9. Functional inability
- Dominancy
- Able to position properly?
- Any trick movements occurring in upper limb?
10. What are usual or pastime activities?
- Whether it affects the joint
- Any of these has altered in past month?

11. Any abnormal nerve distribution pain?

- Presence and location of tingling or numbness
- Snapping on medial side may indicate recurrent dislocation of
ulnar nerve from medial head of triceps over medial epicondyle
12. Any previous history of trauma or injury?
- Gives idea about nature of disease e.g., ulnar nerve may get
affected by tardy ulnar nerve palsy
 OBSERVATION

• Suitably undressed to expose both Elbow joints to compare.

• If H/O insidious onset – must observe full body Posture., especially
neck and shoulder areas for referral symptoms
• Carrying angle : Normal – 5 to 10 degree for male
10 to 15 degree for female
Cubital Valgus > 15 degree
Cubital Varus < 5 to 10 degree
• Gun Stock Deformity
• Joint swelling is often most evident in triangular space
• Swelling resulting from Olecrenon bursitis is more descret being more
sharply demarcated as a “goose egg” over the olecranon process
• Look for normal bony and soft tissue countours.
• Pitchers, throwers or rodeo riders have larger forearm because of
muscle of bone hypertrophy on the dominant side.
• Look for normal functional position of elbow joint i.e., 90 degree of
flexion of forearm with midprone position.
• At 90 degree of elbow flexion, olecranon process of Ulna and the
medial and lateral epicondyles of the humerus normally forms a
triangle.
• When it is in full extension the three points normally form a straight
line.
• When the triangle is no longer exists there are chances of fracture,
dislocation or degeneration which leads to loss of bone cartilage.
 EXAMINATION
Active movements :
Flexion : 140 -150 degree
Extension : 0 - 10 degree
Supination : 90 degree
Pronation : 80 - 90 degree
• Examined with patient in sitting position.
• Active movements are always examined first.
• Most painful movement would be performed last.
• Observe for structures outside the joints.
e.g., position of fingers or wrist may affect the movement due
to tight/shortened extensors of forearm
• Extension up to 10 degree is common(Always compare with other
side)
• It is the first movement lost after the elbow injury
• Loss of extension may indicate some intra-articular pathology
• Under some violent compressive force (e.g., gymnastics, weight
lifting) sometimes there are chances of posterior dislocation of
elbow.
• Terminal flexion loss is more disabling than terminal extension
• During active supination look for shoulder adduction
• During active pronation look for shoulder abduction
• Combined movements, repetitive movements or sustained
positions should be included in Active movement assessment if
patient complaints of pain in specific movement
• If movements are not performed even in the absence of pain there
are chances of tissue rupture or neurological injury
 PASSIVE MOVEMENTS
• If AROM is full overpressure can be applied gently to look for end
feel.
• Endfeels :
Elbow Flexion : tissue approximation
Elbow Extension : bone to bone
Forearm supination : tissue stretch
Forearm pronation : tissue stretch
• Note for Capsular pattern (more limitation for flexion than extension)
• Check for muscle tightness
• If tight end feel will be a muscle stretch
• Check for
- Biceps,
- Triceps,
- Long wrist extensors
- Long wrist flexors
 RESISTED ISOMETRIC MOVEMENTS

• Muscle flexion power at elbow joint is maximum at 900-1000

• 75% of maximum at 450 and 1350 elbow flexion
• Research shows that men are two times stronger than women when
performing isometrics of elbow joint
• Extension is 60% of flexion
• Pronation is 85% of supination
• Elbow flexion
• Elbow extension
• Supination
• Pronation
• Wrist flexion
• Wrist extension
Wrist flexion-extension are
Necessary as large number of
Muscles act both at elbow and
Wrist joint
• If any particular movement is painful during resisted isometric
movements differentiate the cause.
• For e.g., if resisted isometric extension is painful there are chances
of involvement of triceps or anconeus muscle
• If resisted isometric contraction is weak and pain free there may be
major injury to contractile tissues(muscle tear/rupture) or
neurological involvement (nerve injury)
 FUNCTIONAL ASSESSMENT

• Elbow joint is middle portion of integral upper limb chain.

• Allows the hand to be positioned in space,
• Stabilizes the upper extremity for power and detailed work activities,
• Provides power to the arm for lifting activities,
• Thus elbow movements allow the ADL to be performed with ease
• Hence elbow joint is often a part of functional assessment along with
shoulder and wrist joint.
SPECIAL TESTS

FOR

ELBOW JOINT
 LIGAMENTOUS VALGUS INSTABILITY TEST

Patient position: Supine or sitting or standing

Test :
- Stabilize patient’s arm(humerus) with one hand and other hand
above the patient’s wrist with forearm fully externally rotated
- An abduction or valgus force is applied at the distal forearm.
- Note for laxity, decreased mobility or altered pain
Normal : Ligament feels tensed
Positive: excessive laxity is present with soft end feel
 LIGAMENTOUS VARUS INSTABILITY TEST
Patient position: Supine or sitting or standing
Test :
- Stabilize patient’s elbow slightly flexed with one hand and other hand
above the patient’s wrist with forearm fully externally rotated
- An adduction or varus force is applied at the distal forearm.
- Note for laxity, decreased mobility or altered pain
Normal : ligament feels tensed
Positive : excessive laxity is present with soft end feel
- grade – 3 sprain indicates posterolateral instability