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16 Clinical examination of the elbow

CHAPTER CONTENTS

Referred pain 277

Pain referred to the elbow. . . . . . . . . . . . . . 277Pain referred from the elbow . . . . . . . . . . . . 277

History 277

Inspection 278

Functional examination 278

Passive movements . . . . . . . . . . . . . . . . . 278Resisted movements . . . . . . . . . . . . . . . . 279Resisted tests of the flexors and extensors of the wrist . . . . . . . . . . . . . . . . . . . . . . . 279

Palpation 280

Accessory tests 281

Referred pain

One of the rules of referred pain is that the further distally the lesion lies, the more accurately the patient can localize it. It is therefore reasonable to start off with the clinical examina-tion of the elbow and, only when this seems to be negative, to check the cervical spine, the shoulder girdle and the shoulder.

Pain referred to the elbow

Pain referred to the elbow from structures that lie higher up the limb is one possibility. The localization of the pain indicates the segment in which the lesion lies: the lateral aspect of the elbow is formed by the C5 dermatome, the anterior aspect by C6, the inner aspect by T1–T2 and poste-riorly by C7.

Pain referred from the elbow

Pain referred from the elbow is uncommon. A lesion at the origin of the extensor carpi radialis brevis may give rise to pain radiating down the posterior aspect of the forearm to the hand as far as the third and fourth fingers. A lesion at the distal bicipital insertion radiates down the proximal and palmar aspect of the forearm. Proximal reference of elbow pain is very rare.

History

The history is not very important in elbow problems but some questions should be asked.

• Where is the pain? The location of the pain is usually closely related to the site of the lesion. When the patient indicates exactly where the symptoms are felt, all causes that cannot produce pain in that area are automatically excluded.

• How did it all start? Did the symptoms start spontaneously or has there been any trauma; if so, what type? If the onset was spontaneous, did it begin suddenly or gradually, or as the result of a particular activity?

• What was the evolution? Was there any change in the location, intensity or frequency of the painful episodes? Did the pain spread and, if so, where to? This may indicate the dermatome and, in consequence, the segment in which the lesion must be sought.

• Is there any functional loss?• Has the elbow ever been swollen? If the swelling came on

after trauma, how soon did it appear? Immediate general effusion is probably the result of a haemarthrosis; gradually increasing swelling usually indicates the presence of synovial fluid. Spontaneous swelling may be the result of an impacted loose body or a rheumatoid condition.

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tendinitis) may give rise to more localized swelling. There may also be redness of the skin or muscular atrophy.

Functional examination

The examination consists of 10 tests: four passive movements and six resisted movements.

Passive movements

The passive movements (Fig. 16.1) are used to examine the inert structures: the joint, the capsule, the capsular ligaments and the bursae. It is also clear that, by passively testing the elbow, one also indirectly stretches or pinches muscular and tendinous structures.

The range of movement is ascertained and the end-feel noted.

Localized swelling may occur in bursitis or in some exceptional cases of tennis elbow.

• What influences the pain? Is the pain constantly present, or does it come on during or after either general or specific activity? In an arthrotic or arthritic joint the maintenance of a particular posture at the extreme of the possible range may become very painful. Release from this position is usually very uncomfortable. ‘Twinges’ when picking up objects (e.g. a telephone or a coffee pot) with an outstretched elbow is a well-known symptom in tennis elbow.

• Are any other joints involved? In rheumatoid-type conditions other joints may be affected.

Inspection

Inspection may reveal diffuse or local swelling: arthritis causes a more generalized effusion, whereas other lesions (bursitis and

Fig 16.1 • Passive movements: (a) flexion, (b) extension, (c) pronation, (d) supination.

(a) (b)

(c) (d)

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Resisted movements

The same four movements are repeated but against isometric resistance to examine the contractile structures (Fig. 16.2).

