From the Guidelines
To confirm a diagnosis of lateral epicondylitis in this patient, I would perform a focused physical examination including specific provocative tests, such as palpation of the lateral epicondyle, Cozen's test, and Mill's test, as these maneuvers can help identify point tenderness and pain, which are hallmark findings of this condition. The patient's symptoms of severe elbow pain radiating into the forearm, combined with his occupation in construction, which likely involves repetitive wrist extension, suggest a high likelihood of lateral epicondylitis 1. A thorough physical examination should include assessment of grip strength, which is often diminished in patients with lateral epicondylitis, as well as examination of the entire upper extremity to rule out other conditions such as cervical radiculopathy or peripheral nerve entrapment.
Some key points to consider in the physical examination include:
- Palpation of the lateral epicondyle to check for point tenderness
- Cozen's test, which involves having the patient extend their wrist against resistance while the elbow is stabilized
- Mill's test, which involves passively flexing the wrist while the elbow is extended
- Assessment of grip strength
- Examination of the entire upper extremity to rule out other conditions
While imaging is not typically needed for initial diagnosis, X-rays might be considered to rule out fractures or arthritis if the presentation is atypical, and ultrasound or MRI could be considered in refractory cases but are not necessary for initial diagnosis 1. It is also essential to use a professional interpreter rather than the daughter to ensure accurate communication and maintain patient confidentiality.
The patient's occupational history is crucial in identifying repetitive motions that may contribute to the condition, and modifying these activities may be necessary to prevent further injury and promote healing. Rest, icing, and eccentric strengthening exercises are common treatment options for lateral epicondylitis, and nonsteroidal anti-inflammatory drugs (NSAIDs) may be effective in relieving pain and reducing inflammation 1.
From the Research
Diagnosis of Lateral Epicondylitis
To confirm the diagnosis of lateral epicondylitis, the following steps can be taken:
- Take a thorough history of the patient's symptoms, including the location and radiation of pain, as well as any activities that exacerbate or relieve the pain 2, 3.
- Perform a physical examination, including tests such as Maudsley's and Cozen's clinical tests, which have a high sensitivity in diagnosing lateral epicondylitis 3.
- Assess the patient's muscle activation and fatigue indexes, which can be altered in patients with lateral epicondylitis 4.
- Use the resisted wrist extension test (RWET) with the elbow in extension and the forearm pronated, which has been shown to have high sensitivity and specificity for diagnosing lateral epicondylitis 5.
Key Findings
- Lateral epicondylitis is a common musculotendinous degenerative disorder of the extensor origin at the lateral humeral epicondyle, often caused by repetitive occupational or athletic activities 2, 6.
- The typical symptoms include lateral elbow pain, pain with wrist extension, and weakened grip strength 2, 3.
- A thorough understanding of the differential diagnosis is imperative to prevent unnecessary testing and therapies 2.