Examine the elbow by looking at both arms together, palpating the lateral epicondyle, medial epicondyle and olecranon, then testing flexion, extension, pronation and supination. Add resisted wrist extension and Maudsley's test for tennis elbow, and Tinel's sign over the ulnar nerve at the medial elbow, as NICE Clinical Knowledge Summaries describe.

Key takeaways

  • NICE CKS locates tennis elbow pain over and distal to the lateral epicondyle, along the common extensor tendon.
  • Maudsley's test is painful resisted extension of the middle finger.
  • Resisted wrist dorsiflexion with the elbow at 90 degrees hurts more when the elbow is then extended.
  • Tinel's sign at the medial elbow is positive when tapping over the ulnar nerve generates paraesthesia without pain.
  • In tennis elbow, NICE CKS expects a full range of active and passive movement and normal sensation.

What is the examiner marking at the elbow station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking a complete look, feel, move and function sequence, plus a sensible differential. Royal College of Surgeons of Edinburgh describes the applied skills component as covering clinical and procedural skills, and both components must be passed.

This page is written from current guidance rather than from the old site text, because the legacy elbow page carried only a fragment.

How should you start the elbow examination?

Introduce yourself, take consent, expose both arms to the shoulder and ask about pain. Position the patient standing or sitting with the arms relaxed at the sides.

Ask about occupation and activity early. NICE CKS lists construction work, assembly line work, vibratory tools, typing, piano, tennis and kayaking as provoking activities for tennis elbow.

What am I looking for on inspection of the elbow?

Look at both elbows together from the front, the side and behind, comparing carrying angle, swelling and skin.

  • Skin, for scars, psoriatic plaques, rheumatoid nodules and sinuses
  • Swelling over the olecranon, which suggests bursitis
  • Muscle wasting of the forearm and of the first dorsal interosseous, which suggests ulnar nerve involvement
  • Alignment, comparing the carrying angle of the two arms rather than quoting a number

**Olecranon bursitis** is inflammation of the bursa over the olecranon, which presents as a discrete posterior swelling rather than a global joint effusion.

What should you palpate at the elbow?

Palpate the three bony landmarks and the soft tissue between them. Ask about pain before you press and watch the patient's face.

  • Lateral epicondyle and the common extensor origin, tender over and distal to the epicondyle in tennis elbow per NICE CKS
  • Medial epicondyle and the common flexor origin
  • Olecranon and the posterior bursa
  • The ulnar nerve in its groove behind the medial epicondyle, checking for tenderness and for subluxation on flexion

Which movements should you test at the elbow?

Test flexion and extension, then pronation and supination with the elbows tucked in at the sides so the shoulder cannot compensate.

Test each actively, then passively, then against resistance. NICE CKS notes that in tennis elbow a full range of active and passive elbow and wrist movement is usually preserved, so a stiff elbow points elsewhere.

Which special tests confirm tennis elbow?

Two resisted tests, both described by NICE CKS. Resisted middle finger extension, known as Maudsley's test, may be painful, and resisted wrist dorsiflexion with the elbow flexed to 90 degrees becomes more painful when the elbow is extended.

Grip strength may be reduced. NICE CKS also asks you to check for red flags such as a swollen, red, tender joint, which suggests an alternative diagnosis.

How do you assess the ulnar nerve at the elbow?

Tap lightly over the ulnar nerve at the medial elbow for Tinel's sign, which NICE CKS calls positive when it generates paraesthesia without pain, and notes that a negative sign helps rule out cubital tunnel syndrome.

Then test the hand: sensation over the little finger, finger abduction, and Froment's sign, which is positive when the thumb flexes at the interphalangeal joint to hold paper because adductor pollicis is weak.

What are the most common mistakes at the elbow station?

  • Examining one elbow, so the carrying angle and swelling have no comparison
  • Skipping pronation and supination, which is where stiffness often shows
  • Pressing hard on an inflamed epicondyle before asking about pain
  • Ignoring the neck and shoulder, which NICE CKS asks you to assess for referred pain
  • Failing to examine the hand when the history suggests ulnar nerve compression

How should you finish the elbow examination?

Offer to examine the joint above and below, complete a neurovascular assessment of the limb, and summarise your findings with a differential.

NICE CKS notes that investigations are not usually needed in primary care for tennis elbow, so say why you would image rather than requesting films reflexively.

The MRCS Part B Questions bank has an elbow examination station at /Sample-Questions.