Physical Examination of the Elbow and Forearm

Inspection/Palpation Anterior View Inspect the elbow for swelling and ecchymosis. Measure the carrying angle (the angle made by the intersection of the axes of the humerus and the forearm) with the elbow extended and the forearm supinated. Note that the normal carrying angle is a cubitus valgus of 5° to 8°. Cubitus varus (reverse carrying angle) usually results from a malunion of a supracondylar fracture of the humerus. The biceps brachii tendon can be easily palpated in the middle of the antecubital fossa, especially when the patient ﬂ exes the elbow against resistance with the forearm supinated as shown. Absence of this normally palpable tendon with associated tenderness and ecchymosis suggests a complete biceps tendon rupture.

Lateral View Check for an effusion by inspecting and palpating the area in the center of the tri- angle bounded by the lateral epicondyle of the humerus, the tip of the olecranon, and the radial head. Conﬁ rm the position of the radial head by feeling it move with forearm pronation/supination. Palpate the area over the radial head to check for pain and crepitus. These ﬁ ndings, along with limited forearm rotation, suggest a radial head fracture (if acute) or arthritis (if chronic). Tenderness to palpation just distal to the lateral epicondyle indicates lateral epicondylitis. Tenderness 5 cm distal to the lateral epicondyle that is localized deep to the extensor muscles suggests entrapment of the posterior

interosseous branch of the radial nerve. ELBOW AND FOREARM SECTION 3

Medial View Pain and tenderness immediately distal to the medial epicondyle suggest medial epicondylitis. The ulnar nerve lies in the ulnar groove just posterior to the medial epicondyle. Palpation and light percussion in this area may produce local pain and paresthesias in the medial forearm and ulnar two ﬁ ngers (the Tinel sign), in association with ulnar nerve entrapment. Tenderness elicited with speciﬁ c palpation of the sublime tubercle may indicate pathology involving the ulnar collateral ligament.

Posterior View Inspect the area over the olecranon for focal swelling and palpate for tenderness to con- ﬁ rm the presence of olecranon bursitis. An olecranon fracture produces a broader area of swelling with ecchymosis and a possible skin abrasion at the point of impact. Palpate just above the olecranon to identify elbow effusion. A palpable defect, particularly with slight attempts by the patient to extend the elbow, may indicate a triceps brachii tear.

Range of Motion Flexion and Extension: Zero Starting Position Evaluate elbow fl exion and extension with the arm comfortably at the side. Observe from the lateral side. Begin the examination with the patient’s elbow straight. Young children commonly hyperextend the elbow by 10° to 15°, but adults show minimal, if any, elbow hyperextension. Normal elbow range of motion is from 0° to 140° to 150° of fl exion. Mild fl exion contractures are of little functional consequence, as most activities of daily living are accomplished in an arc of ELBOW AND FOREARM elbow fl exion from 30° to 130°. Limitation of motion may be expressed as either “The elbow fl exes from 30° to 90°,” or “The elbow has a fl exion contracture of 30°, with further fl exion to 90°.” SECTION 3

Forearm Rotation Forearm rotation, which includes both pronation and supination, is a compos- ite motion occurring at the proximal and distal radioulnar joints, as well as the radiohumeral joint. Measure forearm rotation by stabilizing the arm against the chest wall and ﬂ exing the elbow to 90°. Begin with the extended thumb aligned with the humerus (A). Palpate the radial and ulnar styloid as the forearm is rotated to estimate pronation and supination. Ask the patient to grasp a pencil or similar object to facilitate visual estimation of forearm rotation. Pronation is the position in which the palm is turned down (B), and supination is the position in which the palm is turned up (C). Normal pronation and supination is approximately 80° in each direction. Many activities of daily living are accomplished in an arc of motion between 50° pronation to 50° supination. A very restricted arc of forearm rotation may be of limited consequence if shoulder mobility is normal and if the forearm is ankylosed in a neutral position. ELBOW AND FOREARM SECTION 3

Muscle Testing Resisted Flexion Test the strength of the ﬂ exors of the elbow, primarily the biceps brachii muscle, by resisting the patient’s maximum effort to ﬂ ex the supinated forearm. Weakness will be present with biceps tendinitis or rupture, dysfunction of the musculocutaneous nerve, or a lesion involving the C5 and C6 nerve roots.

Resisted Extension Test the strength of the extensors of the elbow, primarily the triceps brachii muscle, by resisting the patient’s maximum effort to extend the elbow with the forearm in neutral position. Weakness will be present with triceps tendinitis or rupture, or a lesion involving the C7 or C8 nerve roots.

