Elbow Pain
Elbow pain is a clinical symptom arising from injury or inflammation of the bones, joints, ligaments, tendons, or nerves around the elbow, commonly caused by overuse conditions such as lateral or medial epicondylitis, trauma, or arthritis.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Lateral epicondylitis (tennis elbow) [1][2] | Pain on lateral epicondyle; aggravated by gripping/wrist extension; Cozen's test positive | 「你揸嘢嗰陣手踭外面痛唔痛？」(Pain on gripping?) | ~35% |
| Medial epicondylitis (golfer's elbow) [1][2] | Pain on medial epicondyle; pain on wrist flexion/pronation; tenderness on medial epicondyle | 「扭毛巾或者握拳嗰陣手踭入面痛唔痛？」(Pain on fist-making/wrist flexion?) | ~10% | |
| Serious Not To Miss | Fracture (radial head/supracondylar) | Trauma history + bony tenderness + inability to extend | 「有冇撞親或者跌親？」(Any trauma?) | ~3% |
| Septic arthritis | Acute hot swollen joint + fever; urgent aspiration | 「隻手踭有冇又紅又腫又發燒？」(Red, swollen, fever?) | < 1% | |
| Malignancy (bone tumour) | Night pain, weight loss, constant pain, progressive | 「夜晚痛唔痛？體重有冇輕咗？」(Night pain? Weight loss?) | < 1% | |
| Pitfalls | Olecranon bursitis | Posterior swelling over olecranon; fluctuant | 「手踭後面有冇腫起咗好似波咁？」(Swelling at back of elbow?) | ~10% |
| Elbow OA | Stiffness, crepitus, reduced ROM, history of old injury | 「手踭有冇越嚟越硬、活動唔到？」(Progressive stiffness?) | ~5% | |
| Cubital tunnel syndrome (ulnar neuropathy) | Numbness in ring+little fingers; Tinel's at cubital tunnel; associated with medial epicondylitis [2] | 「第四第五隻手指有冇痺？」(Numbness in 4th/5th fingers?) | ~4% | |
| Osteochondritis dissecans [5] | Locking/catching, younger patient, activity-related | 「隻手踭有冇卡住嘅感覺？」(Locking sensation?) | < 1% | |
| Masquerades | Cervical radiculopathy (C5-C7) [3] | Neck pain, dermatomal numbness, Spurling's test positive | 「有冇頸痛？郁頸嘅時候痛會唔會落手度？」(Neck pain radiating to arm on movement?) | ~5% |
| Gout / crystal arthropathy | Acute onset, very painful, red, swollen; history of gout/hyperuricaemia | 「之前有冇痛風？」(Previous gout?) | ~2% | |
| RA (early presentation) | Morning stiffness > 30 min, symmetrical, small joints also involved [6] | 「朝早起身手踭硬幾耐？其他關節有冇痛？」(Morning stiffness duration? Other joints?) | ~1% | |
| Trying to Tell Me Something? | Work-related stress / occupational concern | Worried about job loss, compensation, or disability | 「你擔唔擔心呢個痛會影響你份工？」(Worried about work impact?) | ~10% |
| Health anxiety / fear of serious disease | Fear of cancer or arthritis | 「你有冇擔心係啲嚴重嘅病？」(Worried it's something serious?) | ~5% |
Elbow Pain — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce yourself, set agenda | 「你好，我係X醫生，今日由我同你傾下。可唔可以先講下你個名同出生日期？今日想了解下你嘅情況，之後會問多幾條問題，最後睇下點樣幫到你，好唔好呀？」 | Rapport, confirms identity, signposts structure → interpersonal marks |
| 0:30–2:30 | HPI: open-ended → focused symptom analysis, red flags | 「咩原因嚟睇醫生呀？」→「隻手踭幾時開始痛？」→「邊度最痛？裏面定外面？」→「有咩動作會特別痛？」→「有冇手指痺或者冇力？」 | Core history; determines DDx; elicits red flags |
| 2:30–3:30 | PMH, DHx, allergy, FHx, social/occupation | 「你之前有冇乜嘢長期病？食開咩藥？有冇藥物敏感？屋企人有冇風濕或者痛風？你做咩工作嘅呢？平時有冇做運動？」 | Occupation key for overuse; meds/allergy for safety |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得係咩原因？」(Idea) →「你最擔心嘅係咩？」(Concern) →「你今日最想我幫你啲咩？」(Expectation) →「除咗隻手踭，仲有冇其他嘢想同我講？」(Hidden agenda) | ICE is directly marked on case report; hidden agenda uncovers RFC |
| 4:30–5:15 | Brief targeted exam (describe what you would do) | 「我而家想檢查下你隻手踭，可唔可以？」→ palpate lateral/medial epicondyle, Cozen's test, Mill's test, check ROM, grip strength, neuro screen | Physical sign directly marked; seek permission → interpersonal marks |
| 5:15–5:45 | Summarise and check understanding | 「等我整理下：你隻手踭外面痛咗X個星期，特別係揸嘢同扭毛巾嗰陣痛啲，冇手指痺，我啱唔啱呀？」 | Summarising = interpersonal mark; catches errors |
| 5:45–6:00 | Closing: plan + safety net | 「我初步覺得可能係筋腱勞損，想安排多少少檢查，跟住再同你商量治療方案。如果痛到瞓唔著或者手指突然冇力，記得即刻返嚟睇。」 | Safe closure; demonstrates competence; safety-net scores |
