Elbow flexion test

The Elbow Flexion Test is a neurological provocation test used to diagnose cubital tunnel syndrome, a condition where the ulnar nerve is compressed at the elbow. It is a valuable tool in clinical assessment of patients presenting with numbness, tingling, or weakness in the hand and fingers, particularly within the ulnar nerve distribution[¹].

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Test Procedure

Patient Position

• The patient may be seated or standing.

Execution

1. The patient is instructed to actively flex the elbow maximally.

2. The wrist is held in full extension.

3. The shoulder girdle is abducted and depressed to 90°.

4. The patient maintains this position for 3–5 minutes[¹].

Interpretation

• Positive Test: Numbness or tingling in the ulnar nerve distribution. Pain may extend beyond the ulnar region into adjacent areas[²].

• Negative Test: No neurological symptoms appear during the test.

Clinical Anatomy

The ulnar nerve passes posterior to the medial epicondyle through the cubital tunnel, where it is vulnerable to compression. Prolonged elbow flexion narrows the tunnel and stretches the nerve, reproducing symptoms of irritation.

Common symptoms of cubital tunnel syndrome include:

• Numbness and tingling in the 4th and 5th digits

• Weakness in grip strength

• Atrophy of intrinsic hand muscles in advanced cases

Diagnostic Validity and Evidence

The Elbow Flexion Test has variable sensitivity, and when used alone, is considered less accurate. Its diagnostic power improves when combined with direct pressure over the cubital tunnel[⁵][²].

Research Findings

• Novak et al. (1994): Elbow Flexion Test alone demonstrated low sensitivity compared to other provocative tests[⁵].

• Ochi et al. (2011): In 25 patients with cubital tunnel syndrome, sensitivity was:

  • 80% for the Shoulder Internal Rotation Test

  • 36% for the Elbow Flexion Test[⁶]

• Rayan et al. (1992): Concluded that the test is a useful, reliable provocation tool for cubital tunnel syndrome, especially when combined with palpation[⁷].

Clinical Considerations

• Low sensitivity alone: A negative result does not exclude cubital tunnel syndrome.

• High diagnostic value in combination: Best performed alongside Tinel’s sign at the elbow, pressure provocation test, and Shoulder Internal Rotation Test.

• Practical advantages: Quick, non-invasive, and requires no equipment.

Conclusion

The Elbow Flexion Test is a simple clinical tool to provoke symptoms of ulnar nerve compression at the cubital tunnel. While its sensitivity is relatively low when performed in isolation, combining it with other provocative maneuvers significantly improves diagnostic accuracy. It remains a valuable test for clinicians evaluating suspected cubital tunnel syndrome.

Sources

1. Rosati M, Martignoni R, Spagnolli G, Nesti C, Lisanti M. Clinical validity of the elbow flexion test for the diagnosis of ulnar nerve compression at the cubital tunnel. Acta Orthop Belg. 1998;64(4):366-370.

2. Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubital tunnel syndrome. Clin Orthop Relat Res. 1988;(233):213-216.

3. Elbow Flexion Test for Cubital Tunnel Syndrome. Ccedseminars. Available from: https://youtu.be%7CmF3bUpeQfzs

4. Ulnar Nerve, Clinical Examination - Everything You Need To Know - Dr. Nabil Ebraheim. nabil ebraheim. Available from: https://youtube%7CPTpUzXdBvpo

5. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994;19(5):817-820. doi:10.1016/0363-5023(94)90193-7

6. Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782-787. doi:10.1016/j.jhsa.2010.12.019

7. Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg Am. 1992 Jan;17(1):86-9. doi: 10.1016/0363-5023(92)90119-a. PMID: 1538117.