Elbow Joint Assessment

Dr. Izza Ayub; PT

Joints
• The elbow complex includes
1. Humeroulnar Joint
2. Humeroradial Joint
3. Proximal Radioulnar Joint.
• Because they are closely related,
the joints of the elbow complex
make up a compound synovial
joint with injury to any one part
affecting the other components as
well.
• The elbow is largely derived from
C6 and C7.

The Annular Ligament stabilizes
the radial head within the radial
notch of the ulna as it rotates during
supination and pronation of the
forearm
Medial collateral ligament:
Located on the inside of the
elbow this ligament connects the
ulna to the humerus.
Lateral collateral ligament
Located on the outside of the elbow this
ligament connects the radius to the humerus
Quadrate ligament
This ligament also connects the radius
to the ulna.
Bursae
Carrying Angle
• The carrying angle is defined as the acute angle made by the
median axis of arm and median axis of forearm in full
extension and supination. This angle permits the forearms to
clear the hips in swinging movements during walking and is
important when carrying.
Gun stock Deformity
EVALUATION OF ELBOW
History
• Activities with vigorous or repetitive use of the arm?
• Except for the inflammatory arthritis, most elbow
conditions are traumatic or degenerative conditions
• Are any other joints involved?
• Rheumatoid arthritis is one of the few remaining causes
of elbow pain of local origin.
Physical Examination
I. Observation
• Carrying angle
• Functional use of arm
II. Inspection (include the entire extremity)
A. Structure. Relaxed standing position.
1. Shoulder height
2. Elbow carrying angle
3. Elbow flexion–extension angle
4. Positions of medial and lateral epicondyles, radial head, and
olecranon
• B. Soft tissue
1. Muscle form. Muscle bulk and muscle tone, comparing left
and right sides. Observe for any evidence of atrophy and
measure the girth of the arm or forearm.
2. Swelling
a. Marked posterior swelling is usually bursal swelling.
b. Articular effusion is often visible in triangular area…joint
held in 70 degree flexion
3. General contours
• C: Skin
Joint Tests
• A. Joint integrity tests
• Observe the relative position of the olecranon and the
medial and lateral epicondyles. They should form a
straight line with the elbow in extension and an isosceles
triangle with the elbow in 90° flexion
Joint and ligamentous tests
Valgus stress
• To test the integrity of the ulnar collateral ligament
• Examiner applies a valgus stress to the elbow with
the arm slightly flexed (slightly out of the close
packed position), thus attenuating the anterior
bundle .
• The test is repeated with the forearm flexed to 90°,
to stress the transverse bundle, and
• Fully flexed, to stress the posterior bundle.
Varus stress
• To test the integrity of the radial collateral ligament .
• Apply a varus stress to the elbow with the arm
slightly flexed (slightly out of the close-packed
position), thus stressing the anterior band of the
radial collateral ligament.
• The test is repeated with the forearm flexed to 90°, to
stress the medial band,
• Fully flexed, to stress the posterior band.
• Excessive movement or reproduction of the client’s
symptoms is a positive test and is indicative of elbow
joint instability.
Anterior Capsule Test.
Hyperextension Test
• Elbow extension beyond 0° is considered hyperextension.
• Reason can be torn or stretched anterior capsule of the elbow.
• The examiner grasps the distal humerus at the medial and lateral
condyle with one hand, while the other hand grasps the distal
forearm and passively extends the elbow until no further motion is
available.
• B. Active physiologic movement (sitting)
• C. Passive movements (supine for optimal
stabilization)
• Elbow flexion–extension
• Elbow pronation–supination
• Common pathological
End-feel =springy block,
suggesting a loose body,
and muscle guarding,
suggesting an acute
inflammation.
• Other joints.
• Cervical spine, shoulder,
and wrist
 Muscle Tests
• A. Resisted isometric movements

