Elbow — Fast Exam

Tap a diagnosis. Tests first, interpretation underneath.

30-second screen

Run this before any special testWhere is the pain → resisted loading → is it the nerve → range

Red flags? Trauma with deformity, a hot swollen joint, night pain — listed at the bottom.
Ask them to point with one finger. Lateral epicondyle → extensor origin. Medial epicondyle → flexor origin. Cubital tunnel → ulnar nerve. Anterior → biceps or joint. Olecranon → bursa or triceps.
Palpation first. In the elbow, focal tenderness at the right place beats every provocative test. This is the highest-yield step.
Resisted loading in each direction — wrist extension (lateral), wrist flexion and pronation (medial), supination (biceps), triceps.
Check the nerve. Tinel at the cubital tunnel, elbow flexion test, and a quick sensation and grip check. Pain radiating below the elbow with pins and needles is a nerve, not a tendon.
Range of motion, including full extension. Losing the last few degrees of extension is the earliest sign of elbow arthritis or of a longstanding problem.
Grip strength compared to the other side. A simple, objective, underused measure — weakness is often the real functional complaint.

The honest caveat: elbow tests have modest accuracy and lots of overlap. The provocative tests for lateral epicondylalgia are sensitive but poorly specific — they hurt in plenty of normal elbows. Location of tenderness plus a compatible load history does most of the work.

Tendon

Lateral epicondylalgia (tennis elbow)Focal lateral epicondyle pain with gripping and lifting

Hallmark

Pain at the extensor origin, made worse by gripping, lifting a kettle, or shaking hands. Non-dominant and dominant sides both affected; usually 35–55 years old. It is a tendinopathy of the common extensor origin — the extensor carpi radialis brevis — not an inflammation.

Tests

Palpation of the extensor origin — just anterior to the lateral epicondyle. Positive: focal tenderness. The single most useful finding.
Cozen — elbow flexed, forearm pronated, wrist extended and radially deviated; resist. Positive: pain at the lateral epicondyle. Sn ~91% (Karanasios)sensitive, poorly specific — hurts in normal elbows too
Mill — elbow extended, forearm pronated, wrist flexed; passively stretch. Positive: lateral epicondyle pain.
Maudsley — resist extension of the middle finger. Positive: lateral epicondyle pain. Sn ~88%published specificity figures are inconsistent — do not rely on this test alone
Grip strength — dynamometer, compare sides. Positive: pain-limited weakness. Also your best objective marker of improvement.

Next: clinical diagnosis. The treatment that works is progressive eccentric and isometric loading of the extensor tendon over months, not rest. Cortisone injection gives short-term relief and worse long-term outcomes — avoid it as a routine.

Medial epicondylalgia (golfer's elbow)Focal medial epicondyle pain with gripping and wrist flexion

Hallmark

Pain at the flexor-pronator origin. Same functional complaints as lateral epicondylalgia but on the other side of the elbow. Must be distinguished from ulnar neuropathy, which is often present at the same time.

Tests

Palpation of the flexor origin — Positive: focal tenderness just distal and anterior to the medial epicondyle.
Resisted wrist flexion with pronation — elbow extended. Positive: medial pain.
Ulnar nerve screen — always. Positive: Tinel over the cubital tunnel, or symptoms in the little and ring finger → coexisting ulnar neuropathy, which changes the plan.

Next: same principle as lateral — loading, not rest. If the ulnar nerve is involved, the prognosis is worse and you need to address both.

Distal biceps ruptureSudden pop with a tearing sensation — then the hook test settles it

Hallmark

A sudden pop in the antecubital fossa with a tearing sensation, often while lifting something heavy with the elbow flexed and the forearm supinated. Bruising appears over days. Supination weakness is more marked than flexion weakness.

Tests

Hook test — with the elbow flexed to 90° and the forearm supinated, try to hook your index finger under the lateral edge of the biceps tendon in the antecubital fossa. Positive: you cannot hook it at all → complete rupture. O'Driscoll: Sn/Sp both 100%; Devereaux: Sn 81% / Sp 100%; a later series: Sn 78% overall, 83% complete, 30% partial
Biceps squeeze test — squeeze the muscle belly; the forearm should supinate. Positive: no supination.
Reverse Popeye sign and palpable defect — Positive: the muscle retracts proximally and you can feel the empty tendon bed.
Resisted supination versus resisted flexion — Positive: supination markedly weaker. Flexion is partly preserved because brachialis is intact.

