Introduction

Clinical assessment is the cornerstone of diagnosing and managing elbow disorders. A detailed history and a well-performed physical examination can provide most, if not all, of the information needed to make a diagnosis and enable treatment recommendations. This can then be confirmed by the appropriate imaging modalities.

Patient history

In addition to taking a general history from the patient, a focused history should concentrate on the salient symptoms specific to the elbow.

Typically, the history begins with the patient’s age, handedness and occupation. One should determine the chief complaint and its chronicity, and identify any precipitating causes such as a traumatic fall, injury during sport or a repetitive use injury. It is important to note whether the symptoms interfere with activities of daily living or occupational tasks. Other relevant history includes the patient’s level of participation in sports, hobbies or recreational activities. Specifics such as position played, musical instrument played and future career plans may also be very relevant in some patients.

Pain is a common chief complaint. It is important to elicit from the patient its location, quality, time of onset and duration, frequency, alleviating and aggravating factors, and whether the pain is continuous or intermittent. A discussion of previous treatment modalities and their relative success or failure should also take place. These often include medications, physical or occupational therapy, braces/splints, injections or surgical intervention. For patients who have had previous surgery it is helpful to obtain operative reports and clinical notes to determine the surgical indications, the occurrence of complications and outcomes.

Some patients may complain of elbow instability. In these cases a history of injury, frequency of instability symptoms, activities that exacerbate perceived instability, timing of onset and alleviating factors, as well as previous interventions, are all important considerations.

Alternatively, patients may describe elbow stiffness. A focused history should determine the impact of the stiffness on the patient’s activities of daily living, occupation and recreational pursuits. One should identify previous injuries or surgery and whether there is a history of inflammatory or degenerative arthritis. In addition it is also important to ask specifically about elbow locking, catching, popping, or grinding. Prior treatments for stiffness may include physical therapy, manipulation under anaesthesia, or surgical contracture release with or without debridement. If possible, determine from the patient whether they improved after any of their earlier treatments. Progressive improvement versus reaching a plateau in progress is an important distinction to make, as is a history of worsening stiffness.

In patients with a history of infection in or around the elbow, it is important to determine whether there has been previous skin compromise such as an open fracture, laceration, puncture wound, gunshot wound or surgery. One should also identify if there are any underlying medical conditions or medications that may contribute to an immunocompromised state.

Screening questions about paraesthesias or dysaesthesias in the extremity as well as neurological symptoms in other extremities are important. Determination of the distribution, quality, duration, onset, frequency and alleviating or aggravating factors is essential. Cervical spine pathology may contribute to these symptoms and the patient should be asked about any prior cervical spine pathology, symptoms or procedures.

In addition, any history of previous or current tumours, benign or malignant, should be explored with regard to type, location, history of metastatic disease and family history.

Based on an appropriate careful history it will be possible to start to develop a differential diagnosis.

Physical examination

General examination of the elbow

After the clinical history has been obtained a detailed physical examination should be performed. This involves four components: inspection, palpation, motion and neurological assessment. In addition, there are many special tests specific to different elbow pathologies that will be described later in this chapter. As with the examination of any joint, a full assessment is incomplete unless the joint above and the joint below have also been examined. Furthermore, an examination of the cervical spine must be performed since neurological abnormalities may present as apparent elbow pathology.

Inspection

Inspection requires appropriate exposure of the cervical spine, shoulder, elbow, wrist and hand. When assessing the skin, notable features include skin integrity, quality, pigmentation, scars or incisions, fistulas or sinuses, masses or ecchymosis. As an example, depigmentation may occur as a result of prior corticosteroid injections (Fig. 4.1).

Figure 4.1 Skin depigmentation secondary to multiple corticosteroid injections.

Following inspection, the surface anatomy and bony landmarks, particularly the medial and lateral epicondyles and the olecranon, must be identified. These structures can help determine the alignment of the elbow. When the elbow is in full extension these three bony structures should be collinear. When the elbow is flexed to 90°, they should form an equilateral triangle and be coplanar. Loss of this normal relationship may indicate fracture, malunion, dislocation, congenital abnormality or other underlying structural pathology.

Assessment of the patient’s carrying angle (Fig. 4.2) is also important and should be compared to the contralateral elbow. It is measured with the arm adducted and externally rotated, the elbow extended, and the forearm supinated. The carrying angle is the angle formed by the long axis of both the arm and the forearm. Although there is with some dispute amongst authors as to whether differences exist between the sexes,^1–3 the normal ranges for men and women are 10–15° of valgus. Some patients may demonstrate excessive cubitus valgus or cubitus varus as a result of previous trauma or disorders of physeal growth. Some overhead-throwing athletes have an increased physiological valgus carrying angle.⁴

Figure 4.2 Assessment of the carrying angle.

Inspection should also include an assessment of the patient’s muscle bulk, specifically noting any significant hypertrophy or atrophy. In some individuals, it may be possible to identify the distal biceps and triceps tendons by inspection alone. At the same time, it is important to note any swelling, and record whether it is localized or generalized. The presence of any masses should also be documented.

Palpation

A systematic approach to palpation will ensure that no significant abnormality is missed. Table 4.1 provides a list of structures to include in the examination. On the lateral aspect of the elbow, the key anatomic landmarks to palpate are the lateral epicondyle, lateral collateral ligament, radial head, lateral soft spot (Fig. 4.3), crista supinatoris and the common extensors (Fig. 4.4).

