A Question a day (23/9/2018)

A 33-year-old right-handed man presents to your clinic with upper extremity pain that started 2
weeks ago. The pain is worse with movement and relieved with ibuprofen. He denies antecedent
trauma but began taking tennis lessons 3 weeks earlier. The pain only occurs in his serving arm and
has recently progressed, prompting his visit today.

1. What additional questions would you ask to learn more about his upper extremity pain? Commented [nlk1]: How to grade the severity of
- Any other history of repetitive recreational or occupational activity and any associated pain repetitive strain injury?
following that? (ask patient to show how he uses his arms at work or leisure time activities -
to identify if pain is secondary to overuse)
- Which aspect of the elbow is the pain mainly from? Lateral or medial? (Ask patient to point
to where the pain is if localised)
- Is the pain occurring more with extension or flexion (through demonstration)? Is it painful to
shake hands, turn door handles, opening jars (mainly extensors) or lift objects from ground
(mainly flexors)?
- Any weak wrist extension or flexion associated? (Bursitis commonly can fully extend elbow
but difficult to fully flex)
- Any decrease range of movement or limitation of ADL? (to identify joint effusion,
osteonecrosis of humerus; tro lateral epicondylitis which is quite rare to have decreased
ROM)
- Any swelling? (common in olecranon bursitis)
- Character of pain and whether pain is persistent? (Epicondylitis and entrapment neuropathy
usually sharp and persistent)
- Any aggravation of the pain with movement of the shoulder or neck? (tro referred pain to
the elbow from cervical radiculopathy or shoulder)
- Any other pain elsewhere? (tro polyarticular diseases eg RA)
- Others (arm dominance, any occupational dysfunction, history of prior medical intervention,
smoking, presence of rash or discolaration)

2. How would localizing the pain help in generating a differential diagnosis?

The differential in this case mainly include those of periarticular (epicondylitis, olecranon
bursitis, nerve entrapment, referred pain). So localising where the pain is, is helpful in
 identifying where the pathology is. For example, if pain is localised at the lateral elbow, by
identifying what structure runs in the lateral elbow area, we could formulate our differential
diagnoses based on that, which would include lateral epicondylitis, intrarticular loose bodies,
radial tunnel syndrome, osteochondral defect. As for medial side, medial epicondylitis,
cubital tunnel syndrome, ulnar neuritis, little league elbow must be considered.

As for pain arising from radiohumoral joint, It is usually not well localised.

If arising in the wrist, medial nerve entrapment or tendinitis should be considered.

3. What activities put the patient at risk for specific upper extremity problems?
- Tennis
- Golfing
 - Competitive rowing (from recent studies)
- Repeated violin playing (source from NHS)
- Pulling levers or handling heavy load

4. How can you use the history to identify serious diagnoses? Commented [nlk2]: What are the 2 serious conditions
- Hx of diabetes, any decreased in range of movement, any fever, fatigue or malaise, TRO?
peribursal swelling and warmth, any skin lesions, punctured wound, signs of bacterial
endocarditis – Septic arthritis
- Swelling accompanied by pain, cyanosis with paresthesias in finger, numbness, weakness,
coldness – Thoracic outlet syndrome
- Any sensory loss or tingling sensation especially in 4th / 5th finger? (to identify entrapment
of ulnar nerve resulting in pain eg in medial epicondylitis, ulnar tunnel syndrome)
- Persistent numbness, tingling and burning sensation with neck pain – Cervical nerve root or
spinal cord disorders
- Any (left) arm complaints associated with chest pain, palpitations, sweating, dizziness,
dyspnea – Ischemic heart disease

Ans: Refer The Patient History book