Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose arms
• General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, sling

Look

You should inspect from the front, sides and behind:

• Carrying angle (men 5-10˚, women 10-15˚)
  • Cubitus valgus = increased angle
  • Cubitus varus (‘gunstock’ deformity) = reversed angle
• Fixed flexion deformity 
• Skin: scars, bruising, sinuses, swelling, erythema
• Rashes: psoriatic plaques, rheumatoid nodules (feel up extensor surface)
• Muscles: wasting, look for biceps ‘Popeye’ sign/lump (biceps tendon rupture)

Feel

Ask about any pain and then start by examining the normal side:

• Skin: palpate general area for temperature, effusions and soft tissue swelling/tenderness (e.g. olecranon bursitis)
• Bony landmarks
  • Palpate olecranon tip, medial epicondyle, lateral epicondyle (palpate in extension and in flexion)
  • Palpate radial head with thumb on rotation of forearm
• Palpate tendons
  • Common extensor origin – just distal to lateral epicondyle (pain = Tennis elbow)
  • Common flexor origin – just distal to medial epicondyle (pain = Golfer’s elbow)
• Palpate ulnar groove between the olecranon process and the medial epicondyle (paraesthesia in ulnar nerve distribution = cubital tunnel syndrome)

Move

Test active then passive movements:

• Flexion (145˚)
• Extension (0˚) 
• Pronation (85˚) of wrist while elbow flexed to 90˚
• Supination (90˚) of wrist while elbow flexed to 90˚
• SPECIAL TESTS:

Lateral collateral ligament	Flex elbow to 30˚and apply varus force while forearm supinated
Medial collateral ligament	Flex elbow to 30˚and apply valgus force while forearm pronated
Tennis elbow test	With elbow at 90˚, forearm pronated, and wrist fully flexed, ask patient to extend wrist while applying resistance (pain at lateral epicondyle = positive test)
Golfer’s elbow test	With elbow at 90˚, forearm pronated, and wrist fully extended, ask patient to flex wrist while applying resistance (pain at medial epicondyle = positive test)

Function

• Move hand to mouth
• Place hands behind head

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would examine the shoulders and wrists, and perform a distal neurovascular examination.’
• Summarise and suggest further investigations you would consider after a full history 

Common elbow pathology

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Valgus and varus forces

Some questions for you

Try a station

1. Elbow exam
2. Find more here