Examination of the Hand and Wrist

The hand–wrist region is a complex structure made up of multiple joints, muscles, and tendons that work together to provide precision and function. These structures represent the most active part of the upper limb, and optimal hand and wrist function is essential for daily activities, including work, leisure, and personal care. A systematic, structured examination of the hand and wrist is therefore crucial to identify the correct diagnosis and initiate appropriate treatment.

Diagnosing hand and wrist conditions can be challenging due to the many anatomical structures involved and the overlap of symptoms across different disorders. Comparing both hands and wrists is often useful to reveal asymmetries or abnormalities [1].

Common Elbow Injuries

Elbow injuries range from overuse disorders to acute trauma. Some of the most common include:

Lateral Epicondylalgia (Tennis Elbow):

One of the most frequent causes of elbow pain, especially in people performing repetitive gripping at work or in sport.【1】

Medial Epicondylalgia (Golfer’s Elbow):

Less common than lateral epicondylalgia but often affects athletes and workers with repetitive tasks that load the medial elbow structures.【2】

Cubital Tunnel Syndrome:

Compression of the ulnar nerve in the cubital tunnel, typically causing tingling or numbness in the 4th and 5th fingers along with elbow pain.【3】

Fractures and Dislocations:

Acute injuries—often after a fall on an outstretched hand—can result in fractures or dislocations of the elbow joint.【4】

Ligament Injuries:

Common in throwing athletes and can lead to elbow instability. The medial collateral ligament (MCL) is particularly vulnerable.【5】

Economic and Societal Impact

Elbow injuries represent a significant burden on healthcare and society. A report from Norwegian health authorities estimates that musculoskeletal disorders, including elbow injuries, account for up to 30% of workplace sick leave.【6】These conditions can reduce work capacity, require prolonged rehabilitation, and sometimes surgery — all of which drive high societal costs.

Treatment costs: Primary-care costs for elbow problems alone may amount to millions of NOK annually.【7】

Productivity loss: Persistent problems such as tennis elbow can reduce productivity, particularly in manual occupations.

Subjective History

A thorough patient history is essential for identifying the mechanism and context of injury.

Key Questions

• Pain Localization: Where exactly is the pain located?

• Symptom Progression: When do symptoms worsen? Are they activity-specific or time-dependent?

• Mechanism of Injury: Was there a fall, repetitive activity, or direct trauma? Numbness in the fifth finger may suggest ulnar neuropathy.【1】

• Neurological Symptoms: Any tingling, burning, or numbness?

• Medication and Past Medical History: Are there relevant previous injuries or systemic conditions?

• Imaging: Has the patient undergone X-ray, MRI, or ultrasound examinations?

Region-Specific Questions

These help differentiate between local and referred pain sources.【2】

• Do neck or shoulder movements reproduce elbow pain?

• Does the elbow ever feel unstable?

• Is pain provoked by gripping or lifting activities?

• Was the elbow hyperextended at the time of injury?

• Are symptoms linked to throwing or repetitive use?

Environmental and Personal Factors

Healing and recovery from elbow injuries can be influenced by various factors.

Factor	Example
Diabetes	Delayed tissue healing
Immunosuppression	Increased infection risk
Infection	May prolong inflammation
Multiple injuries	Complex rehabilitation
Smoking	Reduced circulation and healing potential
Alcohol overuse	Impaired immune function
Complications	Joint stiffness, heterotopic ossification, infection, instability

Self-Report Outcome Measures

Patient-reported tools are valuable for evaluating pain, function, and quality of life.

DASH & QuickDASH:Assess function and symptoms of the upper limb. QuickDASH is a shorter version for faster clinical use.

Patient-Specific Functional Scale (PSFS):Allows patients to identify and rate difficult daily activities to monitor progress.

PREE (Patient-Rated Elbow Evaluation):Evaluates pain and disability specific to elbow disorders.【1】

ASES (American Shoulder and Elbow Surgeons Score):Closely related to PREE; typically correlates above 0.90.【1】

P4 (4-Item Pain Intensity Measure):Assesses pain intensity throughout the day and during movement.

