Background
The patient is 60 years old. Works 40 percent in an office position and is 60 percent disability pensioned due to chronic neck pain. X-rays have shown wear changes with low discs and facet joint wear in the neck. The patient mainly does computer work.
The patient has booked an appointment due to pain located in the right elbow (VAS 5). The pain has gradually worsened over the past three weeks to VAS 6. The patient is unable to use the arm normally. It hurts to lift, and the patient experiences pain in the elbow area when working on the computer. The pain radiates from the radial part of the elbow down to the wrist. The patient has woken up from pain at night and has tried Ibux and Paracet with poor effect. The patient is wondering what is wrong and wants treatment and sick leave.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have pain in my right elbow… and it just keeps getting worse.
- Doctor
How long have you had this?
- Patient
A couple of weeks now. Started a bit gradually.
- Doctor
Where do you feel the pain?
- Patient
On the outside of the elbow… and a little down towards the wrist.
- Doctor
What triggers the pain?
- Patient
When I type on the computer… or lift things.
- Doctor
Do you have pain at night?
- Patient
Yes, I have actually woken up from it.
- Doctor
Have you tried any treatment?
- Patient
Paracetamol and Ibuprofen… but it doesn't help much.
- Doctor
How is your neck now?
- Patient
It's as usual… a little stiff and sore, but not the same as this. I wonder what this is… and if I need sick leave.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Tennis elbow with affection of mm. extensor carpi radialis brevis and longus.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
-
1. Neck screening
Doctor
I will first check your neck.
Patient
Perform all movements. The neck is slightly stiff, with pain at the end range, but without radiation.
It tightens a bit… but it does not go down the arm.
Findings
- Symmetrically reduced mobility.
- End-point pain.
- No radicular pain.
-
2. Active elbow movement
Doctor
Bend and stretch the elbow.
Patient
Performs normally without pain.
Findings
- Normal flexion and extension without pain.
-
3. Passive elbow movement
Doctor
Moves the elbow passively.
Patient
No, that's fine.
Findings
- No pain during passive movement.
-
4. Active wrist movement
Doctor
Make a fist and bend the wrist backward.
Patient
Immediate pain reaction laterally in the elbow.
Yes… it hurts on the outside.
Findings
- Pain VAS about 4 with active extension.
-
5. Isometric strength test
Doctor
Tests isometric dorsiflexion in the wrist.
Tests dorsiflexion combined with radial deviation.
Patient
Holds shortly, but gives way due to pain.
Ow… that doesn't work.
Same pain reaction with radial deviation.
Findings
- Lateral elbow pain with isometric dorsiflexion and radial deviation in the wrist.
Learning points
- 1 Classic tendinopathy with load-related pain and local tenderness on palpation.
- 2 Cervical radiculopathy must be excluded as a differential diagnosis.
- 3 Key tests are isometric strength test in extension and active extension, both of which cause pain.