Uncovering the hidden agenda: The patient may present with "elbow pain" but the real concern could be fear of arthritis/cancer, inability to work, or worry about needing surgery. Always ask: 「你最擔心嘅係咩？」and「除咗呢個問題，仲有冇其他嘢令你擔心？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Inner or outer elbow? | 「邊度最痛？手踭外面、入面、定後面？」 | Lateral → tennis elbow; Medial → golfer's elbow; Posterior → olecranon bursitis | Epicondylitis, bursitis, OA |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？突然間定慢慢痛起嚟？」 | Acute traumatic → fracture/dislocation; Gradual → overuse | Fracture; epicondylitis |
| Character | What kind of pain? Ache, sharp, burning? | 「咩痛法呀？赤赤痛、刺痛、定係酸痛？」 | Burning/tingling → neuropathy; Deep ache → OA | Cubital tunnel, referred pain |
| Radiation | Does the pain spread to forearm/hand/fingers? | 「有冇痛落前臂或者手指度？」 | Radiation to ring/little finger → ulnar neuropathy; down forearm → epicondylitis | Cubital tunnel syndrome, cervical radiculopathy |
| Aggravating | What movements make it worse? Gripping, twisting, lifting? | 「做咩動作會痛啲？揸嘢、扭毛巾、抬嘢嗰陣痛唔痛？」 | Gripping/wrist extension → lateral epicondylitis; Wrist flexion → medial epicondylitis [1][2] | Tennis vs golfer's elbow |
| Relieving | Does rest help? | 「休息嘅時候好唔好啲？」 | Rest relief → mechanical/overuse; No relief → inflammatory/sinister | OA, inflammatory arthritis |
| Timing | Constant or intermittent? Morning stiffness? | 「係成日痛定係做嘢先痛？朝早起身有冇手踭硬晒？」 | Morning stiffness > 30 min → inflammatory arthritis | RA, gout, psoriatic arthritis |
| Severity/function | How does it affect your daily life and work? | 「影唔影響你返工同做家務？」 | Functional impact = biopsychosocial; key for RFC | Occupational impairment |
| Neurological | Any numbness, tingling, or weakness in hand/fingers? | 「有冇手指痺或者冇力？」 | Numbness in ring+little finger → ulnar nerve; weakness → cervical radiculopathy | Cubital tunnel, cervical radiculopathy [3] |
| Trauma | Any injury or fall? | 「有冇撞親或者跌親？」 | Fracture, dislocation, ligament injury | Radial head fracture, Monteggia [4] |
| Swelling/redness | Any swelling, redness, or warmth? | 「有冇腫、紅、或者覺得隻手踭熱辣辣？」 | Hot swollen joint → septic arthritis, gout, RA flare | Septic arthritis, crystal arthropathy |
| Locking/clicking | Does elbow catch, lock, or click? | 「有冇卡住或者「啪」一聲嘅感覺？」 | Locking → loose body, OCD | Osteochondritis dissecans [5] |
| Red flags | Fever? Weight loss? Night pain? | 「有冇發燒？體重有冇輕咗？夜晚瞓覺痛唔痛？」 | Fever → infection; Weight loss + night pain → malignancy | Septic arthritis, tumour |
| PMH | DM, gout, RA, psoriasis, thyroid? | 「你有冇糖尿、痛風、風濕、或者甲狀腺問題？」 | Gout → crystal arthritis; RA → inflammatory; DM → neuropathy | Gout, RA, DM neuropathy |
| DHx | Current medications? NSAIDs tried? | 「食緊咩藥？有冇自己食過止痛藥？」 | Drug Hx; diuretics → gout; fluoroquinolones → tendinopathy | Drug-induced |
| Allergy | Drug allergy? | 「有冇藥物敏感？」 | Safety | — |
| FHx | Family history of arthritis/gout? | 「屋企人有冇風濕或者痛風？」 | RA, gout, psoriatic arthritis | Genetic predisposition |
| Occupation | What is your job? Repetitive arm use? | 「你做咩工作㗎？使唔使成日用手踭嗰度嘅肌肉？」 | Repetitive overuse → epicondylitis [1][2] | Tennis/golfer's elbow |
| Sports/hobbies | Do you play racquet sports, golf, gym? | 「有冇打波、打Golf、或者做Gym？」 | Direct cause of lateral/medial epicondylitis | Epicondylitis |
| Psychosocial | Any stress at work or home? Worried about anything? | 「最近工作壓力大唔大？有冇咩嘢令你特別擔心？」 | Hidden agenda; biopsychosocial | Somatisation, work stress |
| Neck symptoms | Any neck pain or stiffness? | 「有冇頸痛或者頸硬？」 | Referred pain from cervical radiculopathy (C5-C7) [3] | Cervical spondylosis |
Case Report Form Answer Builder
Template: "Elbow pain × [duration], [laterality], [site: lateral/medial/posterior], aggravated by [activity], associated with [radiation/numbness/swelling/stiffness]. No [red flags: fever/weight loss/trauma/night pain]. Occupation: [relevant]. Tried: [OTC meds]. Impact on [function/work/sleep]."
