Examination of the elbow
For the initial medical examination no specific equipment is required. The patient’s part of the body of interest should be uncovered and all other parts of the body should be gowned prior to medical examination. Some critical elements of the investigation such as testing for limb movement may not be applicable if a bone fracture is suspected.
For any musculoskeletal pathology it is essential to have a thorough understanding of the anatomy, as the examination will assess differences to normal anatomical structures and functions. It is necessary to acquire information on preexisting conditions or trauma, including the mechanisms of injury, changes in motility and function, swelling and treatments received. The patient will also provide a clear description of current symptoms.
Important landmarks of the elbow
The landmarks represent a guide to the doctor in the examination of the specific region of the body that may be compromised by injury or degenerative conditions. The main points of reference are the edges of bones that are easily identifiable with palpation. At the elbow they are:
The olecranon is the bony extremity of the elbow protruding in both a relaxed or flexed position. It is most vulnerable to injury due to falls.
Medial and lateral epicondyle
The two epicondyles of the humerus are located at either side of the elbow. They are important landmarks to assess the existence of any conditions that affect the muscles and tendons of the elbow and forearm (e.g. tennis elbow for the lateral, and golfer’s elbow for the medial epicondyle) including alterations in the range of movement of the elbow joint.
The hallmarks of any musculoskeletal pathology are pain, redness (erythema), swelling, increased warmth, deformity, neurological symptoms and loss of function. The doctor will commence with a visual observation of the affected area, which will be compared to the contralateral, unaffected side. This will identify the presence of scars, rashes, lesions, asymmetry, deformity and atrophy that will assist in the formation of a diagnosis.
Palpation of specific areas of the upper extremities aims to reproduce symptoms if a peripheral nerve entrapment is suspected. A positive diagnosis leads to increased pain and specific neurological symptoms as compared to the healthy arm.
With the patient in a sitting position the shoulder is moved in a 90 degrees abduction with extension or flexion of the elbow. Palpation is conducted medially to the bicep (mid humeral) at inner elbow and distally at the wrist.
For assessing the radial nerve, the palpation is performed proximal to the lateral epicondyle (on the posterior side of the elbow), or on the distal radius (wrist) and snuffbox (the natural cavity formed at the radial aspect of the wrist when the thumb is extended).
The elbow is flexed and rotated outwards. The ulnar nerve is gently pressed above the lateral epicondyle along the cubital tunnel of the elbow.
Range of movement
The patient is asked to actively move each joint to determine any changes in function, presence of instability and level of pain. It is also critical to monitor the same movements of the non injured region of the body to obtain an overall functional status of the patient. If abnormalities are present, the patient is subjected to a range of passive activities to assess increased or impaired range of movements. Subsequently, specific instability tests may be performed.
Flexion - Extension
The movements of the elbow joint are constrained to extension and flexion only. Active flexion is limited to 140°. Passive flexion (forearm is bent against the upper arm with flexors relaxed) can reach 160°. Passive flexion is limited by tension in the posterior capsular ligament and triceps brachii.
Pronation - supination
Supination/Pronation is a forearm function, consisting in the rotation of the hand either palm up or down. With supination the ulna and radius are parallel, with pronation they cross one another.
The patient abducts the arm to 90º at shoulder level and then flexes in the elbow with the hand reaching towards the back of the head. This movement is impaired with subacromial bursitis, rotator cuff pathology and frozen shoulder.
Special tests are carried out to confirm nerve irritation of the spine.
Passive neck flexion
With the patient supine, the examiner places the hands on the posterior side of the head over the occiput. Next, the head is passively flexed anteriorly with the chin reaching the chest. A positive result is reproduction of neurological symptoms to the lower extremities.
Vertebral artery test
The patient is in a supine position and the head gently pulled and twisted to each side. If blurred vision, dizziness, slurred speech, level of consciousness (LOC) appear it may indicate a partial or complete obstruction of the vertebral artery.
Spurling test - Foraminal compression
With the patient in a sitting position, the examiner exercises pressure with both hands on the patient’s head pushing downwards and flexing and the head laterally.
If pain arises on the flexed side it may indicate pressure on cervical nerve roots caused by osteoarthritis, osteoporosis, spinal stenosis or instability of the cervical spine. If the vertebral artery test is also positive it suggests damage to the vessel.
