Elbow Examination

The elbow examination is an important clinical exam to be comfortable with. Although it doesn't crop up as commonly as the shoulder/hip examinations in OSCEs, it is an important one to master especially if you will be working in A&E or GP setting. The examination follows the usual 'Look, Feel and Move' structure but it is important that you are aware of certain conditions that can manifest with abnormalities in the elbow. Examples of this are seen in psoriatic arthropathy, rheumatoid arthritis, septic arthritis and olecranon bursitis.

Wash hands

  • Wash your hands using the Ayliffe technique

Introduce yourself

  • Introduce yourself and give your name and grade

“Hi, my name is Rick Deckard and I am a 4th year medical student”

Check patient details

  • Clarify patient's identity by confirming their name and asking for their DOB

Describe examination

  • Explain what examination you are performing and what this involves

“I have been asked to examine your elbow today. This involves having a look, a feel and asking you to do a few exercises.”

Gain verbal consent

“Would this be ok with you?”

Expose appropriately

  • Fully expose the patient's elbow

 

NB: Remember to talk to the patient during the examination to put them at ease.

"To begin with I'll just be having a look at your elbow for any scars, swelling or changes."

Inspect from the front

  • Scars: suggestive of a past surgery or an injury
  • Skin changes: look for bruises, swelling, skin rash and sinuses. Skin rashes may be indicative of psoriatic plaques or rheumatoid nodules.
  • Erythema: may suggest acute inflammation, injury, or infection
  • Carrying angle: 5 to 10 degrees in males and 5 to 15 degrees in females. An increased angle is termed Cubitus Valgus. While a decreased angle (gunstock deformity) is termed Cubitus Varus.

Inspect from the side

  • Olecranon bursitis: soft tissue swelling over the olecranon
  • Fixed flexion deformity: After injury/fractures/mal-union
  • Look for scars and signs of erythema (septic joint)

Inspect from the back

  • Psoriatic plaques: the presence of well-defined red or pink raised lesions with fine silvery scale on the surface. 
  • Rheumatoid nodules: firm lumps on the olecranon or elbow indicating systemic rheumatoid disease, present in up to 20% of rheumatoid arthritis patients.

     

NB: Before starting, ask the patients if they have any pain in the elbow. Then proceed and ask them to let you know if it causes any discomfort

"I'll just move on to have a feel of your elbow, please let me know if this causes you any discomfort"

  • Assess the temperature: Check for the temperature around the elbow joints using the back of your hand. A hot joint may be indicative of infection/ inflammatory arthritis or olecranon bursitis
  • Palpate common extensor tendon starting point: Tenderness just distal to the lateral epicondyle could indicate tennis elbow.
  • Palpate common flexor tendon starting point: Tenderness just distal to the medial epicondyle could indicate golfer’s elbow.
  • Rotate the forearm and palpate the radial head with your thumb
  • Palpate the joint lines including the olecranon and epicondyles for localized tenderness

NB: Ask the patient to start with making these movements actively (they move it themselves) then move on to passively (you move them for the patient)

Assess each of the movements of the elbow joint actively and passively:

  • Ask the patient to bend the elbows one at a time (Flexion: 145°)
  • Ask the patient to extend the elbows (Extension: 0°)
  • Ensure patient has their elbows by their side and flexed at 90º then:
    • Ask the patient to turn the elbows inwards (Pronation: 70º)
    • Ask the patient to turn the elbows outward (Supination: 85º)

NB: While moving the elbow passively, feel for crepitus

Lateral epicondylitis (Tennis Elbow) Test

“I will be asking you to move your wrist up against my hand. Let me know if you feel any pain”

  • Stabilize the patient’s elbow with your right hand
  • Place your fingers over the lateral epicondyle
  • Ask the patient to pronate the forearm while making a fist
  • Place your left hand on their wrist
  • Ask the patient to extend their wrist against the resistance from your left hand

A positive test would cause pain over the lateral epicondyle region

 

Medial epicondylitis (Golfer's Elbow) Test

  • Start with the elbow flexed at 90º
  • Hold the patient’s wrist with your left hand. Palpate the medial epicondyle with the other hand
  • Tell the patient to flex their wrist actively against resistance from your hand and keeping the elbow flexed

A positive test would cause discomfort along the medial part of the elbow over the medial epicondyle region.

Thank patient

  • Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

Summarise your findings and state other exams for completion

“Today I have seen Joe Blogs...To complete the examination I would examine the shoulder and the wrist joints as well as conducting a full upper limb neurological assessment.”

State what investigations you would perform

  • Explain to the examiner what tests and investigations you would perform based on your findings and the patient’s history;
  • Xray

  • MRI/US scan