The elbow joint is integral to the functionality of the upper limb, presenting as a sophisticated hinge joint involving the interplay of the humerus, radius, and ulna, along with a complex arrangement of ligaments, tendons, muscles, nerves, and blood vessels. For healthcare providers, an in-depth grasp of its structural and mechanical nuances is essential for precise evaluation, diagnosis, and management of elbow pathologies. This piece offers an exhaustive yet accessible walkthrough of the orthopedic assessment of the elbow, embedding detailed anatomical insights and appropriate references to empower clinicians with a more efficacious and knowledgeable examination approach.
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Elbow Anatomy
Before we dive into the specifics of the elbow examination, it's essential to familiarize ourselves with the elbow's anatomy, which plays a significant role in its function and the structures involved. The elbow is a multifaceted hinge joint that permits flexion, extension, pronation, and supination of the forearm. Its intricate anatomy consists of bones, muscles, ligaments, tendons, nerves, and vascular structures, all working together to provide stability and movement (9,10,11,12).
Bones
The elbow joint is formed by three primary bones:
Humerus: The elongated bone in the upper arm, which establishes articulations with both the radius and ulna, specifically at the trochlea and capitulum of the distal humerus, respectively.
Radius: The lateral bone of the forearm (on the thumb side) that primarily contributes to the proximal radioulnar joint at the radial head, and the wrist joint distally. It articulates with the capitulum of the humerus and also plays a crucial role in pronation and supination of the forearm.
Ulna: The medial bone of the forearm (on the pinky side) that forms the primary articulation with the humerus at the trochlear notch, creating the hinge joint of the elbow. Additionally, the ulna partakes in the proximal radioulnar joint with the radius, facilitating rotation of the forearm.
Muscles
Numerous muscles surround the elbow joint, facilitating its various movements, and can be categorized based on their primary actions. The origin and insertion points of these muscles are crucial for understanding their functions:
Biceps brachii: Responsible for flexing the elbow and supinating the forearm.
Origin: Comprises two heads; the long head originates from the supraglenoid tubercle of the scapula, and the short head from the coracoid process of the scapula.
Insertion: Inserts into the radial tuberosity.
Brachialis: Acts as a primary flexor of the elbow.
Origin: Arises from the anterior surface of the distal half of the humerus.
Insertion: Inserts into the coronoid process and tuberosity of the ulna.
Triceps brachii: The primary extensor of the elbow.
Origin: Consists of three heads; the long head originates from the infraglenoid tubercle of the scapula, the lateral head from the posterior surface of the humerus (above the radial groove), and the medial head from the posterior surface of the humerus (below the radial groove).
Insertion: Inserts into the olecranon process of the ulna.
Brachioradialis: Aids in flexion and pronation/supination of the forearm.
Origin: Arises from the lateral supracondylar ridge of the humerus.
Insertion: Inserts into the styloid process of the radius.
Pronator teres: Contributes to pronation of the forearm.
Origin: Possesses two heads; the humeral head originates from the medial epicondyle of the humerus, and the ulnar head from the coronoid process of the ulna.
Insertion: Inserts into the lateral surface of the radius, midway down the shaft.
Supinator: Supinates the forearm.
Origin: Arises from the lateral epicondyle of the humerus, the radial collateral ligament, the annular ligament, and the proximal two-thirds of the ulna.
Insertion: Inserts into the lateral surface
Ligaments
Ligaments are strong bands of connective tissue that help stabilize the elbow joint by connecting bones and maintaining proper alignment. The primary ligaments of the elbow include:
Medial collateral ligament (MCL): Also known as the ulnar collateral ligament, the MCL consists of three parts: anterior, posterior, and transverse bundles. It provides stability to the inner (medial) aspect of the elbow.
Origin: Arises from the medial epicondyle of the humerus.
Insertion: Inserts into the sublime tubercle of the ulna.
Lateral collateral ligament (LCL): This ligament complex stabilizes the outer (lateral) aspect of the elbow. It is composed of the radial collateral ligament, lateral ulnar collateral ligament, and accessory lateral collateral ligament.
Origin: Arises from the lateral epicondyle of the humerus.
