Elbow Examination

Commonly Tested

The elbow examination tests your understanding of both osseous and ligamentous anatomy. Examiners commonly present patients with lateral epicondylitis, cubital tunnel syndrome, or post-traumatic stiffness.

Exam day cheat sheet

Elbow Examination Summary

Look

Carrying angle (valgus 10-15°)
Swelling (olecranon bursa, joint effusion)
Scars, rheumatoid nodules
Muscle wasting (forearm)

Feel

Lateral epicondyle and common extensor origin
Medial epicondyle and common flexor origin
Olecranon and triceps insertion
Radial head (rotate forearm)
Ulnar nerve in cubital tunnel

Move

Flexion 0-145°
Extension 0° (hyperextension up to 10°)
Pronation 0-80°
Supination 0-80°

Special Tests

Lateral epicondylitis: Cozen's, Mill's
Medial epicondylitis: Golfer's elbow test
Instability: Valgus/varus stress
PLRI: Pivot shift, posterolateral drawer

Introduction and Setup

Before You Start

Patient Positioning: Standing or seated, both arms exposed from shoulder to hand

Exposure: Both upper limbs fully exposed, compare sides

Consent Script: "I'm going to examine your elbows. I'll look at both sides, feel around the joint, and test the movements. Please tell me if anything is painful."

Key Anatomy:

Elbow is a complex joint: humeroulnar (hinge), humeroradial, and proximal radioulnar (rotation)
Carrying angle: Normal 10-15° valgus (greater in females)

Look (Inspection)

Carrying angle: Normal 10-15° valgus; increased in lateral condyle malunion (cubitus valgus)
Cubital fossa: Fullness suggests effusion or mass
Antecubital veins: Note any obvious vessels
Skin creases: Assess flexion contracture
Muscle bulk: Compare biceps, brachialis, forearm flexors

Key Concept

Effusion Triangle: The soft tissue between the lateral epicondyle, radial head, and olecranon fills with effusion - look for fullness in this triangle on lateral view.

Feel (Palpation)

Systematic Palpation Sequence

Lateral Structures:

Lateral epicondyle: Tenderness = lateral epicondylitis
Common extensor origin: Just distal to epicondyle
Radial head: Rotate forearm to confirm (1cm distal to lateral epicondyle)
Lateral collateral ligament: Posterolateral corner

Medial Structures:

Medial epicondyle: Tenderness = medial epicondylitis
Common flexor origin: Just distal to medial epicondyle
Ulnar nerve: In cubital tunnel, posterior to medial epicondyle
Medial collateral ligament: Anterior band most important

Posterior Structures:

Olecranon: Bony prominence, bursa
Triceps tendon: Insertion into olecranon
Olecranon fossa: Best felt in flexion

Neurovascular:

Brachial pulse in cubital fossa
Radial pulse at wrist
Tinel's sign at cubital tunnel

Move (Range of Motion)

Flexion

normalRange: 0-145°
technique: Touch shoulder with hand
keyPoints: Limited by muscle bulk

Extension

normalRange: 0° (to -10° hyperextension)
technique: Straighten arm fully
keyPoints: Loss = flexion contracture

Pronation

normalRange: 0-80°
technique: Elbow at 90°, thumbs up, rotate palm down
keyPoints: Test at elbow not wrist

Supination

normalRange: 0-80°
technique: Elbow at 90°, thumbs up, rotate palm up
keyPoints: Keep elbow tucked to side

movement	normalRange	technique	keyPoints
Flexion	0-145°	Touch shoulder with hand	Limited by muscle bulk
Extension	0° (to -10° hyperextension)	Straighten arm fully	Loss = flexion contracture
Pronation	0-80°	Elbow at 90°, thumbs up, rotate palm down	Test at elbow not wrist
Supination	0-80°	Elbow at 90°, thumbs up, rotate palm up	Keep elbow tucked to side

Must Know

Functional Range of Motion: Most activities of daily living require 30-130° flexion and 50° pronation/supination (Morrey). Loss of terminal extension is better tolerated than loss of flexion.

Special Tests

Lateral Epicondylitis (Tennis Elbow)

Special test

Cozen's Test

Lateral epicondylitis

Technique

1Patient seated with elbow at 90° flexion
2Forearm pronated, wrist slightly extended
3Patient makes fist and extends wrist against resistance
4Stabilize elbow with other hand

Positive Sign

Pain over lateral epicondyle

Indicates

Lateral epicondylitis (ECRB tendinopathy)

Diagnostic Accuracy

Sensitivity84%

Ability to detect true positives

Specificity0%

Ability to exclude false positives

Special test

Mill's Test

Lateral epicondylitis

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Technique

1Elbow extended, forearm pronated
2Examiner passively flexes wrist while palpating lateral epicondyle

Positive Sign

Pain over lateral epicondyle on stretch

Indicates

Lateral epicondylitis

Diagnostic Accuracy

Sensitivity75%

Ability to detect true positives

Specificity50%

Ability to exclude false positives

Medial Epicondylitis (Golfer's Elbow)

Special test

Golfer's Elbow Test

Medial epicondylitis

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Technique

1Patient seated with elbow extended, forearm supinated
2Examiner resists wrist flexion while palpating medial epicondyle

Positive Sign

Pain over medial epicondyle

Indicates

Medial epicondylitis (common flexor origin tendinopathy)

Diagnostic Accuracy

Sensitivity80%

Ability to detect true positives

Specificity50%

Ability to exclude false positives

Stability Tests

Special test

Valgus Stress Test

Medial collateral ligament integrity

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Technique

1Patient seated, elbow flexed 20-30° to unlock olecranon
2Stabilize humerus with one hand
3Apply valgus stress to forearm
4Assess opening of medial joint line