Table 4.1 Structures to include during palpation of the elbow joint

Lateral

(i) Lateral epicondyle (ii) Lateral condylar ridge/lateral column (iii) Common extensor origin (iv) Posterior capitellum (v) Lateral ulnohumeral joint (vi) Radiocapitellar joint (vii) Radial head (viii) Radial neck (ix) Lateral collateral ligament (LCL) (x) Crista supinatoris

Posterior

(i) Olecranon

(ii) Olecranon fossa

(iii) Triceps insertion

(iv) Posterolateral ulnohumeral joint

(v) Posteromedial ulnohumeral joint

Medial

(i) Medial epicondyle

(ii) Sublime tubercle

(iii) Medial condylar ridge/medial column

(iv) Medial intermuscular septum

(v) Ulnar nerve

(vi) Common flexor origin

(vii) Medial ulnohumeral joint

(viii) Medial collateral ligament (MCL)

(ix) Medial head of triceps

Figure 4.3 Lateral soft spot.

Figure 4.4 Wrist extensors under tension.

Posteriorly, the olecranon tip and the triceps insertion are the most important structures to palpate.

On the medial aspect of the elbow, the key structures are the medial epicondyle, the ulnar nerve (Fig. 4.5), the sublime tubercle and the flexor–pronator group. The latter is best visualized when placed under tension (Fig. 4.6).

Figure 4.5 Ulnar nerve.

Figure 4.6 Flexor–pronator muscles under tension.

Anteriorly, the coronoid (Fig. 4.7) is important to palpate, as is the distal biceps tendon (Fig. 4.8).

Figure 4.7 Coronoid.

Figure 4.8 Distal biceps tendon.

Specific technical tips for palpating some of these structures will be discussed in the sections to follow on specific conditions about the elbow.

Motion

Determining the range of motion of the elbow is incomplete without an assessment of the range of motion of the cervical spine, shoulder and wrist. The use of a goniometer is helpful in collecting reproducible data that may be used for comparison in subsequent visits. The standard deviation of error for a single observer using a manual goniometer is 3.7° for any joint. With respect to the elbow, the standard deviation of measurement error varies with each motion. The following are the reported standard deviations of measurement error for elbow extension, flexion, pronation and supination, respectively: 2.7°, 4.9°, 5.3° and 4.0°. Given the imprecision of these measurements, Boone and Azen recommend that a single observer should perform repetitive measurements over successive encounters.⁵

Documenting the range of motion with standardized methods is important to ensure consistency of information across clinic visits and providers. The American Academy of Orthopaedic Surgeons defined these standards in 1965.⁶ In 1979, Boone and Azen studied normal elbow range of motion in 109 normal subjects. In patients older than 19 years, the flexion–extension arc measured from 0° (full extension) to 140° (full flexion) (Fig. 4.9). Flexion was significantly greater (145°) in subjects younger than 19 years.⁵ Patients with some generalized ligamentous laxity may demonstrate hyperextension of the elbow, and this should be indicated with negative values (e.g. −10°). The functional arc of motion, allowing for most activities of daily living, is 30–130°.⁷

Figure 4.9 (A) Full extension (0°). (B) Full flexion (140°).

In a normal examination, most patients should achieve approximately 75° of pronation and 82° of supination (Fig. 4.10).⁵ Although it may appear that patients achieve 90° of rotation when observing the final hand position, as much as 15° of rotation is generated through the carpus and does not represent isolated forearm rotation. The functional arc of motion for forearm rotation is 50° of pronation to 50° of supination.⁷ It is important when pronation and supination are being measured that the patient’s elbow is flexed to 90° and at their side, since many patients will abduct or adduct the shoulder to compensate for loss of forearm rotation.

Figure 4.10 (A) Full pronation. (B) Full supination.

When using the goniometer to measure angles, consistent surface landmarks should be used to ensure that the arms of the goniometer are parallel to the humeral and ulna diaphyses. In muscular or overweight patients, it can be difficult to palpate the humeral shaft and it is better to use the anterolateral corner of the acromion as a reproducible landmark as it represents the approximate location of the humeral shaft. The hinge of the goniometer is placed at the rotational axis of the patient’s elbow, which is approximated by the lateral epicondyle. The distal arm of the goniometer is aligned with the subcutaneous border of the ulna. This is usually easy to see and palpate regardless of the patient’s body habitus. Flexion and extension should be measured with the forearm in supination (Fig. 4.11A). Measuring forearm pronation and supination should be done with the elbow at the patient’s side and in 90° of flexion. The goniometer arm should be placed parallel to the plane of the volar or dorsal aspect of the distal radioulnar joint and the other arm directed either downward with gravity (perpendicular to the floor) or upward (perpendicular to the ceiling) (Fig. 4.11B).

Figure 4.11 Use of goniometer to measure elbow and forearm range of motion

Active and passive range of motion should be assessed. While testing passive range, one should check for firm or soft endpoints and pain at the extremes of flexion and extension. These findings may give clues to underlying pathology such as bone or soft tissue constraints to motion. Similarly, during range of motion testing it is important to note any pain throughout the arc of motion. This should be tested both with and without gentle resistance through an arc of motion, as this increase in joint reactive forces may elicit crepitus and pain.

Neurological

A complete neurological examination of the upper extremity should be conducted. This includes cervical roots C5–T1, the brachial plexus and the peripheral nerves. The accompanying tables are provided to guide in the examination of individual cervical roots (Table 4.2), as well as the individual peripheral nerves (Table 4.3).

Table 4.3 Peripheral nerves

An important part of the neurological examination is an assessment of strength. This is done with the patient’s elbow flexed 90° and the arm adducted at the side. Table 4.4 lists some common associations regarding elbow strength assessment.

Table 4.4 Strength assessment⁸

Clinical assessment of specific elbow disorders