Key points to capture:
- Duration, onset, laterality, exact location (lateral vs medial epicondyle)
- Aggravating factors (gripping, wrist extension/flexion, lifting)
- Neurological symptoms (numbness, weakness)
- Red flags (fever, trauma, night pain, weight loss)
- Occupation and sports
- Functional impact
- Treatments tried
Likely examples:
- "Pain affecting ability to work" (commonest RFC for epicondylitis)
- "Worried about arthritis / serious disease"
- "Pain not responding to self-treatment"
- "Needs sick leave / referral"
Phrasing: "The patient consulted today because of worsening elbow pain interfering with his/her occupation as a [X], seeking diagnosis and treatment."
| Likely Content | Exam Wording | |
|---|---|---|
| Idea | "I think it might be arthritis / tendon problem / something from my work" | "Patient thinks the pain may be due to overuse at work / arthritis" |
| Concern | "I'm worried it might be something serious / I can't do my job / I'll need surgery" | "Patient is worried this may be a serious condition affecting livelihood" |
| Expectation | "I want an X-ray / painkillers / referral / physiotherapy / sick leave" | "Patient expects investigation and effective pain relief to return to work" |
Lateral epicondylitis (tennis elbow) — most common cause of elbow pain in primary care [1][2]
Minimum supporting evidence:
- Age 30–50, pain over lateral epicondyle
- Aggravated by gripping/lifting/wrist extension
- Occupation or activity involving repetitive forearm use
- Positive Cozen's test (wrist extension against resistance with elbow extended → reproduces lateral elbow pain)
| DDx | Key Discriminator |
|---|---|
| 1. Medial epicondylitis (golfer's elbow) | Pain on medial epicondyle; pain on resisted wrist flexion/pronation [1][2] |
| 2. Cubital tunnel syndrome (ulnar neuropathy at elbow) | Numbness/tingling in ring + little fingers; positive Tinel's sign at cubital tunnel [2] |
| 3. Cervical radiculopathy (C6/C7) | Neck pain radiating to elbow/forearm; dermatomal sensory loss; positive Spurling's test [3] |
| Domain | Problem |
|---|---|
| Biological | Lateral epicondylitis causing pain and reduced grip strength |
| Psychological | Anxiety about diagnosis (fear of arthritis/cancer) or frustration with chronic pain |
| Social/Functional | Inability to perform occupational duties (e.g., manual work, typing) → risk of income loss / need for sick leave |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Lateral epicondylitis (most likely) | Cozen's test positive [1][2][4] | Patient's elbow extended, forearm pronated; ask patient to extend wrist against your resistance → reproduces pain at lateral epicondyle | Demonstrates pathology at common extensor origin; highly specific for lateral epicondylitis |
| Medial epicondylitis | Tenderness on palpation of medial epicondyle + pain on resisted wrist flexion | Palpate medial epicondyle; resist wrist flexion with elbow extended | Localises pathology to common flexor origin [1][2] |
| Cubital tunnel syndrome | Positive Tinel's sign at cubital tunnel | Tap over ulnar nerve groove posterior to medial epicondyle → tingling/electric shock in ring + little fingers | Demonstrates ulnar nerve irritation at elbow |
| Cervical radiculopathy | Positive Spurling's test | Extend + laterally flex + rotate neck to affected side + axial compression → reproduces arm pain/paraesthesia [3] | Confirms nerve root compression in cervical spine |
| Olecranon bursitis | Fluctuant swelling over olecranon | Inspect and palpate posterior elbow; fluctuant boggy mass | Localised fluid collection over olecranon bursa |
| Elbow OA | Crepitus + reduced ROM on passive flexion-extension | Passively flex and extend elbow; feel for crepitus | Cartilage loss producing bone-on-bone grinding |
| Gout | Acutely inflamed joint (red, hot, swollen, exquisitely tender) | Inspect, palpate; check for tophi on olecranon/ear | Crystal deposition causing acute inflammatory arthritis |
Top Traps That Lose Marks
- Forgetting to ask about occupation/sports — epicondylitis is an overuse injury; the examiner WILL expect this.
