3
PHYSICAL EXAMINATION OF THE
ELBOW
JEFFREY R. DUGAS
JAMES R. ANDREWS
A thorough knowledge of the functional anatomy and bio-
mechanical characteristics of the elbow is of tantamount
importance in accurately and adequately performing a phys-
ical examination. Whether on the field or in the office,
making the correct diagnosis will often depend on an under-
standing of the subtleties of elbow stability and mechanical
interactions of the structures in and around this complex
articulation. This chapter discusses how to thoroughly
evaluate the elbow for various types of pathology. As with
many other areas of physical diagnosis, the hallmarks of the
elbow examination include history, inspection, palpation,
range of motion (ROM), accessory movements, strength,
stability, neurovascular examination, and special tests. With
a repetitive stepwise approach, the clinician should be able
to form a sufficient differential diagnosis and proceed with
any further testing that may be indicated.
When examining the athlete’s elbow, the clinician must
remember that certain variations may be encountered that
although not typical or ‘‘normal’’ may not represent true
pathology, but an adaptation as a result of the individual’s
participation in sports.
CLINICAL HISTORY
In the course of the clinical evaluation of the athlete’s elbow,
there is perhaps no more important information than the
clinical history. The examiner should allow the patient to
tell his or her ‘‘story’’ in as much detail as seen fit. The
chronology of events leading the individual to seek medical
attention is also important, including any history of previ-
ous injury. The training regimen before and since the injury
should be documented, as well as any changes in the routine
to which the athlete is accustomed. This includes any
changes in technique, equipment, and coaching. For exam-
ple, a change in arm angle before medial elbow pain in a
American Sports Medicine Institute, Birmingham, Alabama 35255.
thrower may be considered the causative factor, leading to
changes in throwing mechanics to alleviate the symptoms.
The examiner must know what, if anything, the athlete
experienced just before and at the time of the injury. For
example, was there pain and where was the pain? Was there
a ‘‘pop?’’ Were there any neurologic or vascular symptoms?
Was there any swelling or bruising?
Once the specific injury history has been obtained, it is
necessary to find out what, if anything, has happened in
the time since the injury. What prior treatment has been
rendered? Have any medications or exercises been pre-
scribed? Have there been any periods of immobilization? Are
there certain times or conditions during which the elbow is
more symptomatic than others? What activities cause an
increase in symptoms, and how are these symptoms re-
lieved? When dealing with athletes with subacute or recur-
rent injuries, clinicians must know whether there have been
any intervening periods of rest and the course of symptoms
during these periods. For throwing athletes, it is important
to know when they last threw and for how long. Has there
been any decrease in velocity, stamina, or control? A key
piece of information in the evaluation of throwers is the
phase of the throwing motion during which symptoms are
present. As an example, if medial elbow symptoms are pres-
ent during the acceleration phase, the clinician may lean
more toward an ulnar collateral ligament injury, as 85% of
throwers with medial elbow instability will report pain dur-
ing this phase of throwing: Only 25% of throwers with
medial elbow instability will report pain during the follow-
through phase (1).
Although pain is often the first symptom an athlete expe-
riences with an injury, the absence of pain or delayed onset
of pain should not lead the examiner to dismiss the possibil-
ity of serious injury. This is particularly true in elbow inju-
ries in which numbness or tingling in the ulnar distribution
of the hand may be the only symptom in a patient with
medial elbow instability. Such a condition in an elite
thrower may lead to a significant decrease in performance
and loss of playing time and may place the athlete’s ability
to compete in jeopardy, despite the absence of pain.
50 The Athlete’s Elbow
Finally, any history of cervical spine injury should be
elicited. A history of prior ‘‘burners’’ or ‘‘stingers’’ may indi-
cate a primary pathology at the cervical root or brachial
plexus level, as opposed to a more distal injury. The clinical
examination of the cervical spine is beyond the scope of
this book but should include ROM, palpation, strength
testing, and neurovascular examination at the very min-
imum.
A thorough history will often aid the examiner in localiz-
ing the specific injury. The actual physical examination will
be much more efficient and more likely to lead to an accu-
rate and timely diagnosis after having obtained the complete
clinical history.
INSPECTION/OBSERVATION
Inspection and observation of the elbow begins as the pa-
tient walks into the examination room or as he or she comes
off the field. The examiner should note the resting position
of both elbows. A patient with significant joint effusion
will hold the elbow at 70 to 80 degrees of flexion, as this
corresponds to the position of maximum volume of the
elbow joint.