Resisted Supination Test the strength of the forearm supinators, the most powerful of which is the biceps brachii muscle, by grasping the patient’s distal forearm, supporting the elbow with your other hand, and resisting the patient’s maximum effort to turn the palm up. Weakness will be evident with rupture or tendinitis of the biceps tendon at the elbow, sublux- ation of the biceps tendon at the shoulder, a lesion of the musculocutaneous nerve, or a lesion involving the C5 and C6 nerve roots. Patients with lateral epicondylitis also may experience pain with this maneuver.

Resisted Pronation Test the strength of the forearm pronators, the most powerful of which is the pronator teres muscle, by grasping the patient’s distal forearm, supporting the elbow with your other hand, and resisting the patient’s maximum effort to turn ELBOW AND FOREARM the palm down. Weakness will be evident with rupture of the pronator origin from the medial epicondyle, fracture of the medial elbow, or lesions involving the median nerve or the C6 and C7 nerve roots. Patients with medial epicondylitis also may experience pain with this maneuver. SECTION 3

Resisted Wrist Flexion Test the strength of the wrist fl exors with the patient’s arm at the side, forearm supported on a table, and elbow fl exed 90°, with the wrist in fl exion and the fi ngers extended. (This position eliminates wrist fl exion activity by the fi nger fl exors.) Ask the patient to keep the wrist fl exed while you push the wrist into extension. Weakness will be evident with rupture of the muscle origin, fracture of the medial elbow, medial epicondylitis, or lesions involving the ulnar nerve (C8 and T1 nerve roots) or median nerve (C6 and C7 nerve roots).

Resisted Wrist Extension Test the strength of the wrist extensors, the most powerful of which are the extensor carpi ulnaris and extensor carpi radialis brevis muscles, with the patient’s arm at the side, forearm supported on a table, and elbow fl exed 90°, with the wrist in extension and the fi ngers in fl exion. (This eliminates wrist extension activity by the fi nger extensors.) Ask the patient to hold the wrist in extension as you push the wrist into fl exion. Weakness will be evident with rupture of the extensor origin, fracture of the lateral elbow, lateral epicondylitis, or lesions involving the radial nerve or C6 to C8 nerve roots. ELBOW AND FOREARM SECTION 3

Stability Testing

Valgus Stress Test Test the stability of the medial ligamentous structures, primarily the ulnar collateral ligament, by placing the patient in a seated or supine position. Stabilize the lateral side of the elbow with one hand and place your other hand distally on the medial aspect of the distal forearm. Place the elbow in approximately 20° of ﬂ exion to disengage the olecranon tip from the olecranon fossa of the distal humerus. While maintaining stability with your proximal hand, use your distal hand to abduct the forearm, which applies valgus stress and opens up the medial joint line of the elbow.

Varus Stress Test Test the stability of the lateral collateral ligament and lateral capsule by placing the patient in a seated or supine position with the forearm supinated. Stabilize the medial side of the elbow with one hand and place your other hand distally on the lateral aspect of the distal forearm. Place the elbow in approximately 20° of ﬂ exion to disengage the olecranon tip from the olecranon fossa of the distal humerus. While maintaining stability with your proximal hand, use your distal hand to adduct the forearm, which applies varus stress to the elbow and opens up the lateral joint line of the elbow. ELBOW AND FOREARM SECTION 3

Long Finger Test Position the patient with the forearm in pronation. Resist extension of the third digit of the hand distal to the proximal interphalan- geal joint, stressing the extensor digitorum and tendon. Pain over the lateral epicondyle is a positive test for lateral epicondylitis.

Moving Valgus Stress Test (Milking Sign) Stand behind the sitting patient on the side of the involved elbow. Place one hand on the back of the patient’s shoulder and use the other hand to grasp the patient’s thumb. Stabilize the shoulder and guide it into 90° of abduction and external rotation with the patient’s elbow ﬂ exed generally around 90°. Additional posterior pull on the thumb further stresses the ulnar collateral ligament. Pain over the ulnar collateral ligament with stress in this position is indicative of ulnar collateral ligament pathology. The milking sign should be applied in various degrees of ﬂ exion, both greater and less than 90°.

Elbow Flexion Test Instruct the patient to fully ﬂ ex the elbow with wrist extension, shoulder girdle abduction, and depression and hold this position for 3 to 5 minutes. Tingling, numbness, and paresthesia in the ulnar nerve distribution is a positive test for cubital tunnel (ulnar nerve) syndrome. ELBOW AND FOREARM SECTION 3