Resisted flexionThe patient holds the forearm in supination. The examiner puts the contralateral hand on top of the patient’s shoulder to prevent it from moving upwards during the contraction. The other hand is placed on the distal forearm with the examiner’s forearm held vertically, to prevent the patient’s forearm from moving as the flexor muscles are contracted (Fig. 16.2a).

The muscles thus tested are the brachial biceps, the brachia-lis and the brachioradialis. The brachialis is a strong flexor and the brachioradialis is clinically unimportant.

Resisted extensionAgain the contralateral hand is placed on top of the patient’s shoulder. The other one is placed vertically under the patient’s forearm and prevents the arm from moving downwards (Fig. 16.2b). If necessary, in a very strong patient, the examiner’s own elbow may be supported on the thigh.

The muscles that are tested with this movement are the triceps and, secondarily, the anconeus muscle.

Pain at the shoulder during this movement has the same applications as painful arc (see online chapter Disorders associ-ated with a painful arc).

Resisted pronationThe patient’s forearm is held in the neutral position between pronation and supination. In order to prevent any movement during the resisted movement, the examiner’s hands should be placed as follows: the ipsilateral hand, held in supination, is placed under the patient’s distal forearm; the contralateral hand, held in pronation, is placed on top. The patient is asked to perform a pronation movement and resistance is supplied by the heels of both hands (Fig. 16.2c).

This movement mainly tests the pronator teres muscle but will also be painful in the presence of golfer’s elbow.

Resisted supinationThe hands are placed in a slightly different position from the previous test so that there is resistance against the palmar aspect of the distal ulna and the dorsal aspect of the distal radius (Fig. 16.2d).

In this test, the brachial biceps is tested with respect to its secondary function, and also the supinator brevis muscle.

Resisted tests of the flexors and extensors of the wrist

There are two muscle groups – the flexors and extensors of the wrist – that control wrist movements but lie at the elbow and therefore can give rise to symptoms around this joint. They should be systematically tested in the elbow examination.

The four passive tests give the examiner an idea of the behaviour of the inert structures around the elbow. The pattern that is formed suggests a lesion of either the capsular type – arthritis, in the joint between forearm and humerus or in the upper radioulnar joint – or the non-capsular type.

Passive flexionThe examiner places the contralateral hand at the dorsal aspect of the patient’s shoulder to prevent the body from trying to move backwards in order to escape from the pain. The ipsilat-eral hand takes hold of the patient’s forearm just proximally to the wrist and moves the joint as far into flexion as possible (Fig. 16.1a).

The normal end-feel is one of tissue approximation as the muscles of the forearm come in contact with the brachial muscles at an angle of about 160°.

Passive extensionWith the contralateral hand, the examiner takes hold of the patient’s upper arm at the level of the olecranon. The ipsilat-eral hand is put at the distal end of the patient’s forearm. Both hands move in opposite directions so as to extend the elbow (Fig. 16.1b).

The normal end-feel in passive extension is hard and bony, caused by the olecranon coming into contact with the posterior aspect of the humerus, and by tightening of the anterior capsule of the joint. As the forearm now lies in line with the upper arm, the angle of extension is 0°. In instances of over-extension, the angle may become 5–10°.

Passive pronationThe elbow is bent to a right angle. The examiner stands in front of the patient and grasps the distal forearm just proximal to the wrist with both hands. The heel of the contralateral hand is placed at the palmar aspect of the ulna, the fingers of the other hand at the dorsal aspect of the radius. A simultaneous movement of both hands presses the wrist into full pronation (Fig. 16.1c).

The extreme of movement is characterized by an elastic, capsular end-feel as the 85° range is approached. Together with passive supination, this movement tests the integrity of the upper radioulnar joint. Pain at the end of the range may also be a localizing sign in tendinitis of the insertion of the bicipital tendon on to the radial tuberosity, because of pinching of the tendon between the radial tuberosity and the ulna.