The carrying angle is the angle formed by a line drawn
along the longitudinal axis of the humerus and another line
along the longitudinal axis of the forearm with the wrist in
supination (Fig. 3.1). According to the classic study by Beals
(2), the normal carrying angle is 10 to 11 degrees of valgus
in the adult man and 13 degrees of valgus in the adult
woman. Other earlier studies documented similar results
with similar differences between men and women (3–6).
An alteration of the normal carrying angle when compared
FIGURE 3.1. The carrying angle of the upper extremity is defined
as the angle formed between a line drawn along the axis of the
upper arm and a line drawn along the axis of the forearm. Histor-
ically, normal carrying angles in the adult are 11 degrees of valgus
in men and 13 degrees of valgus in women.
to the opposite side may be indicative of previous trauma
or developmental abnormality. Repetitive stresses such as
the repetitive valgus overload seen in throwing athletes may
lead to an increase in the carrying angle. Increased carrying
angles are commonly seen in professional throwers and may
exceed 15 degrees of valgus (7). This increase in carrying
angle is often associated with an increase in forearm circum-
ference.
Further inspection of the elbow should be carried out in
a systematic fashion. Regardless of the order of inspection,
the clinician should make note of several important ana-
tomic areas including the lateral recess, olecranon, medial
epicondylar region, and antecubital fossa (Fig. 3.2). The
contour of the olecranon and the lateral recess should be
assessed carefully. Joint effusion, radial head pathology, or
other cause of increased joint volume such as proliferative
synovitis will present with fullness in the lateral recess, lo-
cated just distal to the lateral condyle of the humerus. Elbow
dislocation occurs most frequently in the posterior and pos-
terolateral directions. In these cases, the radial head or the
olecranon tip will be prominent and the contour of the
elbow articulation will be abnormal. Prominence of the ole-
cranon tip is also seen with distal triceps avulsion.
Further examination of the elbow should reveal a promi-
nent medial epicondyle unless the patient is obese. Ecchy-
mosis on the medial side of the elbow may be associated with
fracture of the medial epicondyle, avulsion of the medial
collateral ligament, or olecranon fracture. Ecchymosis in the
antecubital fossa in an athlete may be indicative of distal
biceps rupture. Although olecranon bursitis is not fre-
quently seen in throwing athletes, it may be more common
in athletes involved in contact sports. Spontaneous subluxa-
tion of the ulnar nerve can be seen with flexion of the elbow
in some cases, although this is rare (8). The presence of
ulnar nerve subluxation should be evaluated in each patient.
The clinician should complete the inspection by looking
at the topographical landmarks of the entire upper extremity
and trunk. Scapular winging or significant atrophy of the
deltoid or rotator cuff musculature may be the cause of
abnormal mechanics that result in undue stresses across the
elbow articulation. This determination will permit the clini-
cian to prescribe appropriate treatment to correct the true
pathology. Similarly, the distal aspect of the extremity
should be inspected to assess for discoloration of the fingers
and fingertips or bony deformity.
RANGE OF MOTION
Active and passive ROM should be assessed in both elbows
(Fig. 3.3). The elbow articulation is comprised of a hinge-
type joint, which allows motion in the sagittal plane with
a normal arc of motion of 0 to 140 degrees Ⳳ10 degrees,
and a ginglymoid joint (radiocapitellar articulation and
proximal radioulnar articulation), which allows forearm ro-
 3. Physical Examination of the Elbow 51

A B

C D
FIGURE 3.2. Four views of the normal adult elbow: (A) lateral, (B) posterior, (C) medial, and (D)
anterior.

A B
FIGURE 3.3. Views of the medial aspect of the elbow in both (A) flexion and (B) extension. The
routine use of a goniometer allows accurate and reproducible measurement of these angles. Nor-
mal adult elbow range of motion is from 0 to 140 degrees of flexion Ⳳ10 degrees.