SF-36 (Short Form-36):A general health questionnaire, less specific for elbow pathology.【1】

Special Questions

Red Flags

Conditions requiring immediate medical evaluation include:

• Infection or inflammation

• Malignancy

• Fracture or dislocation

  • Positive Elbow Extension Test may indicate a fracture

• Inflammatory arthritis

• Abnormal neurological or vascular findings

• Heterotopic ossification (especially post-surgery)

• Lack of clinical improvement after conservative treatment

Yellow Flags

Psychological or social factors that may delay recovery:

• Anxiety, depression, or stress

• Dependence on passive treatments

• Fear of movement or re-injury (fear-avoidance behavior)

Radiological Considerations

Radiographs (lateral and anteroposterior) can confirm suspected structural abnormalities. Correlation between imaging findings and patient history is crucial for accurate interpretation.【1】

Objective Examination

Observation

• Posture: Thoracic kyphosis or forward head posture can predispose to elbow overload.

• Scapular position: Assess scapular alignment and movement control.

• Carrying angle: Average 10° in men, 13° in women; varies during adolescence.【4】

• Signs of pathology: Swelling, bruising, deformity, or muscle wasting.

• Triangle Sign: Assess symmetry of the epicondyles and olecranon during elbow flexion and extension.

Functional Tests

Functional evaluation helps identify reproducible “asterisk signs” for before-and-after comparisons.

• Pain-Free Grip Strength: Measures ability to grip without pain.

• Push-Off Test: Evaluates weight-bearing capacity through the arm (ICC = 0.31–0.97).【1】

• FIT-HaNSA Test: Assesses upper-limb functional ability; useful for overall evaluation.【1】

Palpation

Palpate anatomical landmarks for tenderness, swelling, or irregularities.

Bony Structures:

• Medial and lateral epicondyles

• Olecranon process and fossa

• Radial head

Ligaments:

• Medial (UCL) and lateral (LCL) collateral ligaments for pain or instability

Soft Tissues:

• Check for warmth, tenderness, or edema along flexor and extensor muscle groups

Neurological Assessment

Neurological Assessment

Reflex Testing

Reflex	Spinal Level	Description
Biceps	C5	Tests musculocutaneous nerve
Brachioradialis	C6	Tests radial nerve
Triceps	C7	Tests radial nerve

Myotomes

Myotome	Level	Primary Motion
C5	C5	Shoulder abduction
C6	C6	Elbow flexion, wrist extension
C7	C7	Elbow extension, wrist flexion
C8	C8	Finger flexion
T1	T1	Finger abduction/adduction

Dermatomes

Dermatome	Level	Region
C5	C5	Lateral shoulder
C6	C6	Lateral forearm and thumb
C7	C7	Middle finger
C8	C8	Medial forearm and little finger
T1	T1	Medial arm and elbow

Range of Motion (ROM)

Elbow:Flexion and extension — note pain, limitation, or crepitus.Positive Elbow Extension Test → possible fracture (refer).

Forearm:Pronation and supination.

Wrist:Flexion and extension.

Cervical, Shoulder, and Thoracic Spine:Assess mobility and perform posterior-anterior glides to check for distal symptom reproduction.

Resisted Testing

Elbow flexion and extension

• Forearm pronation and supination

• Wrist flexion and extension

• Pain-free grip testing

• Finger and thumb resistance

Accessory Motion Testing

Assess joint play and mobility restrictions:

• Humeroulnar traction

• Humeroradial traction

• Proximal and distal radioulnar glides (anterior/posterior)

Special Tests

Cubital Tunnel Syndrome

• Elbow Flexion Test: Hold maximum flexion for 60 seconds to provoke symptoms.

• Tinel’s Sign: Tap over ulnar nerve in cubital tunnel.

• Ulnar Nerve Compression Test: Apply direct pressure to reproduce symptoms.

Lateral Epicondylalgia

• Mill’s Test: Passive wrist flexion with elbow extension and pronation.

• Cozen’s Test: Resisted wrist extension with radial deviation.

• Maudsley’s Test: Resisted long-finger extension.

Ligament Tests

• Varus Stress Test: Evaluates lateral collateral ligament integrity.

• Valgus Stress Test: Evaluates medial collateral ligament.

• Moving Valgus Stress Test: Assesses dynamic valgus stress through range.

Neurodynamic Tests

• Median nerve bias: ULNT1

• Radial nerve bias: ULNT2b

• Ulnar nerve bias: ULNT3

Conclusion

Elbow injuries are frequent in clinical practice, especially among athletes and manual workers. A structured examination combining subjective and objective findings allows physiotherapists to detect the source of dysfunction, apply evidence-based treatment, and guide safe return to activity. Early recognition of red and yellow flags ensures appropriate referral and optimal recovery outcomes.

Sources:

1. MacDermid JC, Michlovitz SL. Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther. 2006; 19(2):82-97.

2.  Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion, 2008.

3. King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Commitee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999; 8:351–4.

4. Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. 1999; 30(1):15-20.