Neck distraction test - Manual traction test
With the patient lying on a supine position, the examiner places one hand under the patient’s chin and the other on the occiput. The head is gently lifted and an axial traction force is gradually applied up to 30 pounds. The test is positive if the pain is relieved or decreased when the head is lifted or distracted, indicating pressure on nerve roots.
Shoulder abduction test
The patient places the hand of the affected extremity on the head to support the arm in the scapular plane. A positive response is alleviation of patient symptoms that are associated with the relief of a sensory sign (also named Bakody’s sign) possibly due to a disc protrusion, impinging on the nerve or the nerve root. When positive, this test is also combined with motor weakness, radicular paraesthesia, lateral extradural lesions and a good response to surgical treatment.
When the patient has difficulties in swallowing (dysphagia), this could be due to the obstruction of the cervical spine caused by subluxation, osteophyte protrusion, soft tissue swelling, tumors of the anterior spine or a pathology of the esophagus (i.e. herniation of the mucous membrane). Lateral views of the cervical spine demonstrated approximately 25% anterolisthesis in a bilateral facet subluxation. There is a narrowing of the central canal secondary to the anterolisthesis.
Tinel’s sign - Brachial plexus test
This test determines the status of the brachial plexus, which is a group of nerves exiting the vertebrae from C4 to T1 innervating the shoulder and the arm. The patient is sitting with the head slightly bent to the side. The examiner taps the brachial plexus of the same side along the nerves from the neck to the shoulder. A positive sign shows a tingling sensation on the nerve fibres, indicating a pathology of the brachial plexus.
Mechanisms of “burners.”
(A) Traction to the brachial plexus from ipsilateral shoulder depression and contralateral lateral neck flexion.
(B) Direct blow to the supraclavicular fossa at Erb's point
(C) Compression of the cervical roots or brachial plexus from ipsilateral lateral flexion and hyperextension.
Brachial plexus stretch test
Pathologies of the brachial plexus produce a feeling of electric shock, numbness or burning sensation at the neck radiating to the arm. (In most severe cases when the nerves are severed the movement of the shoulder, arm and fingers may be impaired). For the stretch test, the patient is seated and the examiner places one hand on the shoulder and the other onto the head and stretches the brachial plexus by flexing the patient’s head. By stretching the neck to the right the pain radiating to the left shoulder indicates a pathology of the plexus. Conversely, a pain sensation radiating on the opposite right shoulder, is indicative of possible impingement of the nerve roots.
The patient holds both arms at shoulder level and bent at the elbows. The hands are opened and closed to a fist. The test is positive if the patient is unable to maintain the position, shows reduced hand function, or loss of sensation in the upper extremities? This may indicate a thoracic outlet syndrome (disorders caused by compression to vessels or nerves between collarbone and first rib (thoracic outlet). This causes pain in shoulders and neck and finger numbness.
Straight leg raise
Straight leg raise (SLR) is used to determine the irritation of the lumbosacral nerve. While lying on the back, passively flex the straight leg from the hip up to 90 degrees. Pain should be felt at an angle between 30º and 70º and disappear when lowering the leg at 10º. If positive, this test demonstrates a possible herniated disk and irritation of the sciatic nerve.
Test for lumbosacral nerve root irritation. Patient is supine, and the physician passively elevates each of the patient's legs in turn, keeping the knee extended, and flexing at the hip to an angle of 90º.
This test is used for lumbosacral nerve root irritation and to discriminate between a nerve or muscle origin of lower back pain. The patient is supine, and the examiner lowers the patient's leg about an inch from the position in which pain was elicited. While holding the leg elevated, the patient's foot is passively dorsiflexed. If pain is increased, a nerve aetiology is likely at L4, L5, or S1 levels; conversely a muscle aetiology is likely if no pain arises.
Variations of straight leg raise test:
Once reached the leg elevation causing the pain, flex the knee. If no pain is felt with straight leg raise, flex the cervical spine to the chest and repeat the test. Pain should be relieved by flexing the knee (Kerning) or aggravated by flexing the neck (Brudinski). Used for herniated disk and dural sheath irritation.
Well straight leg raising test
The patient straightens and raises the opposite leg to the one causing pain. If pain is felt on the leg lying low, it may indicate a herniated disk.
Seated at table edge, bend forward, flex the neck, extend one knee and dorsiflex the foot. If sciatic pain occurs it indicates a problem to the sciatic nerve.
Tension sign/Bowstring test
Passive straight leg rise until pain is felt, flex the knee to release symptoms, apply pressure to the popliteal fossa (depression behind the knee joint). If pain returns it means sciatic nerve issues.