52 The Athlete’s Elbow

tation. Normal values are between 80 and 90 degrees of not uncommon for overhead-throwing athletes to have di-
pronation and supination (9–15). With increasing elbow minished ROM. In a 1969 study of professional baseball
flexion, the carrying angle changes from valgus to varus, pitchers, more than 50% of the study subjects had elbow
making evaluation of the carrying angle difficult in situa- flexion contractures, and these tended to occur in older
tions of contracture (9,10). Although increased joint laxity pitchers (7).
is commonly seen in the shoulders of overhead-throwing
athletes, hyperextension and hyperflexion of the elbow,
which is associated with generalized ligamentous laxity, is PALPATION
distinctly uncommon in throwing athletes. The normal full
arc of elbow motion exceeds what is required for daily activi- This portion of the physical examination should be divided
ties, which has been estimated by Morrey et al. (13) to be into bony palpation and soft tissue palpation. Again, a sys-
from 30 to 130 degrees of flexion and 50 degrees of both tematic approach to examination will eliminate most errors
forearm pronation and supination. During ROM testing, of omission. When performing this portion of the examina-
the examiner should be aware of any attempt to compensate tion, the clinician must note the contour of the anatomy
for loss of elbow motion by changes in shoulder position. as well as any pain that may be induced by palpation.
Changes in shoulder position can compensate for loss of
elbow motion; therefore, for accurate assessment, we prefer Bony Architecture
to measure elbow flexion extension with the forearm in
neutral rotation and the arm adducted. Forearm supination On the medial side of the elbow, the medial epicondyle is
and pronation should be assessed with the arm adducted to the most prominent bony landmark. It is the origin of the
the side with the elbow in 90 degrees of flexion. ulnar collateral ligament as well as the flexor-pronator mus-
Loss of elbow motion of the throwing athlete may be cle mass, which includes the pronator teres, flexor carpi
the result of anterior or posterior capsular strain, capsular radialis, palmaris longus, and flexor carpi ulnaris (Fig. 3.4).
contracture, muscle strain/sprain, musculotendinous con- Pain with palpation directly over the medial epicondyle may
tracture, loose bodies, and osteophyte formation. Thorough be indicative of medial epicondylitis. Certain provocative
examination of both elbows will allow the examiner to nar- maneuvers, including resisted wrist flexion and pronation,
row the spectrum of the differential diagnosis. should elicit pain at the medial epicondyle in patients with
Pain, crepitus, and endpoint quality should be assessed in this condition. In a skeletally immature patient, pain with
each case. Significant differences between active and passive palpation of the medial epicondyle should alert the exam-
ROM are usually due to pain. The specific location of the iner to the possibility of injury to the medial epicondylar
pain and the point during the arc of motion in which it is growth plate. Extending proximally from the medial epicon-
the greatest should be noted. In patients with triceps ten- dyle is the supracondylar ridge of the distal humerus. If
donitis, full flexion may not be possible and even lesser present, a congenital supracondylar process will generally
degrees of flexion may cause pain in the posterior aspect of be found in this area and may cause symptoms related to
the elbow. Crepitation is generally accentuated with active
ROM, as opposed to passive ROM. This is due to the in-
crease in joint contact pressure caused by the force of ac-
tively contracting muscles. The point during the arc of mo-
tion at which crepitation is the greatest should be noted.
Perhaps one of the most important parts of assessing the
athlete’s elbow is the end-feel to ROM testing. Normally,
the endpoint feel is bony in terminal extension and soft
in terminal flexion. In extension, the olecranon tip makes
contact with the depth of the olecranon fossa to create the
endpoint. In flexion, the volar forearm musculature contacts
the upper arm musculature to create a soft endpoint. If there
is any loss of flexion or extension, the quality of the endpoint
will give the examiner an insight into the possible causes of
the deficit. A solid endpoint will often be indicative of an
osseous block to motion. For instance, in a throwing athlete
with loss of terminal extension, osteophyte formation or
loose bodies in the olecranon fossa may be the cause. A soft
endpoint is generally not associated with bony impingement FIGURE 3.4. Palpation of the bony medial epicondyle. Pain with
palpation of this structure may be indicative of medial epicondyl-
and may represent capsular contracture, joint effusion, mus- itis or in a skeletally immature patient of apophysitis or growth-
culotendinous contracture, or ligamentous pathology. It is plate injury.

median nerve or brachial artery compression. Supracondylar
lymph nodes and osteophytes may also be found in this
area.