Positive Sign

Increased laxity or medial joint line opening compared to other side

Indicates

MCL insufficiency (throwing athletes, trauma)

Diagnostic Accuracy

Sensitivity66%

Ability to detect true positives

Specificity75%

Ability to exclude false positives

Special test

Varus Stress Test

Lateral collateral ligament complex

Technique

1Patient seated, elbow flexed 20-30°
2Stabilize humerus
3Apply varus stress to forearm

Positive Sign

Increased laxity laterally

Indicates

Lateral collateral ligament insufficiency

Diagnostic Accuracy

Sensitivity50%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

Special test

Posterolateral Rotatory Instability (Pivot Shift)

Posterolateral rotatory instability

Technique

1Patient supine, arm overhead, elbow extended
2Apply axial compression, valgus, and supination
3Flex elbow from extension

Positive Sign

Apprehension or clunk as radial head subluxates then reduces around 40° flexion

Indicates

PLRI (LCL insufficiency, usually post-dislocation or iatrogenic)

Diagnostic Accuracy

Sensitivity38%

Ability to detect true positives

Specificity100%

Ability to exclude false positives

Nerve Tests

Special test

Tinel's Sign (Cubital Tunnel)

Ulnar nerve compression at elbow

Technique

1Elbow flexed to 90°
2Percuss over ulnar nerve in cubital tunnel (behind medial epicondyle)

Positive Sign

Tingling or electric shock sensation radiating to little and ring fingers

Indicates

Cubital tunnel syndrome (ulnar neuropathy)

Diagnostic Accuracy

Sensitivity70%

Ability to detect true positives

Specificity98%

Ability to exclude false positives

Special test

Elbow Flexion Test

Ulnar nerve compression

Technique

1Patient fully flexes both elbows, wrists in neutral
2Hold position for 60 seconds

Positive Sign

Reproduction of ulnar nerve symptoms (numbness in ulnar digits)

Indicates

Cubital tunnel syndrome

Diagnostic Accuracy

Sensitivity75%

Ability to detect true positives

Specificity99%

Ability to exclude false positives

Neurovascular Assessment

Neurological Examination

Motor Testing:

Radial (C6,7,8)

Test: Wrist/finger extension
Action: Extend wrist against resistance

Median (C6,7,8,T1)

Test: Wrist flexion, finger flexion (FDP to index)
Action: "OK" sign, FPL

Ulnar (C8,T1)

Test: Finger abduction, FDP to little finger
Action: Spread fingers, cross fingers

Nerve	Test	Action
Radial (C6,7,8)	Wrist/finger extension	Extend wrist against resistance
Median (C6,7,8,T1)	Wrist flexion, finger flexion (FDP to index)	"OK" sign, FPL
Ulnar (C8,T1)	Finger abduction, FDP to little finger	Spread fingers, cross fingers

Sensory Testing:

Radial nerve: First dorsal web space
Median nerve: Palmar tip of index finger
Ulnar nerve: Palmar tip of little finger

Reflexes:

Biceps (C5,6)
Brachioradialis (C5,6)
Triceps (C7)

Complete the Examination

Must Know

Always state to the examiner:

"To complete my examination, I would like to:

Examine the shoulder as the joint above
Examine the wrist and hand as the joint below
Complete neurological assessment of the upper limb
Examine the cervical spine for referred pain
Obtain X-rays (AP, lateral, +/- radial head view)"

Summary Presentation

Viva scenarioStandard

Presenting Your Findings

Clinical prompt

“45-year-old right-hand dominant office worker with lateral elbow pain for 3 months, worse with gripping.”

Common Conditions Table

Lateral Epicondylitis

look: Usually normal
feel: Lateral epicondyle tenderness
move: Full ROM
specialTests: Cozen's +, Mill's +

Medial Epicondylitis

look: Usually normal
feel: Medial epicondyle tenderness
move: Full ROM
specialTests: Resisted wrist flexion +

Cubital Tunnel Syndrome

look: Intrinsic wasting late
feel: Tinel's at cubital tunnel
move: Full ROM
specialTests: Elbow flexion test +, Froment's +

OA/Post-traumatic Stiffness

look: Swelling, deformity
feel: Crepitus, osteophytes
move: Limited flexion-extension arc
specialTests: Flexion contracture common

PLRI

look: May be normal
feel: Posterolateral corner tenderness
move: Apprehension
specialTests: Pivot shift +, drawer +

condition	look	feel	move	specialTests
Lateral Epicondylitis	Usually normal	Lateral epicondyle tenderness	Full ROM	Cozen's +, Mill's +
Medial Epicondylitis	Usually normal	Medial epicondyle tenderness	Full ROM	Resisted wrist flexion +
Cubital Tunnel Syndrome	Intrinsic wasting late	Tinel's at cubital tunnel	Full ROM	Elbow flexion test +, Froment's +
OA/Post-traumatic Stiffness	Swelling, deformity	Crepitus, osteophytes	Limited flexion-extension arc	Flexion contracture common
PLRI	May be normal	Posterolateral corner tenderness	Apprehension	Pivot shift +, drawer +

Examiner Tips

Exam day cheat sheet

Scoring High in the Elbow Examination

Do

Assess carrying angle systematically
Palpate radial head with rotation
Always check ulnar nerve
Test stability after trauma history
Assess functional arc of motion

Don't

Confuse cubital tunnel with carpal tunnel
Forget to examine shoulder and wrist
Miss subtle effusion
Ignore posterolateral corner
Rush through neurological assessment