A: Eblow
Extension
B: Elbow
Flexion
C: Forearm
Supination
D: Forearm
Pronation
E: Wrist
Flexion
F: Wrist
Extension
Muscle Length
Muscle Strength
• Grip strength (median nerve),
• Thumb abduction strength (interosseous nerve),
• Intrinsic muscle strength (ulnar nerve)
Special Tests and common
Pathologies
Tests for Ligamentous Instability
• Ligamentous Valgus Instability Test.
• Ligamentous Varus Instability Test.
• +ve findings = excessive laxity , soft end feel
Moving Valgus Stress Test
• The patient lies supine or stands
with the arm abducted and
elbow flexed fully.
• While maintaining a valgus
stress, the examiner quickly
extends the patient’s elbow.
• Reproduction of the patient’s
pain between 120° to 70°
indicates a positive test and a
partial tear of the medial
collateral ligament
Milking Manoeuver
• Pt sitting
• Forearm supinated
• Elbow flexed to 90 degree
• Examiner grasp pt’s thumb
and pulls it imparting a
valgus stress to the elbow.
• Reproduction of symptoms
indicates a positive test
and a partial tear of the
medial collateral ligament.
Stand Up Test
• The patient is seated in a chair
without arms.
• The patient is asked to push up
on the seat with his or her hands
with the forearms fully
supinated into standing.
• If the patient’s symptoms are
reproduced, the test is positive
for injury to the posterior band
of the medial collateral ligament
Tests for Epicondylitis
• Lateral Epicondylitis (Tennis Elbow or Cozen’s) Test
(Method 1).
• The patient’s elbow is stabilized by the examiner’s thumb, which
rests on the patient’s lateral epicondyle.
• The patient is then asked to actively make a fist, pronate the
forearm, and radially deviate and extend the wrist while the
examiner resists the motion.
• A sudden severe pain in the area of the lateral epicondyle of the
humerus is a positive sign.
Lateral Epicondylitis (Tennis Elbow or
Mill’s) Test (Method 2).
• While palpating the lateral epicondyle, the examiner
passively pronates the patient’s forearm, flexes the wrist fully, and
extends the elbow.
• Pain over the lateral epicondyle of the humerus indicates a positive
test.
• This maneuver also puts stress on the radial nerve and, in the
presence of compression of the radial nerve, causes symptoms
similar to those of tennis elbow.
• Electrodiagnostic studies help differentiate the two conditions.
Medial Epicondylitis
(Golfer’s Elbow) Test.
• While the examiner palpates the patient’s medial
epicondyle, the patient’s forearm is passively supinated
and the examiner extends the elbow and wrist.
• A positive sign is indicated by pain over the medial
epicondyle of the humerus.
Tests for Joint Dysfunction
• To differentiate between the radiohumeral and ulnohumeral joints
• To test the radiohumeral joint , the examiner positions the
elbow joint at the position of pain and then radially deviates the
wrist to compress the radial head against the humerus. The
production of pain would be considered a positive test.
• To test the ulnohumeral joint , the examiner again positions the
elbow joint at the position of discomfort and causes compression of
the ulnohumeral joint by ulnar deviation at the wrist. Again, pain
indicates a positive test.
Tests for Neurological Dysfunction
• Elbow Flexion Test:
• The patient is asked to fully flex the elbow with wrist extension and
shoulder abduction and depression and to hold this position for 3-5
minutes.
• Tingling and paresthesia in ulnar nerve distribution indicate
positive test.
Pinch Grip Test.
• For pathology to the
anterior interosseous
nerve (median nerve).
• This finding may indicate
an entrapment of the
anterior interosseous
nerve as it passes between
the two heads of the
pronator teres muscle.
Tinel Sign (at the Elbow)
• The area of the ulnar nerve in
the groove (between the
olecranon process and medial
epicondyle) is tapped.
• A positive sign is indicated by
a tingling sensation in the
ulnar distribution of the
forearm and hand distal to the
point of compression of the
nerve.
Wartenberg Sign
• The patient sits with his or her hands resting on
the table.
• The examiner passively spreads the fingers apart
and asks the patient to bring them together
again.
• Inability to squeeze the little finger to the
remainder of the hand indicates a positive test
for ulnar neuropathy.