11/13/24, 8\:09 PM Guide | Elbow pain history

Elbow pain history

Table of contents

Background

Elbow pain is a common presenting complaint, and it may be assessed in OSCEs or written exams. This guide helps provide an
overview of how to take a history when a patient presents with elbow pain.
A range of conditions can cause elbow pain. It can be helpful to divide the causes into acute/subacute and chronic.

Acute/subacute elbow pain

Septic arthritis
Septic arthritis is an infection within a joint. This infection usually reaches the joint via the blood but can be spread directly
through the skin via a break in the skin, such as a wound. Septic arthritis is most common in the elderly, the immunosuppressed
and children, and is a presentation that needs to be managed urgently.
Septic arthritis usually presents acutely (for example, in less than two weeks). Commonly, the joint is swollen, hot, tender and
painful. There may be a painful, restricted range of movement and tachycardia. In about 60% of people, there is a fever.
Tip
Remember that a hot, swollen joint is septic arthritis until proven otherwise!
Fracture
With a fracture, there is usually a signi
swelling, physical deformity of the joint, abnormal movement of the joint and loss of function.
Olecranon bursitis
The olecranon bursa is a sac under the skin over the olecranon process of the elbow. It contains
of the elbow joint. This area can become in
septic arthritis) or non-infectious causes.
With bursitis, there may be swelling over the olecranon process and symptoms appear over hours to days. The area may be
tender and hot and feel
Tennis elbow (lateral epicondylitis)
Tennis elbow is intendons attached to the lateral epicondyle of the humerus.
This often occurs in middle age with a history of overuse of forearm muscles. Commonly, the dominant upper limb is a
There is lateral epicondyle tenderness, which may radiate. Wrist extension against resistance produces pain, and there may
be reduced grip power. Usually there is normal range of movement at the elbow and normal sensation in the upper limb.
Golfer's elbow (medial epicondylitis)
Golfer’s elbow is intendons attached to the medial epicondyle of the humerus.
As with tennis elbow, this often occurs in middle age with history of overuse of forearm muscles and commonly the dominant
upper limb is a
There is medial epicondyle tenderness which may radiate. Wrist
reduced grip power. Usually there is normal range of movement at the elbow and normal sensation in the upper limb.
Gout
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This is a kind of arthritis that is caused by monosodium urate crystals developing in the joint. Usually, this a
joints such as the toes (particularly the
commonly a
The onset of symptoms is rapid, with signi
Pseudogout
This may present the same way as gout but is more likely to a
pyrophosphate crystals form within the joints.

Chronic elbow pain

Osteoarthritis
Osteoarthritis is when damage to the joint leads to repair processes that cause structural changes within the joint. Risk factors
include being over 50 years old and having a history of a physically intense job or sport. There may be a history of previous
injury to the joint. The radiocapitellar joint, consisting of the proximal radius and the round lateral part of the humerus
(capitulum), is usually most a
Symptoms include chronic elbow pain and sti
as osteoarthritis advances and there may be loss of extension and
movement of the joint.
Rheumatoid arthritis
Rheumatoid arthritis is a chronic systemic in
of the hands are typical sites but it can occur in any joint.
Usually, the whole synovial joint is in
for over one hour. There may be systemic features, such as malaise and fatigue.
Sarcoma
Sarcomas can be cancers of the soft tissue (e.g. fat, muscle or other) or bone. Red
that is increasing in size or unexplained bone pain or bony swelling. With advanced malignancy, there may be systemic
features such as weight loss and fatigue.
Cubital tunnel syndrome
This is when the ulnar nerve gets entrapped in the cubital tunnel on the medial side of the elbow near where the ‘funny bone’ is.
There may be medial epicondyle pain, an ulnar distribution of reduced sensation in hand and hand weakness. Tinel’s sign is
usually positive. This involves tapping over the cubital tunnel (around the medial epicondyle), producing a numbness or
tingling sensation in the little or ring
Radial tunnel syndrome
This is caused by entrapment of the posterior interosseous nerve, a branch of the radial nerve, within the radial tunnel in the
elbow. It is associated with repetitive upper limb activities. There is pain over the radial neck, about four
the lateral epicondyle. Resisted thumb and index

