Elbow Examination

Introduction

Reliability and Utility of Examination of the Elbow

A search of MEDLINE 1966-1998 using the MESH terms “diagnosis” and “elbow” failed to detect any studies concerning the characteristics of any clinical examination features around the elbow. Therefore, any recommendations that might be offered concerning examination of the elbow are based on tradition and concept validity.

Inspection

In contrast to the examination of deep axial structures such as the spine, the inspection of a superficial joint like the elbow is likely to be highly rewarding. It should be systematic, carefully addressing each of the structures and tissues around every aspect of the joint, for shape and contour. The key findings at issue are the presence of any fixed or reducible deformities, any bony, articular or olecranon bursal swelling and any signs of inflammation. The features of complex regional pain syndrome type 1, such as oedema, excessive or impaired sweating , skin discolouration and trophic skin changes can also be readily determined on simple inspection.

Palpation

Other than further evaluating any observed swelling, the true value of palpation is in determining the site of any tenderness around the elbow. This should be undertaken systematically, carefully addressing each of the structures and tissues around the joint. Any tenderness should be defined in terms of its anatomical location in relation to the joint – lateral, medial, anterior, posterior, and in terms of the structure or tissue involved, if possible – bony tenderness, joint margin, ligament, tendon, or skin.

However, in this context it should be recognised that when several structures overlie one another tenderness evoked by pressing over a region cannot be validly ascribed to any one of these structures. Under those circumstances, the most honest description of the tenderness is on in terms of its general anatomical location. For tenderness to be ascribed selectively to a particular tendon or like structure, that structure should be palpable from at least three directions, such that it is tender not only upon pressing the structure but also upon selectively squeezing it. Only in this manner can it be shown that the tenderness is not located in an underlying or overlying structure.

Range of movement

The range of movement in the elbow is readily determined. However, no explicit data have been published on the diagnostic value of such assessments. It is generally accepted that patients with medial or lateral epicondylitis will have no significant restriction on flexion or extension of the elbow1, but may have pain with the combination of pronation, wrist flexion and elbow extension (Mill’s manoeuvre)2.

Other Manoeuvres

The extensor carpi radialis brevis tendon (ECRB) inserts into the proximal part of the dorsum of the third metacarpal.3. It has been suggested that lateral epicondylar pain reproduced by wrist extension resisted by pressure over the distal third metacarpal is specific for pain arising from the origin of ECRB4. No data has been advanced to support or refute this viewpoint.

In challenging restraints on the ulnar side of the elbow recommendations have been to test with the elbow at 30o of flexion, with examination for the end feel of the ligament.5. Again, no data have been found to verify that this is a reliable or valid test.

References

1. Geoffroy P, Yaffe MJ, Rohan I. Diagnosing and treating lateral epicondylitis. Can Fam Physician 1994; 40:73-78. 2. Sölveborn SA. Radial Epicondylalgia ('tennis elbow') treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements. Scand J Med Sci Sports 1997; 7:229-237. 3. Briggs CA, Elliott BG. Lateral epicondylitis. A review of structures associated with tennis elbow. Anat Clin 1985; 7:149-153. 4. Wadsworth TG. Tennis elbow: conservative, surgical and manipulative management. BMJ 1987; 294:621-624. 5. Field LD, Altchek DW. Elbow injuries. Clin Sports Med. 1995; 14:59-78.