Posteriorly, palpation should begin with the olecranon
bursa, which overlies the triceps aponeurosis as it inserts
onto the olecranon. Any pain with palpation, thickening of
the bursa, or the presence of an osteophyte or loose body
should be noted. The tip of the olecranon and the olecranon
fossa are palpable with the arm in more than 60 degrees of
flexion, which brings the tip out of the olecranon fossa. The
posteromedial aspect of the olecranon is a site of osteophyte
formation and of subsequent impingement in athletes
whose sport requires the forceful snap of their elbows into
full extension, such as basketball, baseball, javelin, and shot
put. Pain with palpation in this area may be indicative of
soft tissue or bony impingement. Bony impingement in this
area may be due to osteophyte formation or loose body
entrapment. Palpation of the proximal third of the olecra-
non should be performed along its subcutaneous border, as
stress fractures may be seen in this area in overhead athletes
(Fig. 3.5).
The lateral epicondyle is smaller and less prominent than
its medial counterpart and lies just lateral to the olecranon.
The wrist extensors originate on the lateral epicondyle,
which may be tender to palpation in lateral epicondylitis.
This condition will also cause pain with resisted wrist exten-
sion and supination. The lateral supracondylar line repre-
sents the proximal continuation of the epicondyle and ex-
tends up to the deltoid tuberosity. The radial nerve crosses
the lateral supracondylar line as it proceeds from the poste-
rior to the anterior compartment of the arm approximately
10 to 14 cm above the elbow.
Finally, the radial head lies in a soft spot posterior and
medial to the wrist extensor musculature and 2 cm distal
FIGURE 3.5. Pain with palpation along the lateral subcutaneous
border of the olecranon may be evidence of a stress fracture.
3. Physical Examination of the Elbow 53
FIGURE 3.6. View of the lateral aspect of the adult elbow. The
radial head is palpated 2 cm distal to the lateral epicondyle. The
X in the photograph represents the soft lateral recess located in
the center of the triangle formed by the tip of the olecranon,
the lateral epicondyle, and the radial head. This is typically the
easiest and safest location for injection or aspiration of the elbow
joint.
to the lateral epicondyle (Fig. 3.6). It can be palpated by
placing the thumb of one hand in this region and rotating
the forearm with the other hand. Crepitation within the
radiocapitellar joint should be noted as well as any percep-
tion of pain as the radial head is rotated. In addition, no
movement other than rotation should be appreciated. If
there is any subluxation of the radial head caused by rota-
tion, this should be documented.
Soft Tissue Architecture
Soft tissue anatomy in the antecubital fossa, from lateral to
medial, includes the following structures: musculocuta-
neous nerve, lacertus fibrosus, biceps tendon, brachial ar-
tery, and median nerve. In general, the median and muscu-
locutaneous nerves are not directly palpable, as the median
nerve traverses beneath the brachioradialis muscle and the
musculocutaneous nerve terminates as the lateral antebra-
chial cutaneous nerve. Particular attention should be paid
to palpation of the distal biceps tendon. A hypovascular
zone of the biceps tendon lies just proximal to the distal
insertion of the tendon onto the radius (16). High stresses
occur in the area of the biceps tendon insertion during the
follow-through phase of throwing. It is not surprising that
pain in this area is common in throwers and other overhead-
throwing athletes. The brachial artery pulse should be as-
sessed at this point and compared to that of the unaffected
side for rate and quality. Any difference in quality between
the two sides should be noted carefully.
On the medial side of the elbow, palpation of the flexor-
pronator muscle group is performed before palpation of the
54 The Athlete’s Elbow
deeper structures. Gentle palpation beginning at the medial
epicondyle and progressing distally and anteriorly along the
muscle group is the first step. The ulnar nerve can be pal-
pated beginning above the cubital tunnel and then progress-
ing around the posterior and distal aspect of the medial
epicondyle and distally into the flexor muscle group. Gener-
ally, gentle palpation of the nerve should not elicit any pain-
ful response. Similarly, no radicular symptoms should be
expected from gentle palpation. Aggressive palpation of the
ulnar nerve may cause both pain and paresthesias but is not
likely to be indicative of any pathology. Gently tapping
on the nerve within the tunnel may elicit a sensation of
paresthesias. This is considered a positive Tinel sign and
may be indicative of ulnar nerve irritation. Attempts should
be made to subluxate the ulnar nerve out of the cubital
tunnel. A hypermobile ulnar nerve can be a source of signifi-
cant medial elbow pain but may not declare itself on palpa-
tion of the nerve alone. The stability of the nerve is opti-
mally tested with the patient supine and the arm abducted
90 degrees and externally rotated. The elbow is then flexed
from 20 degrees to 70 degrees repeatedly while the nerve
is palpated in the cubital tunnel (8,17,18). While palpating
the ulnar nerve proximal to the cubital tunnel, the examiner
should also palpate for the medial aspect of the triceps ten-
don. Anomalous bands of the triceps tendon have been
shown to cause ulnar nerve symptoms as they snap over the
medial epicondyle (19).
