Introduction
The elbow is a common musculoskeletal OSCE station. Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow) are the highest-yield diagnoses. Always assess the ulnar nerve at the cubital tunnel and screen for referred pain from the cervical spine.
💎 Clinical Pearl
Examine the unaffected elbow first for comparison. The elbow has three joints sharing one synovial cavity: radiohumeral, ulnohumeral, and proximal radioulnar.
Preparation
- Introduce yourself, confirm patient identity
- Explain the examination and obtain verbal consent
- Expose both arms fully
- Ask about pain before touching
1. Look
| Finding | Significance |
|---|---|
| Carrying angle (cubitus valgus > 15 degrees) | Previous lateral condyle fracture, Turner's syndrome |
| Cubitus varus | Previous supracondylar fracture |
| Swelling over olecranon | Olecranon bursitis (gout, RA, trauma) |
| Rheumatoid nodules | Seropositive RA |
| Fixed flexion deformity | Haemarthrosis, loose body, RA |
| Surgical scars | Prior trauma or surgery |
2. Feel
The three bony landmarks form an equilateral triangle in 90 degrees of flexion:
| Structure | Pathology |
|---|---|
| Lateral epicondyle | Lateral epicondylitis (tennis elbow) |
| Medial epicondyle | Medial epicondylitis (golfer's elbow) |
| Olecranon | Bursitis, fracture, tophi (gout) |
| Radial head | Fracture, OA, synovitis |
| Cubital tunnel (medial) | Ulnar nerve tenderness or thickening |
Also palpate for an effusion in the triangle between the radial head, lateral epicondyle, and olecranon.
3. Move
| Movement | Normal range |
|---|---|
| Flexion | 145 degrees |
| Extension | 0 degrees (full extension) |
| Supination | 90 degrees |
| Pronation | 90 degrees |
A fixed flexion deformity (loss of full extension) is an early sign of intra-articular pathology.
4. Special Tests
Cozen's Test (Tennis Elbow / Lateral Epicondylitis)
Ask the patient to make a fist, pronate the forearm, and extend the wrist against resistance. Positive if pain is reproduced at the lateral epicondyle.
Medial Epicondyle Stress Test (Golfer's Elbow)
Ask the patient to flex the wrist against resistance with the elbow extended and forearm supinated. Positive if medial epicondyle pain is reproduced.
🧠 Mnemonic
Lateral = back of hand (extension). Medial = palm up (flexion).
Tennis elbow hurts when resisting wrist extension (back-of-hand motion). Golfer's elbow hurts when resisting wrist flexion (palm-up swing motion).
Ulnar Nerve Assessment (Cubital Tunnel Syndrome)
- Tinel's sign: tap over the ulnar nerve at the medial elbow — tingling in the ring and little fingers is positive
- Test intrinsic hand muscles: first dorsal interosseous, hypothenar eminence
- Sensation: medial one-and-a-half fingers on the palmar surface
Common OSCE Diagnoses
| Diagnosis | Key features |
|---|---|
| Lateral epicondylitis | Cozen's test positive, lateral epicondyle tenderness, resisted extension pain |
| Medial epicondylitis | Medial stress test positive, medial epicondyle tenderness |
| Olecranon bursitis | Posterior soft fluctuant swelling, usually non-tender |
| Cubital tunnel syndrome | Ulnar Tinel's positive, intrinsic weakness, ring and little finger numbness |
| Elbow OA | Crepitus, reduced ROM especially extension |
| RA | Bilateral synovitis, fixed flexion deformity, rheumatoid nodules |
How to Present
"On examination of the right elbow there was no swelling or deformity. Palpation revealed point tenderness over the lateral epicondyle. Cozen's test was positive, reproducing the patient's pain on resisted wrist extension. Range of motion was full and equal bilaterally. Ulnar nerve assessment was normal. My findings are consistent with lateral epicondylitis."
"What is the difference between tennis elbow and golfer's elbow?"
Tennis elbow (lateral epicondylitis) involves degeneration of the common extensor origin at the lateral epicondyle, causing pain on resisted wrist extension. Golfer's elbow (medial epicondylitis) involves the common flexor origin at the medial epicondyle, causing pain on resisted wrist flexion. Both are tendinopathies rather than true inflammatory conditions.
"How do you test for lateral epicondylitis?"
Cozen's test: ask the patient to make a fist, pronate the forearm, and extend the wrist against your resistance. Pain at the lateral epicondyle is a positive result. Mill's test is an alternative: passively flex the wrist with the elbow extended and forearm pronated and pain at the lateral epicondyle is positive.
"What are the signs of cubital tunnel syndrome?"
Cubital tunnel syndrome is compression of the ulnar nerve at the medial elbow. Signs include tingling in the ring and little fingers (Tinel's sign over the cubital tunnel), weakness of intrinsic hand muscles (interossei, hypothenar group, medial two lumbricals), and sensory loss over the medial 1.5 fingers.
"What are the three bony landmarks of the elbow and what is their clinical significance?"
The medial epicondyle, lateral epicondyle, and olecranon form an equilateral triangle in 90 degrees of flexion. This triangle is intact in supracondylar fractures but disrupted in posterior dislocations (all three shift posteriorly together). Preserving this relationship helps distinguish fracture from dislocation in clinical practice.
Related guides: [Shoulder Examination OSCE](/blog/shoulder-examination-osce) | [Hand Examination OSCE](/blog/hand-examination-osce) | [Musculoskeletal History OSCE](/blog/musculoskeletal-history-osce)