Passive supinationThe position of the examiner’s hands is slightly changed: the heel of the ipsilateral hand applies pressure at the dorsal aspect of the ulna and the fingers of the other hand pull at the palmar aspect of the radius. The forearm is twisted into supination as far as it goes (Fig. 16.1d).

Normally the capsular end-feel is noted at about 90°.

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Resisted extension of the wristThe patient remains in the same position as in the previous test. The examiner puts the hand on top of the patient’s hand to resist an attempt to execute an extension movement (Fig. 16.3b).

The muscles tested are the extensors of wrist and fingers: extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor indicis proprius, extensor digitorum communis and extensor digiti minimi.

Palpation

After the clinical examination (and only if it is likely to supply more information), the elbow is palpated.

The patient’s elbow is held in extension, so as to put maximum stress on these structures (Fig. 16.3).

Resisted flexion of the wristThe patient’s hand is held palm downwards. The examiner passes the contralateral arm under that of the patient and grasps the forearm just proximally to the wrist in order to fix the upper limb. The upper arm lies under the patient’s elbow and holds it in full extension. The hand of the other arm is now brought into the palm of the patient’s hand and resists the patient’s attempt to flex the wrist (Fig. 16.3a).

The following muscles are tested: flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus.

Fig 16.2 • Resisted movements: (a) flexion, (b) extension, (c) pronation, (d) supination.

(a) (b)

(c) (d)

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of the wrist is now executed, as already described (Fig. 16.4).

Resisted radial and ulnar deviationWith the elbow in extension and the wrist in the neutral posi-tion between flexion and extension, radial and ulnar deviation are tested against resistance (Fig. 16.5). These tests differenti-ate between a lesion of the radial extensors or flexors of the wrist or of the ulnar extensors or flexors.

Resisted extension and flexion of the fingersWhen a lesion of the finger extensors has been diagnosed, the examiner may test resisted extension of each finger in turn (Fig. 16.6a) to find out which tendon is at fault.

If a finger flexor is affected, resisted flexion of each finger (Fig. 16.6b) may disclose the exact tendon.

Resisted supination in extensionIn order to differentiate between lesions of the brachial biceps and the supinator brevis muscle, this test should be performed. When the arm is brought into extension, the action of the biceps is diminished considerably but the supinator contracts normally.

The elbow joint can be palpated either at rest or during movement, in order to detect warmth, swelling, synovial thick-ening (palpation laterally over the head of the radius), crepitus or clicking. The muscle or tendon at fault is palpated to define the exact site of the lesion.

Accessory tests

Resisted extension of the wrist with the fingers actively flexedThe patient is asked to flex the fingers actively by pressing the fingertips into the palm of the hand. Resisted extension

Fig 16.3 • Resisted movements: (a) flexion and (b) extension of the wrist.

(a)

(b)

Fig 16.4 • Accessory test: resisted extension of the wrist with the fingers actively flexed.

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Fig 16.5 • Accessory tests: resisted (a) radial and (b) ulnar deviation.

(a) (b)

Fig 16.6 • Accessory tests: resisted (a) extension and (b) flexion of the fingers.

(a) (b)

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Fig 16.7 • Accessory test: Tinel’s sign.

Box 16.1

Summary of clinical examination1. History2. Inspection3. Functional examinationPassive tests

• Flexion• Extension• Pronation• Supination

Resisted tests• Flexion• Extension• Pronation• Supination• Flexion wrist• Extension wrist

4. Palpation5. Accessory tests

Tinel’s signPercussion to the ulnar nerve in the groove between the ole-cranon and the medial epicondyle (Fig. 16.7) gives rise to distal paraesthesia in the territory of the ulnar nerve – in the forearm

and the hand – Tinel’s sign. This test can be used to assess the progress of regeneration of the sensory fibres of the nerve. The most distal point where the pins and needles are felt indicates the limit of regeneration.

The clinical examination is summarized in Box 16.1.