Palpation of the ulnar collateral ligament beginning
proximally and continuing along its entire substance should
be performed. The ulnar collateral ligament originates on
the distal aspect of the medial epicondyle and inserts onto
the sublime tubercle of the proximal ulna, just distal to the
articular surface (Fig. 3.7). Tenderness along any portion
of the ligament should cause concern about primary ulnar
collateral ligament pathology. Pain with palpation in this
region may also be due to injury of the flexor-pronator
muscle group, specifically the flexor carpi ulnaris, because
these tissues directly overlie the ulnar collateral ligament.
Laterally, the ‘‘mobile wad of Henry,’’ consisting of the
brachioradialis, extensor carpi radialis longus and extensor
carpi radialis brevis, is easily distinguished and palpated.
These muscles originate on the lateral aspect of the distal
humerus from proximal to distal in the order listed above.
Pain with palpation of the medial aspect of the ‘‘mobile
wad’’ may be indicative of radial nerve entrapment such
as in the radial tunnel syndrome. The lateral ligamentous
structures are very difficult to palpate directly. Elbow joint
effusion is determined by palpating the soft area on the
lateral aspect of the elbow outlined by the triangle formed
by the olecranon tip, the radial head, and the lateral epicon-
dyle (Fig. 3.6). Fullness in this region generally indicates a
joint effusion or synovial proliferation.
FIGURE 3.7. Palpation of the ulnar collateral ligament is difficult
due to the overlying tissues. The ulnar collateral ligament origi-
nates on the distal aspect of the medial epicondyle and inserts
onto the sublime tubercle of the ulna just distal to the articular
surface. The ligament is easier to palpate with the elbow flexed,
as this tends to bring the overlying musculature anterior to the
fibers of the ulnar collateral ligament.
MOTOR AND NEUROVASCULAR
EXAMINATION
A cursory sensory examination is performed from the level
of the shoulder down to the fingertips. Determination of the
sensory status of the extremity begins in the supraclavicular
region and proceeds toward the axillary nerve distribution
on the lateral aspect of the arm. Next, the posterior and
medial aspect of the upper arm should be tested, followed
by the antecubital fossa, which represents the sensory distri-
bution of the musculocutaneous nerve. The volar, dorsal,
radial, and ulnar aspects of the forearm should be tested,
followed by a detailed sensory examination of the hand in-
cluding each fingertip. The first dorsal web space (radial
nerve), the pad of the index finger (median nerve), and the
lateral border of the small digit (ulnar nerve) should be
tested, as these are specific areas of sensory innervation with
little overlap from contiguous sensory innervations. While
discrete sensory abnormalities may not represent any limit-
ing functional problem, they may be the first or only indica-
tion of significant nerve entrapment, which may ultimately
lead to disability.
A routine examination of the elbow should include test-
ing the strength of upper extremity muscles beginning at
the shoulder. This is particularly important because any
weakness of the shoulder musculature will lead to altered
throwing mechanics, potentially leading to increased stress
in the soft tissues of the elbow. Strength testing should be
performed on both the affected and unaffected side.
The trapezius muscles are tested by requesting that the

FIGURE 3.8. Manual testing of the brachialis muscle is done by
resisting elbow flexion with the forearm in full pronation.
patient ‘‘shrug’’ his shoulders simultaneously against resis-
tance. The internal rotation (subscapularis) and external ro-
tation (infraspinatus) strength of the shoulder is tested with
the elbow flexed to 90 degrees and with the elbow at the
side. The supraspinatus is tested by elevating the arm with
the elbow extended in the scapular plane against resistance.
The brachialis is tested by resisting elbow flexion with the
forearm in pronation (Fig. 3.8). With the forearm in neutral
rotation, resisted elbow flexion assesses the brachioradialis
strength. The biceps brachii, the most powerful supinator
of the forearm, is tested with the arm in 45 degrees of for-
ward flexion with the forearm in supination (Fig. 3.9). Tri-
ceps strength can be assessed by resisted active extension of
FIGURE 3.9. Testing of the biceps brachii is done by resisting
elbow flexion with the forearm in full supination and the elbow
flexed 45 degrees. The biceps brachii is the most powerful supi-
nator of the forearm.