Insertion: The radial collateral ligament inserts into the annular ligament, the lateral ulnar collateral ligament inserts into the supinator crest of the ulna, and the accessory lateral collateral ligament inserts into the ulna distal to the supinator crest.
Annular ligament: A strong fibrous band that encircles the radial head and maintains its articulation with the ulna, allowing for rotation of the radius during pronation and supination.
Origin and Insertion: The annular ligament originates from the anterior and posterior margins of the radial notch of the ulna and attaches to the anterior and posterior margins of the neck of the radius.
Tendons
Tendons are fibrous connective tissues that attach muscles to bones, transmitting the force generated by muscle contraction to produce movement. Some key tendons in the elbow joint include:
Biceps tendon: Composed of two heads - the long head and short head - this tendon attaches the biceps brachii muscle to the radial tuberosity and the supraglenoid tubercle of the scapula, respectively. It enables elbow flexion and forearm supination.
Origin: The long head originates from the supraglenoid tubercle of the scapula, while the short head arises from the coracoid process of the scapula.
Insertion: Inserts into the radial tuberosity.
Triceps tendon: This tendon connects the three heads of the triceps brachii muscle to the olecranon of the ulna, facilitating elbow extension.
Origin: The long head originates from the infraglenoid tubercle of the scapula, the lateral head arises from the posterior humerus, and the medial head arises from the distal posterior humerus.
Insertion: Inserts into the olecranon of the ulna.
Common extensor tendon: A conjoined tendon formed by the extensor muscles of the forearm, including the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. It attaches to the lateral epicondyle of the humerus.
Origin: Arises from the lateral epicondyle of the humerus.
Insertion: Inserts into various structures in the forearm and hand, depending on the specific muscle.
Common flexor tendon: A conjoined tendon of the flexor muscles of the forearm, including the flexor carpi ulnaris, palmaris longus, flexor carpi radialis, and flexor digitorum superficialis. It attaches to the medial epicondyle of the humerus.
· Origin: Arises from the medial epicondyle of the humerus.
· Insertion: Inserts into various structures in the forearm and hand, depending on the specific muscle.
Nerves
Nerves play a crucial role in transmitting sensory and motor information between the brain and the elbow joint. Some of the major nerves involved in the elbow region include:
Median nerve: This nerve arises from the brachial plexus and travels through the arm and forearm. It innervates most of the anterior forearm flexor muscles, including the flexor carpi radialis, palmaris longus, and flexor digitorum superficialis, as well as the pronator teres and pronator quadratus. In the hand, it supplies the thenar muscles, the first and second lumbricals, and the lateral two digits' palmar digital nerves.
Origin: Formed by the medial and lateral cords of the brachial plexus.
Course: Descends through the arm and forearm, passing between the two heads of the pronator teres and entering the hand via the carpal tunnel.
Ulnar nerve: Also originating from the brachial plexus, the ulnar nerve supplies the flexor carpi ulnaris and flexor digitorum profundus in the forearm. In the hand, it innervates the hypothenar muscles, the interossei muscles, the medial two lumbricals, and the adductor pollicis, among other intrinsic hand muscles.
Origin: Arises from the medial cord of the brachial plexus.
Course: Descends through the arm and forearm, passing posterior to the medial epicondyle of the humerus (the "funny bone"), and enters the hand via Guyon's canal.
Radial nerve: Stemming from the brachial plexus, the radial nerve innervates the triceps brachii, anconeus, and brachioradialis muscles in the arm. In the forearm, it supplies the extensor muscles, including the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris.
Origin: Formed by the posterior cord of the brachial plexus.
Course: Descends through the arm, wrapping around the humerus and branching into the posterior interosseous nerve, which innervates the forearm extensors.
Vascular Structures
The elbow region is supplied by an intricate network of blood vessels that ensure adequate blood flow to the surrounding tissues. The primary vascular structures involved in the elbow region include:
Brachial artery: This artery is the principal blood supply to the elbow joint, originating as a continuation of the axillary artery. It courses along the medial aspect of the humerus, passing through the cubital fossa and dividing into the radial and ulnar arteries at the level of the neck of the radius.
Branches: Profunda brachii artery, superior ulnar collateral artery, and inferior ulnar collateral artery.
