A 55-year-old man comes to the office due to elbow pain. For the past 3 weeks, the patient has had vague, achy pain in the left elbow that radiates to the forearm. It is worse with activity and at the end of the day and is not relieved with acetaminophen. The patient works as an airport baggage handler and has been seen in the office previously for minor occupational injuries. His medical history is otherwise unremarkable. The patient smokes a half pack of cigarettes daily and does not use alcohol or illicit drugs. Vital signs are normal. Inspection of the left elbow shows no erythema or swelling. Range of motion is normal. There is severe pain on palpation at the lateral distal humerus. With the elbow held in extension, terminal passive flexion of the wrist reproduces the pain. Which of the following is the most likely diagnosis in this patient?
Lateral epicondylitis | |
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The patient's subacute elbow pain that is reproduced by stretching (ie, passive wrist flexion) the wrist extensors is consistent with lateral epicondylitis (tennis elbow). Lateral epicondylitis is caused by overuse of the extensor muscles, primarily the extensor carpi radialis brevis and the extensor digitorum communis. It leads to noninflammatory angiofibroblastic tendinosis at the common extensor origin on the lateral epicondyle. An analogous disorder can occur at the origin of the wrist flexors at the medial epicondyle (medial epicondylitis).
Patients usually have a history of repetitive, forceful extension at the wrist. Examination findings may include tenderness at the lateral epicondyle and reproduction of pain with resisted extension (ie, muscle contraction) or passive flexion (ie, muscle stretching) at the wrist. Management includes activity modification, nonsteroidal anti-inflammatory drugs, and counterforce bracing.
(Choice A) Cervical radiculopathy usually causes pain at the neck and upper arm. It worsens with changes in neck position and is not reproduced with flexion at the wrist.
(Choice C) Olecranon bursitis is caused by repetitive pressure or friction on the elbows. It presents with posterior elbow pain and is usually associated with visible swelling of the bursae.
(Choice D) Osteoarthritis involving the humeroulnar joint is uncommon, although it may occur in patients with prior injury to the joint. It usually causes chronic pain, and most patients have crepitus and limited range of motion.
(Choice E) Calcium pyrophosphate dihydrate crystal arthritis (pseudogout) commonly affects the elbows and other large joints, but symptoms are typically acute and are often associated with erythema and swelling.
(Choice F) Radial tunnel syndrome is caused by compression of the radial nerve where it passes under the supinator. Although it may cause lateral elbow pain resembling lateral epicondylitis, the tenderness is typically greatest at the margin of the supinator several centimeters distal to the elbow, rather than at the lateral epicondyle (eg, lateral distal humerus) as in this patient.
(Choice G) Stress fracture of the radius is rare and can be caused by repetitive lifting of heavy loads. This patient's pain is located at the humerus, not the radius.
Educational objective:
Lateral epicondylitis (tennis elbow) is painful noninflammatory angiofibroblastic tendinosis at the common extensor origin caused by repetitive, forceful wrist extension. Examination reveals tenderness at the lateral epicondyle and pain with passive flexion or resisted extension at the wrist.