Next: a complete rupture in a fit or active patient is a surgical conversation, and outcomes are better with early repair. The hook test is quick and decisive — do it whenever the history fits.

Ligament

Ulnar collateral ligament (UCL) injuryMedial elbow pain in a throwing athlete — the moving valgus stress test

Hallmark

Medial elbow pain in an overhead thrower, worst at the late cocking and acceleration phases and often with a loss of velocity. Must be separated from a flexor-pronator strain, which overlaps heavily and has a much better prognosis.

Tests

Moving valgus stress test — apply a valgus load and take the elbow briskly from full flexion to extension. Positive: pain reproduced between 70° and 120° of flexion (the throwing arc). Sn 100% / Sp 75% in the original description; a later series found Sn 98% with the highest accuracy of the tests studied
Milking manoeuvre — lift the thumb and pull the forearm into valgus with the elbow flexed and the shoulder rotated. Positive: medial pain. Better for the anterior bundle and for patient comfort than static stress.
Static valgus stress — elbow flexed 20–30°, forearm supinated. Positive: excess laxity compared with the other side. This one assesses laxity, not pain — the two are different questions.

Next: a real trap — valgus laxity is common in asymptomatic overhead athletes, so laxity alone is not the diagnosis. Pain on the moving valgus stress test matters more than the degree of opening. Imaging: MRI with or without arthrography, and only in a surgical candidate.

Posterolateral rotatory instabilityPainful clicking and a sense of the elbow giving way

Hallmark

A history of a fall on an outstretched arm, then a sense of instability and painful clicking, often with pushing up from a chair. Part of the spectrum of a chronic elbow dislocation mechanism.

Tests

Lateral pivot shift — supine, arm overhead, elbow flexed, forearm supinated, valgus and axial load applied while extending. Positive: a visible and palpable rotatory shift of the radial head, with apprehension. Provoking apprehension without a demonstrable shift is not the same finding — and this test is hard to elicit in an awake, guarded patient.
Chair push-up sign — Positive: the arm cannot be pushed up from a chair without apprehension or giving way.
Posterolateral rotatory drawer — a supine variation for a more controlled examination.

Next: rare and genuinely hard to examine. If the history is convincing, refer — this is one to recognise, not to diagnose confidently in a fast consult.

Nerve

Cubital tunnel syndrome (ulnar neuropathy)Pins and needles in the little and ring finger, worse with the elbow bent

Hallmark

Medial elbow pain with paraesthesia in the little and ring fingers, worse with the elbow flexed — holding a phone, sleeping. Symptoms are often worse at night. The ulnar nerve is the commonest trapped nerve at the elbow.

Tests

Tinel at the cubital tunnel — tap behind the medial epicondyle. Positive: tingling radiating into the little and ring fingers. Beware: a positive Tinel is often present in normal people too.
Elbow flexion test — hold the elbow in full flexion for 60 seconds. Positive: provoked symptoms in the ulnar distribution. Better than Tinel, still not robust.
Froment sign — pinch a sheet of paper between thumb and index, pull away. Positive: the thumb flexes (Froment's) to compensate for a weak adductor pollicis → motor involvement.
Sensation and grip — test two-point discrimination in the little finger, abductor digiti minimi bulk, and grip strength. Any motor loss shifts urgency.
Check the neck and the shoulder — a C8/T1 lesion and thoracic outlet both mimic this. Screen before you treat.

Next: nerve conduction studies if symptoms are persistent or if there is motor weakness. Night splinting in extension and load modification help early; delay in the presence of motor loss or muscle wasting makes the recovery worse.

Radial tunnel syndromeLateral forearm pain with no weakness — and no numbness

Hallmark

Deep, aching lateral forearm pain with activity, without the discrete paraesthesia of a true nerve entrapment. Easily mistaken for lateral epicondylalgia, and the two frequently coexist.

Tests

Tenderness over the radial tunnel — 3–5 cm distal to the lateral epicondyle, in the line of the nerve. Positive: pain distal to the epicondyle, rather than at it — the location is the discriminator from epicondylalgia.
Resisted supination with the elbow extended — Positive: pain reproducing the patient's symptoms.
Resisted middle finger extension — Positive: pain. Note this is also Maudsley's test for epicondylalgia, which is precisely why the two are so hard to separate.