Radial artery: A branch of the brachial artery, the radial artery supplies blood to the lateral aspect of the forearm. It runs along the radial side of the forearm, crossing the anatomical snuffbox, and eventually forming the deep palmar arch in the hand.
Branches: Radial recurrent artery, palmar carpal branch, and dorsal carpal branch.
Ulnar artery: Another branch of the brachial artery, the ulnar artery supplies blood to the medial aspect of the forearm. It descends through the forearm and passes superficial to the flexor retinaculum, ultimately forming the superficial palmar arch in the hand.
Branches: Anterior ulnar recurrent artery, posterior ulnar recurrent artery, common interosseous artery, and palmar and dorsal carpal branches.
A solid grasp of elbow anatomy is vital for performing a competent elbow examination. Comprehensive anatomical knowledge allows medical practitioners to accurately identify potential pathologies, understand the underlying biomechanics, and correlate clinical findings with the involved structures. This understanding improves not only diagnostic accuracy but also guides appropriate treatment options and interventions, ultimately resulting in better patient outcomes and overall care.
Inspection of the Elbow
The inspection phase consists of a visual examination of the elbow from anterior, lateral, and posterior views.
Anterior View
In the anterior view, the practitioner should look for asymmetry, scars, swelling, and skin changes such as erythema (1). The carrying angle (cubitus valgus), the angle between the humerus and forearm, should be observed. In normal conditions, the carrying angle should be between 5 and 15 degrees (1).
Lateral View
The practitioner should look for swelling, scars, visible atrophy, or deformities in the lateral view. The presence of a flexion deformity should be noted, as this could indicate a previous injury (1).
Posterior View
From the posterior view, the olecranon process and fossa should be observed for edema, muscle asymmetries, atrophy, and skin changes. Additionally, the practitioner should look for rheumatoid nodules, present in about 20% of patients with rheumatoid arthritis (2), and psoriatic plaques, which can be associated with underlying conditions such as cardiovascular disease, cancer, and autoimmune disorders (3).
Palpation of the Elbow
After inspection, palpation should be performed to assess the temperature and key structures of the elbow, including the lateral and medial epicondyles, radial head, olecranon process and fossa, ulnar nerve, and distal biceps tendon (1).
Temperature
Using the backs of the hands, the practitioner should check the temperature of both sides of the elbow and compare them to identify any potential inflammation (1).
Key Structures
The key structures to be palpated include:
Lateral epicondyle: the origin of the common extensor tendon.
Medial epicondyle: the origin of the common flexor tendon.
Radial head: palpate while performing supination and pronation.
Olecranon process and fossa: assess for swelling and tenderness.
Ulnar nerve: palpate in the groove between the medial epicondyle and olecranon.
Distal biceps tendon: palpate during forced or resisted supination (1).
Range of Motion
After palpation, active and passive range of motion should be assessed, followed by specific orthopedic tests to evaluate for tendinopathy or ligamentous instability (1).
Active and Passive Range of Motion (ROM)
Assessing the active and passive ROM of the elbow is crucial to determine joint stability and integrity. The practitioner should evaluate the following movements:
Flexion: normal range is 0 to 150 degrees (4).
Extension: normal range is 0 degrees (full extension) (4).
Pronation: normal range is 0 to 80 degrees (4).
Supination: normal range is 0 to 90 degrees (4).
Compare the range of motion between the affected and unaffected elbow to identify any limitations or asymmetries.
Special Tests
Several special tests can help identify specific pathologies within the elbow joint:
Cozen's Test (Lateral Epicondylitis Test):
The patient's elbow is stabilized while they make a fist, pronate their forearm, and extend their wrist against resistance. Pain at the lateral epicondyle indicates a positive test for lateral epicondylitis, also known as tennis elbow (5).
Golfer's Elbow Test (Medial Epicondylitis Test):
The patient's elbow is stabilized while they flex their wrist against resistance. Pain at the medial epicondyle indicates a positive test for medial epicondylitis, also known as golfer's elbow (6).
Varus and Valgus Stress Test:
The examiner applies a varus (lateral) or valgus (medial) force to the elbow while stabilizing the humerus. Increased laxity or pain in the lateral collateral ligament (LCL) or medial collateral ligament (MCL) may indicate a ligament injury (1).