3. Physical Examination of the Elbow 55
FIGURE 3.10. Testing of the triceps mechanism is done by resist-
ing elbow extension with the forearm in neutral rotation and the
elbow at 45 degrees of flexion. In most cases, the triceps tendon
is easily palpated medially and laterally just above the insertion
onto the olecranon.
the elbow with the forearm in neutral and the elbow flexed
to 90 degrees (Fig. 3.10). Resisted pronation and supina-
tion, as well as wrist flexion and extension, should be tested
with the elbow at 90 degrees of flexion. Grip strength (me-
dian nerve), thumb abduction strength (radioposterior in-
terosseous nerve), and intrinsic muscle strength (ulnar
nerve) should be tested to ensure that distal motor function
is intact. Any side-to-side difference should be noted.
STABILITY
The elbow is not an inherently stable articulation. If not
for the soft tissue envelope surrounding the joint, the radius
and ulna would fall away from the humerus. The humer-
oulnar articulation does have some inherent stability de-
pending on the angle of flexion. For example, at lesser de-
grees of flexion, the tip of the olecranon process lies within
the olecranon fossa, preventing dissociation with varus or
valgus stresses. In patients with articular cartilage loss, there
is potential for increased reliance on ligamentous and other
soft tissue structures for stability. Similarly, in patients with
radial head fractures, the lateral buttress, which is usually
provided by the radial head, may be lost, leading to in-
creased valgus opening.
The primary structure providing valgus stability is the
medial collateral ligament, specifically the anterior band
(20–25). Testing the integrity of the medial collateral liga-
ment complex is performed by applying a valgus stress to
the elbow with the joint flexed approximately 25 degrees.
This is best done with the upper arm in maximum external
rotation. To isolate the ligament, it is essential to prevent
56 The Athlete’s Elbow
FIGURE 3.11. The integrity of the ulnar collateral ligament is
confirmed by placing the arm of the supine patient in abduction
and external rotation, followed by the application of a valgus
stress to the elbow. By placing the patient in this position, upper
arm rotation is dampened, making it easier to apply a true valgus
stress. An assessment of both the amount of opening and the
quality of the endpoint should be noted and compared to the
opposite side.
rotation of the upper arm. It is for this reason that we prefer
to perform this test with the patient supine with the arm
in abduction and external rotation (Fig. 3.11). With this
positioning, further external rotation is eliminated. In a ca-
daver study, Calloway et al. (26) demonstrated that com-
plete division of the anterior bundle of the ulnar collateral
ligament resulted in only a small increase in valgus rotation,
which according to the authors, may be too small to be
detectable on clinical evaluation. The test for medial insta-
bility should not elicit any pain in the healthy elbow. Any
perception of pain or any increase in the amount of opening
when compared with the opposite side should be noted.
This pain or increased laxity may be indicative of partial or
complete ulnar collateral ligament injury.
The radial collateral ligament complex consists of the
radial collateral ligament and the lateral ulnar collateral liga-
ment. These structures provide the vast majority of the varus
stability to the elbow. Although the radial collateral liga-
ment maintains consistent tension throughout the ROM,
the complex is generally tested by applying a varus stress to
the elbow with the joint flexed approximately 15 degrees
with the upper arm maximally internally rotated. Again,
any pain or appreciable increase in laxity should be noted.
Injury to the lateral ulnar collateral ligament has been shown
to be the primary pathology leading to posterolateral rota-
tory instability of the elbow (27,28). This condition results
in the involuntary subluxation of the radial head posterolat-
erally with rotatory subluxation of the humeroulnar joint.
The test for posterolateral rotatory instability is called the
pivot shift test of the elbow. This test is performed with the
FIGURE 3.12. The pivot shift test for the elbow is used for the
diagnosis of posterolateral rotatory instability. This test is diffi-
cult to perform adequately in the awake patient. The patient is
placed supine with the arm in forward flexion and supination. An
axial load and a valgus stress are applied simultaneously in an
attempt to cause the radial head to subluxate posteriorly away
from the capitellum.
patient supine and the arm in forward flexion (Fig. 3.12).
