A 35-year-old man presents to you complaining of elbow pain. He has recently been doing a lot of painting. Previously he did not have trouble with his elbow. What is your differential diagnosis for his pain?
Common causes of elbow pain are usually not due to the joint itself. Most cases (as in he case above) are due to localized tendonitis or bursitis. It is uncommon for synovitis to affect the elbow joint in isolation. If there is isolated synovitis then it is most likely due to infection, gout or psoriatic arthritis.
Examination begins with careful observation. Position the elbow at 90° on a pillow. Look for swelling over the olecranon. If swollen it is most likely olecranon bursitis. This is often due to gout but trauma and infection can look similar. Look for swelling over the lateral and medial epicondyles. These points are the insertion points for the common extensor tendons and flexor tendons of the wrist respectively. Inflammation of these points results in lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow) respectively. An effusion of the elbow will be seen with swelling between the lateral epicondyle and tip of the olecranon and fullness of the cubital fossa.
Palpate the joint next. Palpate the lateral and medial epicondyles. These are tender with inflammation. Palpate the olecranon feeling for a distinct fluid collection due to bursitis. There maybe nodules which should be palpated at the same time. Rheumatoid nodules are rubbery in texture and usually non-tender. Gouty tophi at hard and often show white areas close to the surface. They may also be ulcerated. Other causes of nodules in this location are much less common and include sarcoidosis, xanthelasma, sarcoidosis, rheumatic nodules and lipomas. Check for joint tenderness by palpating between the lateral epicondyle and the tip of the olecranon.
Passive movement should be checked first. Gently move the elbow through its range of motion (0-140°). With an effusion the elbow will not be able to be fully extended and can be limited in lateral epicondylitis. Hold the elbow at 90° and check for supination and pronation. Hold the hand on the same side and rotate through 180°. Limitations in movement are due to joint pathology. Pain on pronation can occur with medial epicondylitis and pain with supination can occur with lateral epicondylitis.
By now the examiner should have a diagnosis for the cause of the elbow pain. Active movements will confirm your clinical suspicion. To test for lateral epicondylitis, hold the elbow flexed at 30° with the wrist extended. Ask the patient to keep the wrist extended whilst the examiner pushes on the dorsum of the hand. This is painful with lateral epicondylitis. (diagram)
Similarly check for medial epicondylitis. Hold the elbow at 30° flexion with the wrist flexed. Ask the patient to hold the wrist in flexion and push against the palm of the hand. This will be painful in medial epicondylitis.
Triceps tendonitis and bicipital tendonitis are much less common. Triceps tendonitis will give pain over the olecranon with active extension of the elbow. Bicipital tendonitis will give pain in the middle of the cubital fossa with active elbow flexion.