Special Tests for the Physical Exam of the Elbow
The physical examination of the elbow should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patients elbow pain. In general, a thorough physical examination will include inspection, palpation, active and passive range of motion, strength, neurovascular and special tests. The purpose of today’s post is to review some of the special tests for the elbow exam that all members of the sports medicine team should be familiar with. We will review some of the more commonly used exam techniques but it is worth mentioning there are dozens of others that are not covered here. It is also worth noting that some of these examination techniques may overlap with more than one disease process.
Tennis Elbow (Lateral Epicondylitis)
Cozen’s Test. The patient cant be seated or standing. The examiner should stabilize patients elbow in 90° flexion with one hand on the lateral epicondyle. The examiner then positions the patients hand into pronation and radial deviation. Then, the patient is asked to return the hand to the supinated position against resistance. A positive test is reproduction of the pain.
Maudsley’s Test. This is sometimes called the middle finger extension test. The examiner places one hand on the common extensor tendon and one hand on the middle finger in a neutral position. The examiner then asks the patient to extend the middle finger of the affected arm. A positive test is reproduction of the pain at the lateral epicondyle or common extensor tendon. A slight modification of the test involves performing the exam with the patients hand flat on the table (pictured).
Golfer's Elbow (Medial Epicondylitis)
Golfer’s Elbow Test. The examiner places one hand on the medial epicondyle or common flexor tendon. The examiner uses the other hand to passively supinate the arm and extend the elbow and wrist. A positive test is pain or discomfort along the medial epicondyle or common flexor tendon.
Bicep's Tendon Rupture
Hook Test. The patient is asked to flex to 90° and fully supinate their forearm. The examiner then uses their index finger to hook the lateral edge of the biceps tendon. In a normal exam, the finger can be inserted 1 cm beneath the tendon. In biceps tendon ruptures, no cord-like structure under which the examiner may hook a finger. Note, in partial tears this test can still be normal.
Ulnar Collateral Ligament Injury
Milking Maneuver. The elbow and shoulder are flexed to 90°, forearm is supinated. The physician pulls on the patients thumb. A positive test is apprehension, instability, or pain,
Elbow Valgus Stress Test. The elbow is held in 20° flexion, one hand supporting the elbow with the humerus somewhat externally rotated. The other hand is on the forearm applying valgus stress. A positive test is pain or laxity compared to the unaffected arm. Note this test can also be used for little leaguers elbow.
Radial Collateral Ligament Injury
Elbow Varus Stress Test. The elbow is held in sight flexion at 20° with one of the examiners arms on medial side of the elbow. The other arm holds the wrist and applies a varus stress to the joint. A positive test is pain or laxity on the affected arm compared to the contralateral limb.
Pushup Apprehension Test. The patient is asked to perform a pushup from the floor. The elbows are placed at 90° flexion, forearms supinated, arms abducted greater than shoulder width. Repeat the test with forearms in pronation. A positive test is apprehension when the elbow is terminally extended from a flexed position with voluntary and involuntary guarding or complete dislocation. Elbow pain with supination which improves with pronation is also considered a positive finding.
Posteromedial Rotatory Instability
Hyperpronation Test. The elbow is passively placed at 90° of flexion. The examiner hyperpronates the patient’s forearm. This hyperpronation imparts a medial rotatory force to the ulnohumeral joint. A positive test is visualization or palpation of the posteromedial rotatory ulnohumeral subluxation.
Radial Tunnel Syndrome
Resisted Active Forearm Extension Test. The patient patient actively extends their forearm against resistance. A positive test is a dull achy pain in posterior forearm just distal to the lateral epicondyle of the humerus. Weakness in extensor muscles dorsally can also be seen.
Cubital Tunnel Syndrome
Tinel’s Test. This special maneuver is used to diagnose a series of neuropathies, most commonly carpal tunnel syndrome. For cubital tunnel, tapping or pressing against the cubital tunnel can recreate the symptoms if an ulnar neuropathy is present.
Active Radiocapitellar Compression Test. The patient’s elbow is fully extended. Apply an axial force down the arm. Pronate and supinate the forearm while maintaining axial force. A positive test is elbow pain during forearm rotation. You may feel locking or catching from loose bodies.