Next: the honest position — radial tunnel syndrome is difficult to distinguish from lateral epicondylalgia and commonly misdiagnosed. Pain distal to the epicondyle, no epicondylar tenderness, and no weakness or numbness points this way. Treat conservatively first; true entrapment with weakness is a referral.

Other

Elbow osteoarthritis and loose bodiesLost the last few degrees of extension, with crepitus

Hallmark

Progressive stiffness, an inability to fully straighten the elbow, crepitus, and pain at end range. Often a history of manual work, a previous injury, or a throwing background.

Tests

Range of motion, measured against the other side — Positive: a lost extension arc, the earliest and most clinically significant finding.
Crepitus and end-range pain — Positive: with a matching radiograph.
Locking or catching — Positive: a loose body. This blocks the joint mechanically and needs arthroscopy rather than therapy.

Next: radiograph. Not a special-test diagnosis. A lost extension arc is functionally significant and worth treating early.

Olecranon bursitisA boggy swelling over the point of the elbow

Hallmark

A fluctuant swelling over the olecranon, usually from repeated pressure or a single traumatic event. Painless in the simple mechanical case.

Next: the whole question is whether it is infected. Hot, red, tender, febrile, or an open wound over it → aspirate and treat as septic. Do not inject a possibly infected bursa. Simple mechanical bursitis needs padding and time, not aspiration.

Choosing the imagingRadiograph for arthritis and trauma · MRI only for a surgical question

Radiograph first — trauma, suspected arthritis, loose bodies, or a calcific tendon.
Ultrasound — tendons, the bursa, and guided injection. Good for confirming a distal biceps rupture if the hook test is equivocal.
MRI or MR arthrography — UCL injury, osteochondral lesions, and surgical planning. Only useful if the answer changes what you do.
Nerve conduction studies — persistent ulnar symptoms, or any motor deficit.

Worth remembering: in the elbow, examination and the history carry more of the diagnosis than in the shoulder. Resist ordering an MRI to answer a question your hands can answer.

Red flags — before you test

Re-route before you testSix findings that take precedence over any special test

Stop and re-route

Trauma with obvious deformity, or an elbow that will not flex or extend → dislocation or fracture. Radiograph before any movement or reduction. Check the neurovascular status and document it.
Hot, swollen, red, held in mid-flexion with severe pain → septic arthritis. Urgent aspiration. The elbow is a common site for this.
Progressive numbness, weakness or intrinsic hand wasting → significant nerve compression. Refer, do not watch.
A child with elbow pain and reluctance to use the arm after a fall → supracondylar fracture until excluded. Radiograph.
Night pain, unexplained weight loss, or a history of cancer → malignancy. Urgent referral.
Anterior elbow pain with a biceps bulge but no tendon palpable → distal biceps rupture. Missed cases become chronically retracted and much harder to repair.

Built for Ruby — PRM & sports medicine elbow reference.
Single file, works offline. Edit the <details> blocks directly; each card is self-contained.

Sources. [1] Moving valgus stress test — original description Sn 100% / Sp 75%; a later clinical-utility study found Sn 98% with the highest accuracy (93%) and the lowest negative likelihood ratio of the tests studied. [2] Hook test — O'Driscoll 2005: sensitivity and specificity both 100% in the original cohort; Devereaux 2013: specificity 100% with sensitivity 81%; Luokkala 2019 (PMC7400716): sensitivity 78% overall, 83% for complete and 30% for partial tears. The spread across these three is why the card quotes a range. [3] Cozen's test — Sn ~91%, cited from Karanasios et al. in Physiopedia's elbow hook test entry. [4] Maudsley's test — Sn ~88%. Published specificity values for this test are inconsistent between sources, so none is quoted. [5] Biceps squeeze test — reported at 96% sensitivity and 100% specificity in one series. [6] Static valgus stress — assesses laxity, not pain; valgus laxity is common in asymptomatic overhead athletes. [7] Tests without figures are described from standard technique. Where the literature does not provide robust accuracy data, none is quoted rather than inventing one.

Diagnostic accuracy figures are pooled from the cited literature and vary widely between studies and populations. Interpret alongside history and pre-test probability. Not a decision-support system, and not a substitute for your own clinical judgement or local protocols.