Tinel's Sign:
The examiner taps the ulnar nerve at the cubital tunnel. Tingling or numbness in the ulnar nerve distribution (ring and little fingers) suggests ulnar nerve compression or irritation (1).
Moving Valgus Stress Test:
The examiner stabilizes the patient's humerus and applies a valgus force to the elbow while moving the elbow from flexion to extension. Pain between 70 to 120 degrees of flexion suggests MCL injury (7).
Orthopedic Examination Video
Join us for this instructional video on elbow assessment and orthopedic testing, presented by Dr. Brian Abelson DC, the creator of Motion Specific Release (MSR). In this tutorial, Dr. Evangelos Mylonas DC will lead you through a detailed elbow examination process.
Following the video, the remainder of this article offers a summary of the main topics covered, highlighting the essential components of an elbow orthopedic evaluation.
Conclusion
In summary, the orthopedic elbow examination is crucial for medical practitioners to master and accurately assess, diagnose, and treat various elbow conditions. A thorough understanding of the elbow's anatomy, including bones, muscles, ligaments, tendons, nerves, and vascular structures, is essential for conducting a comprehensive and accurate examination. Following a systematic approach and incorporating relevant special tests, practitioners can efficiently identify potential pathologies and tailor treatment plans accordingly. As a result, a well-executed elbow examination plays a vital role in ensuring optimal patient care and improved clinical outcomes.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred personalized care.
As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.
Despite being in the field for over three decades, Dr. Abelson remains open to welcoming new patients at Kinetic Health, save for the periods he dedicates to teaching or enjoying travels with his cherished wife, Kamali. However, be forewarned, he will anticipate your commitment to carry out the prescribed exercises and punctuality for your appointments (smile). His dedication towards your health is absolute, particularly in ensuring that you can revel in life unimpeded. He genuinely delights in greeting both new faces and familiar ones at the clinic (403-241-3772).
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References:
O'Driscoll, S. W. (2000). Classification and evaluation of recurrent instability of the elbow. Clinical Orthopaedics and Related Research, 370, 34-43.
Scott, D. G., Wolfe, S. W., & Huisinga, H. R. (2013). Green's Operative Hand Surgery: The Elbow (Vol. 1, 7th ed.). Elsevier Churchill Livingstone.
Gisondi, P., Tessari, G., Conti, A., Piaserico, S., Schianchi, S., Peserico, A., ... & Girolomoni, G. (2007). Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case-control study. British Journal of Dermatology, 157(1), 68-73.
Morrey, B. F., & An, K. N. (2005). Functional evaluation of the elbow. In Morrey's The Elbow and Its Disorders (4th ed., pp. 80-92). Elsevier.
Coonrad, R. W., & Hooper, W. R. (1973). Tennis elbow: its course, natural history, conservative and surgical management. Journal of Bone and Joint Surgery, 55(6), 1177-1182.
Ciccotti, M. G., Schwartz, M. A., & Ciccotti, M. C. (2004). Diagnosis and treatment of medial epicondylitis of the elbow. Clinical Sports Medicine, 23(4), 693-705.
O'Driscoll, S. W., Lawton, R. L., & Smith, A. M. (2005). The "moving valgus stress test" for medial collateral ligament tears of the elbow. American Journal of Sports Medicine, 33(2), 231-239.
Bishop, J. Y., & Kaeding, C. C. (2006). A systematic review of the diagnostic accuracy of provocative tests of the neck and shoulder. American Journal of Sports Medicine, 34(3), 429-437.
Standring, S. (Ed.). (2015). Gray's Anatomy: The Anatomical Basis of Clinical Practice (41st ed.). Elsevier.
Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2013). Clinically Oriented Anatomy (7th ed.). Lippincott Williams & Wilkins.
Netter, F. H. (2018). Atlas of Human Anatomy (7th ed.). Elsevier.
Tortora, G. J., & Derrickson, B. H. (2016). Principles of Anatomy and Physiology (15th ed.). Wiley.
Abelson, B. J., & Abelson, K. T. (2010, June 1). Release Your Kinetic Chain with Exercises for the Shoulder to Hand.
Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioners Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.
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