The forearm is placed in supination. Both an axial compres-
sion and a valgus stress are applied simultaneously to the
elbow. The radial head is palpated while these stresses are
applied to feel for subluxation. Also, the skin overlying the
radiocapitellar joint is inspected for dimpling or indentation
resulting from subluxation of the radial head. In general,
this test is very difficult to perform in an awake patient due
to the discomfort level caused by it.
An assessment of elbow stability is particularly important
in the setting of acute dislocation after adequate reduction.
Elbow dislocation is discussed elsewhere in this text; how-
ever, it is important to note that the acute nature of the
injury should not prevent the clinician from adequately per-
forming an examination to determine postreduction stabil-
ity. In doing such an assessment, the clinician should take
the elbow through a full ROM to determine what angle of
flexion, if any, causes instability. In addition, gentle varus
and valgus stresses should be applied with the elbow at 20
degrees of flexion to ascertain the presence of medial or
lateral laxity. Note also that instability after reduction may
be due to incarcerated fragments distracting the joint.
SPECIAL TESTS
Valgus Extension Overload Test
Valgus extension overload of the elbow is commonly seen
in overhead-throwing athletes. This is the result of impinge-
ment of the posteromedial aspect of the olecranon tip upon
the soft tissue or bony architecture of the medial inner brim

FIGURE 3.13. The valgus extension overload test is performed
by repeatedly snapping the slightly flexed elbow into extension
with a valgus load applied simultaneously. This test attempts to
recreate the conditions in the thrower’s elbow during the acceler-
ation phase of throwing. Pain in the posteromedial aspect of the
olecranon fossa is considered a positive test result and may be
indicative of posteromedial impingement by osteophyte or soft
tissue.
of the olecranon fossa. This impingement results in recur-
rent posteromedial pain when valgus stress is applied to the
rapidly extending elbow. The valgus extension overload test
(Fig. 3.13) is performed by repeatedly forcing the elbow
into full extension with a valgus stress applied (29). This
test is an attempt to recreate the forces across the elbow
joint during the acceleration phase of the throwing motion.
In addition, pain associated with palpation of the postero-
medial aspect of the olecranon tip is considered a positive
test result. Despite that this condition occurs most fre-
quently in throwers, other subsets of athletes suffer from
valgus extension overload. Any athlete who suffers an elbow
injury is at risk for developing valgus extension overload
due to hypertrophy of the soft tissues in the olecranon fossa
or due to loose bodies in the posterior aspect of the elbow.
The Tinel Test
The Tinel test is performed by gently percussing the skin
overlying a superficial nerve. This gentle repetitive compres-
sion will cause paresthesias and/or tingling in the sensory
distribution of inflamed or irritated nerves. Positive Tinel
test results should alert the clinician to the presence of some
intrinsic or extrinsic cause of nerve irritation. Common
causes of such irritation involving the ulnar nerve are nerve
hypermobility, intraneural edema, fixed bony impinge-
ment, dynamic bony impingement resulting from medial
instability, and soft tissue compression. Due to the difficulty
in assessing ligamentous stability on clinical examination,
3. Physical Examination of the Elbow 57
positive Tinel test results should alert the examiner that
further assessment of the medial stabilizing structures is in
order.
Tests for Medial and Lateral
Epicondylitis
Tests for inflammation of the soft tissues overlying the hu-
meral epicondyles involve resisting the active contraction
of the muscles that originate on the bony structures. For
example, with lateral epicondylitis, wrist dorsiflexion is re-
sisted with the elbow in extension while the lateral epicon-
dyle and wrist extensors are palpated. Another test for lateral
epicondylitis is performed by fully extending the elbow with
the wrist in full pronation. The wrist is then forced into
volar flexion, placing a tensile stress on the wrist extensors.
For medial epicondylitis, the test is performed by resisting
elbow flexion with the forearm in supination while the me-
dial epicondyle and the flexor-pronator muscle mass are
palpated. Similarly, resisted forearm pronation will gener-
ally elicit pain on the medial aspect of the elbow in a patient
with medial epicondylitis.
SUMMARY
The physical examination is an integral part of the diagnos-
tic workup for any athlete with an elbow injury. By rou-
tinely performing the various aspects of the physical exami-
nation in sequence, the examiner is less likely to overlook
subtle pathology. Frequently, the findings of a well-per-
formed physical examination will direct the clinician in or-
dering any diagnostic tests that may be necessary. The com-
bination of physical findings and radiographic analysis
allows the clinician to appropriately recommend a treatment
plan ideally suited to the individual athlete.
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