Elbow

Make a list of conditions causing painful, locking, stiff, flail and unstable elbow. Painful elbow pathology could be best remembered by its anatomical position – anterior, medial, posterior and lateral. Do not forget the nerves around the elbow while making your list.

Elbow structured oral examination question 1

EXAMINER: A 36-year-old right-hand dominant manual worker, referred by GP with painful right elbow. His elbow radiograph is essentially normal. What would you like to do?

CANDIDATE: Well, I need to assess the patient’s elbow ... after I had asked the history of his pain.

EXAMINER: Pain is on the lateral side, started gradually 3 months ago ... no history of injury, aggravated by using hammer and was initially relieved by rest. Now it is constant. He has normal range of movements. The point of tenderness is just around the lateral epicondyle.

CANDIDATE: From history and examination I think he has got tennis elbow ...

EXAMINER: What do you do to confirm the diagnosis?

CANDIDATE: I will test if the pain is reproduced by resisted wrist extension.

EXAMINER: Well, he has more pain on resisted finger extension than wrist extension. Does it make you think more specifically?

CANDIDATE: ...

EXAMINER: Which tendons are involved in tennis elbow?

CANDIDATE: ECRB ...

EXAMINER: Can EDC also be affected?

CANDIDATE: ...

EXAMINER: Well, tell me the pathophysiology of tennis elbow.

CANDIDATE: It is termed angiofibroblastic hyperplasia, which is ... hyperplasia of the angiofibroblasts ...

EXAMINER: Do you know any other similar pathology around the elbow?

CANDIDATE: Golfer’s elbow, which is tendonitis of the common flexor origin.

EXAMINER: Why do you say tendonitis? What is the difference between tendonitis and tendonosis?

...

EXAMINER: Going back to the provocation test, if he had tenderness over the lateral proximal forearm on resisted finger extension, what does it tell you?

CANDIDATE: Maybe the disease process is extensive into the common extensor muscle belly.

EXAMINER: We’ll move onto the next scenario.

How easy it is to mess up a simple scenario? Is the candidate a classic example for tennis elbow misdiagnosis? Does the candidate deserve anything above a score of 4? Will you approach this subject differently? Think and analyse before looking into the performance of the next candidate.

EXAMINER: A 36-year-old right-hand dominant manual worker, referred by GP with painful right elbow. His elbow radiograph is essentially normal. What would you like to do?

CANDIDATE: I want to know the history of his right elbow pain please.

EXAMINER: It is on the lateral side, started gradually 3 months ago ... no history of injury, aggravated by using hammer and was initially relieved by rest. Now it is constant.

CANDIDATE: I will proceed with his examination ... posture of elbow, range of movements especially looking for the lack of full extension and rotation ... proceed to examine the specific site of tenderness on the lateral aspect.

EXAMINER: He has normal range of movements. The point of tenderness is just around the lateral epicondyle.

CANDIDATE: I would like to know if he has tenderness anterior or posterior to the lateral epicondyle and also any tenderness just distal to the lateral epicondyle.

EXAMINER: What does it tell you?

CANDIDATE: Anterior and distal to lateral epicondyle – ECRB tendonosis. Posterior and distal to lateral epicondyle – EDC tendonosis.

EXAMINER: It is anterior and distal to lateral epicondyle. Tell me the provocation test for ECRB tendonosis.

CANDIDATE: Pain on elbow extension/forearm pronation/fingers flexion/wrist in extension against resistance.

EXAMINER: What is the test for EDC?

CANDIDATE: EDC tendonosis should have pain on elbow

extension/forearm pronation/wrist neutral/fingers extension/ long finger extension against resistance.

Does the EDC provocation test tell you anything else?

CANDIDATE: Yes. If EDC provocation test produces pain over EDC origin, it suggests EDC tendonosis. Pain over radial tunnel – radial tunnel syndrome.

EXAMINER: What do you understand by tennis elbow?

CANDIDATE: It is the tendonosis and not tendonitis of ECRB/ EDC tendons.

EXAMINER: Tell me the histological appearance of tendonosis.

CANDIDATE: Histologically, there are no acute inflammatory cells. There is granulation-like tissue consisting of immature fibroblasts and disorganized non-functional vascular elements called angiofibroblastic hyperplasia. It is theorized to result from an aborted healing response to repetitive micro-trauma. Pain arises possibly from tissue ischaemia. Electron microscopy has shown that these vascular elements do not have lumina. Essentially the repetitive tensile overload, which exceeds tissue stress tolerance, causes tissue damage. If the tissue damage occurs at a rate which exceeds tissue’s ability to heal, this causes tissue degeneration.

EXAMINER: Lastly, do you know any other tendonosis around the elbow other than golfer’s elbow?

CANDIDATE: Yes, the posterior tennis elbow, which is triceps tendonosis.

If you were the examiner, what score would you give this candidate?