Passive flexion

The 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 ipsilateral 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 extension

With the contralateral hand, the examiner takes hold of the patient’s upper arm at the level of the olecranon. The ipsilateral 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 pronation

The 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 supination

The 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°.

Resisted flexion

The 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 brachialis and the brachioradialis. The brachialis is a strong flexor and the brachioradialis is clinically unimportant.

Resisted extension

Again 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 associated with a painful arc).

Resisted pronation

The 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 supination

The 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 flexion of the wrist

The 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.

Resisted extension of the wrist

The 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.

Resisted extension of the wrist with the fingers actively flexed

The patient is asked to flex the fingers actively by pressing the fingertips into the palm of the hand. Resisted extension of the wrist is now executed, as already described (Fig. 16.4).

Resisted radial and ulnar deviation

With the elbow in extension and the wrist in the neutral position between flexion and extension, radial and ulnar deviation are tested against resistance (Fig. 16.5). These tests differentiate 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 fingers

When 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 extension

In 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.

Tinel’s sign

Percussion to the ulnar nerve in the groove between the olecranon 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.