- Not screening for cervical radiculopathy — elbow pain can be entirely referred from the neck. Ask about neck pain and check if neck movements reproduce elbow symptoms [3].
- Missing ulnar neuropathy with medial epicondylitis — associated ulnar nerve neuropathy is a known pitfall [2][4]. Always ask about ring/little finger numbness.
- Not eliciting ICE — ICE is directly marked. Students who skip it lose easy points.
- Writing "tennis elbow" without evidence — you must document the specific physical sign (Cozen's test) and the relevant history (repetitive use, lateral epicondyle tenderness).
- Confusing lateral vs medial epicondylitis — lateral = wrist extensors = gripping pain = MORE common; medial = wrist flexors = throwing/golf = LESS common [1][2].
Must Not Miss Red Flags — Urgent Referral
- Hot swollen joint + fever → septic arthritis → urgent aspiration + IV antibiotics
- Post-trauma with bony tenderness / inability to extend → fracture → X-ray + orthopaedic referral
- Progressive night pain + weight loss → malignancy → urgent investigation
- Rapidly progressive weakness / wasting in hand → cervical myelopathy or motor neuron disease → urgent neurology referral
- Acute locked elbow → loose body / displaced fracture fragment → orthopaedic referral
Key GC lecture slide points from Upper Limb Painful Conditions [1][2]:
- Lateral epicondylitis: Age 30-50, M & F, pain located over outside aspect of elbow, produced by any activity placing stress on the tendon e.g. gripping/lifting, pain starts at elbow down the forearm hand
- Medial epicondylitis: > 35 yr old, M = F, pain/tenderness on medial epicondyle, pain when try to make a fist / swing a golf club / turn a doorknob / lift weight, +/- weakness in hand and wrist
- Cozen's test: pronate + radially deviate forearm → extend wrist against resistance [4]
- Mill's test: pronate forearm, flex wrist and extend elbow [4]
Shortest safe management/safety-net line: 「多數係筋腱勞損，可以先休息、避免嗰個動作、用止痛藥同冰敷。如果兩三個禮拜冇好，我哋可以考慮轉介物理治療或者打針。但如果突然腫起嚟、發燒、或者手指冇力，記得即刻返嚟。」
High Yield Summary
What to ASK: Site (lateral vs medial vs posterior), aggravating activities (gripping vs flexion), occupation/sports, neurological symptoms (numbness ring/little finger), neck symptoms, red flags (fever/trauma/night pain/weight loss), ICE, and hidden agenda.
What to WRITE: Lateral epicondylitis is the most likely Dx in a 30–50 y/o with lateral elbow pain aggravated by gripping. Support with positive Cozen's test. DDx: medial epicondylitis, cubital tunnel syndrome, cervical radiculopathy. Biopsychosocial: pain (bio), anxiety/frustration (psych), work impairment (social).
What NOT to MISS: Ulnar neuropathy with medial epicondylitis; cervical radiculopathy masquerading as elbow pain; septic arthritis in a hot swollen joint with fever; and ALWAYS ask about occupation — it is the #1 discriminator for overuse conditions.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Upper Limb Painful Conditions_Dr. Margaret Woon Man FOK.pdf (pp. 21, 25 — lateral and medial epicondylitis clinical features) [2] Lecture slides: Upper Limb Painful Conditions_Dr. Margaret Woon Man FOK_1. Overuse conditions.pdf (pp. 18, 22 — lateral and medial epicondylitis clinical features) [3] Senior notes: Ryan Ho Neurology.pdf (pp. 172–173 — cervical radiculopathy and myelopathy) [4] Senior notes: Maksim Surgery Notes.pdf (pp. 239–240 — epicondylitis, Cozen's test, Mill's test, forearm fractures) [5] Senior notes: Adrian Lui Pediatrics Notes.pdf (p. 448 — osteochondritis dissecans) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p. 1676 — RA elbow manifestations)
Ear Discharge (otorrhoea)
Otorrhoea is the drainage of fluid—serous, mucoid, purulent, or bloody—from the external auditory canal, arising from conditions affecting the external ear, middle ear, or rarely the intracranial compartment.
Epistaxis
Bleeding from the nasal cavity, most commonly originating from the Kiesselbach plexus on the anterior nasal septum.