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| ==Introduction== | | ==Introduction== |
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| It is an oft-quoted maxim that the clinical history provides the bulk of the diagnostic discriminating power available to the clinician, with formal study demonstrating that the initial elements of history focuses attention to 2 to 5 differential diagnoses within the first few minutes of the clinical interview 1.
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| For pain problems, a systematic format for the history has been proposed that is detailed in Appendix NA.5. The application of this format to the problem of elbow pain has not been the subject of formal study. Moreover, a detailed search for the entire MEDLINE database using the MESH heading “ELBOW”, combined with scrutiny of the bibliographies of retrieved articles, failed to reveal any articles concerning the validity, reliability, discriminatory or predictive value of historical features in the diagnosis of elbow disorders.
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| Nonetheless, for elbow pain a history can be systematically obtained following categories of enquiry that are applicable for pain in any region of the body, and which were originally developed for the assessment of headache 2,3. Although the significance of particular categories differs for pain in different regions, and although some categories may appear irrelevant for elbow pain in particular, following the categories ensures that a history is systematically obtained, leaving no possible stone unturned.
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| ==Duration of illness== | | ==Duration of illness== |
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| For pain in general it is pertinent to determine how long the complaint has been present. In the present context, this simply defines the problem as acute or chronic; no worthwhile inferences can be drawn.
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| ==Circumstances of onset== | | ==Circumstances of onset== |
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| For any musculoskeletal pain it is most critical to determine if trauma was responsible for the pain. Trauma implies injury. The greater the trauma the greater the likelihood of injury, and the nature of the trauma predicates the nature of the possible injury in terms of its location and the type of tissues involved. Severe trauma increases the likelihood of fractures. Bending forces raise the possibility of fractures on the compression side, and fractures or ligament injuries on the tension side.
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| Compression forces across the elbow can result in fractures of the humerus, trochlea, capitulum, coronoid process, and radial head. Falls onto a flexed elbow can result in fractures of the olecranon. Valgus or varus stresses on the elbow can result in tears of the respective collateral ligaments, or avulsion fractures of their attachments.
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| Significant trauma is an indication for radiography, for there are no valid clinical features that rule out the possibility of fracture. However, there are no guidelines by which “significant” can be defined in the context of the elbow. This remains a matter of intuitive judgement on the part of the physician.
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| Trauma also includes the notions of acute or repetitive strain. In the context of the elbow, the cardinal conditions are those that involve throwing or swinging motions in occupational or sporting activities that might strain the medial collateral ligament, the common flexor origin, or the common extensor origin. In such conditions, radiography is not indicated in the first instance; the patient should be assessed as a patient with an atraumatic onset of pain.
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| In principle, pain that comes on spontaneously should always arouse suspicion of a serious underlying process such as inflammatory joint disease, infection or tumour. However, given the rarity of red flag conditions (see Appendix EP1), spontaneous onset alone is not a justification for pursuing these conditions with medical imaging, unless and until other features increase their pre-test likelihood.
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| ==Mode of Onset== | | ==Mode of Onset== |
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| An insidious onset of pain should again arouse suspicion about a serious underlying disorder. An acute onset is non-specific.
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| Site of Pain
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| Elbow pain is often well localised and this provides vital diagnostic information. Pain over the lateral epicondyle virtually defines lateral epicondylitis, a fact reflected in the early use of the term “humeral epicondylalgia” for the entity (see Appendix EP7). Similar considerations apply to pain over the medial epicondyle (see Appendix EP8). Anterior elbow pain implies pain arising from one of the structures in the cubital fossa, with biceps tendonitis being the most likely diagnosis (see Appendix EP8). Posterior elbow pain suggests pain arising from the triceps tendon or olecranon (Appendix EP8).
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| ==Radiation== | | ==Radiation== |
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| As is the case with most peripheral articular structures distal to the hips and shoulders, elbow pain tends to remain well localised to the elbow, with little in the way of radiation, although pain from lateral and medial epicondylitis often may be perceived along the extensor and flexor compartments of the forearms respectively.
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| ==Quality== | | ==Quality== |
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| Musculoskeletal pain should typically be deep, dull and aching in quality. Superficial and shooting or stabbing pain, or dysaesethesia rather than pain, should alert the physician to the possibility of neurogenic pain.
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| ==Frequency== | | ==Frequency== |
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| Elbow pain is rarely, if ever, spontaneously paroxysmal, but it may occur intermittently when aggravated by activities such as twisting, lifting and grasping.
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| ==Time of Onset== | | ==Time of Onset== |
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| Pain that is worse during the day is consistent with many forms of mechanical pain, because it is progressively aggravated by activity and compounded by fatigue. Pain that is worse or particularly severe at night should raise suspicion of more sinister underlying cause.
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| ==Precipitating and Aggravating Factors== | | ==Precipitating and Aggravating Factors== |
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| Pain arising from the extensor or flexor origins is typically worsened by power gripping. The pain of lateral epicondylitis is characteristically worsened by “overhand” lifting, such as lifting a briefcase away from one’s body. However, such is the complexity of most everyday activities that some patients will have difficulty identifying particular movements or activities that aggravate their elbow pain.
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| Pain on flexing the forearm without strain being placed on the forearm flexor or extensor muscles suggests pain arising from the biceps apparatus or elbow joint itself. Pain and stiffness worse after rest invites a consideration of inflammatory causes, and pain at rest or unchanged by activity should prompt a further consideration of “red flag” disorders.
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| Pain in the elbow reproduced by pronation and supination of the forearm, particularly if associated with crepitus or locking the joint raises the possibility intra-articular pathology such as chondromalacia, osteochondritis and loose bodies.
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| ==Relieving Factors== | | ==Relieving Factors== |
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| Relief of elbow pain by rest is a non-specific finding. Relief by targeted anaesthetic injection would, at face value, be at least moderately predictive of pain arising from the target area. No formal studies have addressed this.
| | ==Associated features== |
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| ==Associated features==
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| As in other areas of musculoskeletal medicine, it is typically the absence of features of disease in other systems or regions that permits some confidence in the local and benign nature of the mechanical problem. It is therefore essential to conduct a detailed and systematic systems review in all patients presenting with pain. (see appendix NA.5, table 5.1) and should specifically include enquiry as the presence of fevers, weight loss and malaise as indicators of systemic or multisystem disease.
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| ==Recommendations== | | ==Recommendations== |
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| From a patient presenting with elbow pain,
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| A systematic history should be obtained in the categories of
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| * duration of illness,
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| * circumstances of onset
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| * mode of onset
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| * site of pain
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| * radiation
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| * quality
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| * frequency
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| * time of onset
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| * precipitating and aggravating factors
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| * associated features
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| Positive features emerging from the history should be judiciously taken into consideration, recognising that at best such features only raise the possibility of a particular diagnosis; no historical feature alone is diagnostic.
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| A history of significant trauma is an indication for investigation with radiography in order to diagnosis or exclude fractures.
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| Potentially more significant than any aspect of the pain itself is the patient’s general medical history and systems review.
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| ==References== | | ==References== |
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| 1. Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology A Basic Science for Clinical Medicine. Boston: Little, Brown, 1985.
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| 2. Lance JW. Mechanism and Management of Headache, 3rd edn. London: Butterworths, 1978.
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| 3. Lance JW. Mechanism and Management of Headache, 5th edn. Oxford: Butterworth-Heinemann, 1993.
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| [[Category:Elbow & Forearm]] | | [[Category:Elbow & Forearm]] |