This test is used to determine if patient is malingering. The examiner cups the calcaneus of each leg with his/her hands. When the patient raises the leg straight, the examiner should feel pressure on calcaneus remaining onto the bed, which is used as leverage for the opposite, elevating leg. If no pressure is felt, the patient is simulating the spine problem.
Femoral nerve stretch test
Lying on the side, passively extend the leg at the hip with the knee bent at 90º. If pain, numbness or tingling is felt at the anterior/lateral thigh, it shows femoral nerve root impingement.
Stork/Single stance test
While balancing on leg, arch the spine backwards. If pain occurs, it indicates spondylolysis or spondylolisthesis.
A blunt object is run along the lateral side of the inner foot from the heel to the big toe (fanning of toes). The test is positive if the big toe extends and the other toes abduct. This is a plantar reflex and may indicate brain or spinal cord trau
The examiner runs fingernails gently along the crest of the patient’s calf bone (tibia). If the big toe extends and the other toes abduct, and plantar reflex it can indicate brain or spinal cord trauma.
The patient holds a deep breath and blows into the closed fist by strongly contracting the abdominal muscles. If spinal pain increases it may indicate a herniated disk.
The patient is asked to lift the feet of 2-6 inches off the bed for 30 seconds. If the patient is unable to lift, hold the legs or feels spinal pain, it may indicate herniated disk and impinged lumbar nerve.
The modified Phalen's test, or wrist flexion test is mostly used to diagnose the symptoms of a carpal tunnel syndrome caused by increased pressure on the median nerve. The examiner flexes the patient’s wrists maximally and holds this position for one minute by pushing firmly the hand. Tingling into the thumb, index finger, the middle and lateral half of the ring finger indicates a positive test. The original test was described as pushing both flexed wrists together.
Tinel’s sign (Ulnar nerve - elbow)
This test is used to examine the ulnar nerve (at the elbow). The examiner taps the area of the ulnar nerve in the groove between the olecranon process and medial epicondyle. A positive sign is indicated by a tingling sensation in the ulnar distribution of the forearm and hand distal to the point of compression. The most distant point, at which the abnormal sensation is felt, represents the limit of nerve regeneration.
Tinel’s sign (Median nerve - wrist)
The examiner taps the area of the medial nerve over the wrist and a positive sign is indicated by a tingling sensation in the medial nerve distribution of the palm of the hand. The most distant point at which the abnormal sensation is felt, represents the limit of nerve regeneration.
There are four types of vascular examination:
Pulses of the upper extremity
An absent or weak pulse may affect the entire or one part of the body. It is measured in areas were an artery passes close to the skin such as the wrist.
To measure the pulse of the radial artery the examiner places the index and middle finger over the underside of the wrist, proximal to the base of the thumb. Once the pulse is felt, the number of beats is counted for one full minute.
Two areas of the wrist are chosen for this examination:
1. Pulse of the radial artery over the distal end of the radius on the palmar side (see picture)
2. Pulse of ulnar artery over the palmar side of the distal ulna.
Capillary refill is a test performed to assess the rate at which blood refills empty capillaries. Normally it should take less than three seconds. The examiner applies pressure to the finger until it turns white, indicating that blood has been forced out from the tip of the finger. Iftimerequired to return to colour following the pressure release exceeds three seconds it indicates poor peripheral perfusion and dehydration.
Oedema - cyanosis - clubbing
Oedema is caused by fluid building up in the body's tissue and usually occurs in the feet, ankles and legs but can also be observed in the upper extremities. Cyanosis refers to a low oxygen level in blood. It is a condition in which fingers, toes and lips appear blue. Clubbing results from chronic low levels of blood oxygen. The ends of the finger appear enlarged and the nails adopt a shape curved downwards.
The lymphatic system is a network of tissues and organs, which play a very important role in the immune system by clearing away infection and keeping your body fluids in balance. If the lymphatic system is impaired, fluid will build in the tissues, causing swelling or lymphoedema.
The Allen’s test is used to determine changes in arterial blood flow to the hand. The examiner applies pressure on the wrist to occlude both the radial and ulnar arteries. When the patient opens the hand, it will appear pale due to the lack of blood flow. Then the examiner releases only one artery (ulnar artery) ad if the colour at the finger tips returns within 7 seconds, it indicates that the opposite, radial artery is intact and supplies sufficient blood. This test is often carried out prior to radial artery canulisation for medical treatment.