What type of physical assessment is recommended for chronic elbow pain?

Physical Assessment for Chronic Elbow Pain

For chronic elbow pain, a comprehensive physical assessment should include radiography as the initial imaging modality, followed by targeted physical examination of the four anatomical regions of the elbow (medial, lateral, anterior, and posterior), with advanced imaging such as MRI reserved for persistent symptoms. 1, 2

Initial Assessment

Physical Examination Components:

1. Four-quadrant approach - Examine each region systematically:

   • Lateral: Assess for lateral epicondylitis (tennis elbow)

     • Tenderness over lateral epicondyle
     • Pain with resisted wrist extension
     • Pain with passive wrist flexion with elbow extended

   • Medial: Assess for medial epicondylitis (golfer's elbow)

     • Tenderness over medial epicondyle
     • Pain with resisted wrist flexion
     • Assess ulnar nerve for entrapment (Tinel's sign)

   • Anterior: Assess for biceps tendinopathy

     • Tenderness over anterior elbow
     • Pain with resisted supination and elbow flexion

   • Posterior: Assess for olecranon bursitis or triceps tendinopathy

     • Swelling or tenderness over olecranon process
     • Pain with resisted elbow extension 3, 4

2. Range of motion assessment:

   • Active and passive flexion/extension (normal: 0° to 140°)
   • Pronation/supination (normal: 80° pronation, 85° supination)
   • Compare with unaffected side 4

3. Stability testing:

   • Valgus and varus stress tests for collateral ligament integrity
   • Assessment for joint laxity 4

Imaging Assessment

Initial Imaging:

• Radiographs (X-rays) - Usually appropriate as first-line imaging:
  • Standard views: anteroposterior, lateral, and oblique views
  • Can detect intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis
  • Comparison with asymptomatic side is often useful 1, 2

Advanced Imaging (for persistent symptoms):

• MRI - Preferred for chronic elbow pain assessment:

  • Best for detecting bone marrow edema, tendinopathy, nerve entrapment, and joint effusion
  • Complements initial radiographic findings 2, 3

• Ultrasound - Useful for evaluating soft tissue injuries:

  • High sensitivity for detecting medial epicondylalgia
  • Allows dynamic assessment of tendons, ligaments, and cartilage
  • Cost-effective alternative to MRI for certain conditions 2, 3

Special Considerations

• Provocative tests for specific conditions:

  • Lateral epicondylitis: Cozen's test (pain with resisted wrist extension)
  • Medial epicondylitis: Golfer's elbow test (pain with resisted wrist flexion)
  • Ulnar neuropathy: Tinel's sign at cubital tunnel, elbow flexion test
  • Radial tunnel syndrome: Pain with resisted middle finger extension 5, 4

• Polk's test may help differentiate between lateral and medial epicondylitis by identifying activities of daily living that may be aggravating the condition 6

Common Pitfalls to Avoid

1. Failure to assess all four anatomical regions of the elbow, potentially missing concurrent pathologies

2. Overlooking referred pain from cervical spine or shoulder pathology

3. Neglecting to evaluate for nerve entrapment syndromes (ulnar, median, or radial) when epicondylitis treatment is unsuccessful 5

4. Relying solely on imaging without correlating with clinical findings - Remember that radiographic findings may not always correlate with symptoms

5. Jumping to advanced imaging before appropriate physical examination and initial radiographs 1, 2

By following this systematic approach to physical assessment of chronic elbow pain, clinicians can accurately diagnose the underlying pathology and develop an appropriate treatment plan that will improve patient outcomes in terms of morbidity, mortality, and quality of life.