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
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Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e p a i n y o u’ v e b e e n e x p e r i e n c i n g .
”
This allows the patient to give you their symptoms in their own words without you directing their response.
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?”
“ C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?”
Clarify any unclear comments they make, for example\:
" C o u l d y o u l e t m e k n o w w h a t y o u m e a n b y w e a k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Gather further details about the patient’s elbow pain using the SOCRATES acronym.
Site
Ask about the location of the elbow pain\:
“ W h e r e e x a c t l y i s t h e p a i n ?”
“ C a n y o u p o i n t t o w h e r e t h e p a i n i s ?”
In tennis elbow, patients are likely to point to the lateral epicondyle of the humerus. On the other hand, golfer’s elbow or
cubital tunnel syndrome patients are likely to point to the medial epicondyle of the humerus.
Osteoarthritis typically causes pain at the radiocapitellar joint (consisting of the proximal radius and the round lateral part of the
humerus), whereas rheumatoid arthritis causes bilateral symmetrical small joint pain.
In olecranon bursitis, patients will likely point to the skin over olecranon process. In radial tunnel syndrome, patients are likely to
point to the radial neck area (about four
Onset
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Clarify how and when the pain developed\:
“ W h e n d i d t h e p a i n
“ D i d t h e p a i n s t a r t s u d d e n l y o r d e v e l o p g r a d u a l l y ?”
“ W h a t w e r e y o u d o i n g w h e n t h e p a i n s t a r t e d ?”
Septic arthritis usually presents acutely (for example, in less than two weeks). Olecranon bursitis symptoms often appear over
hours to days usually. Similarly, in gout, the onset of symptoms is rapid, usually within a day.
Tennis elbow, golfer’s elbow, rheumatoid arthritis, osteoarthritis, cubital tunnel syndrome and radial tunnel syndrome are more
likely to have a chronic presentation.
Character
Ask about the speci
“ H o w w o u l d y o u d e s c r i b e t h e p a i n , e .g. b u r n i n g, s t a b b i n g , a c h i n g?”
“ D o e s t h e p a i n c o m e a n d g o , o r i s i t c o n s t a n t ?”
Burning or sharp pain may be more suggestive of nerve entrapment, such as in radial tunnel or cubital tunnel syndrome.
Radiation
Ask if the pain moves anywhere else\:
“ D o e s t h e p a i n s p r e a d e l s e w h e r e ?”
Tennis elbow or golfer’s elbow may have pain that radiates from the epicondyle.
Associated symptoms
Ask if there are other symptoms which are associated with the pain\:
“ A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m t o b e a s s o c i a t e d w i t h t h e e l b o w p a i n ?”
Some symptoms that you may want to speci
Fever
Swelling/lump
Redness
Warmth
Reduced range of movement
Weakness
Bruising
Each of these should be explored in more detail if present.
These questions can help identify potential di
septic arthritis, the joint is often swollen, hot, tender and painful, and there may be a painful restricted range of
movement. With septic arthritis, about 60% of people have a fever.
Tennis elbow and golfer’s elbow usually have a normal range of movement at the elbow and normal sensation in the upper
limb. There may be reduced grip power in both.
Rheumatoid arthritis usually causes in
usually early morning sti
worsens with activity or weight bearing. The range of movement reduces as osteoarthritis advances, and there may be loss of
extension and
In a fracture, there is often bruising, swelling, physical deformity of joint, abnormal movement of the joint and loss of function.
Red sarcoma include an unexplained lump that is increasing in size or bony swelling.
Cubital tunnel syndrome may include an ulnar distribution of reduced sensation in hand and hand weakness. The patient may
have noticed that tapping over the cubital tunnel (around the medial epicondyle) produces a numbness or tingling sensation in
the little
Gout and pseudogout are usually associated with swelling and redness in the joint.
Time course
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Clarify the time course of the pain and whether it occurs in discrete episodes or is continuous\:
“ D o e s t h e p a i n c o m e a n d g o , o r i s i t a l w a y s t h e r e ?”
“ H o w l o n g d o e s t h e p a i n l a s t f o r ?”
“ H a s t h e p a i n a l w a y s f e l t t h e s a m e , o r h a s i t c h a n g e d o v e r t i m e ?”
" I s t h e r e a p a r t i c u l a r t i m e o f d a y y o u n o t i c e t h e p a i n o c c u r s ?"
Establishing an accurate time course of the pain can help identify the underlying diagnosis.
Olecranon bursitis, septic arthritis and a fracture are likely to cause continual pain while the joint is aRheumatoid
arthritis is likely to cause pain that is worse at rest. In contrast, osteoarthritis is likely to be associated with pain that is worse
with activity.
Exacerbating or relieving factors
Ask if anything triggered the pain and if anything makes it better or worse\:
“ W h a t w e r e y o u d o i n g w h e n t h e p a i n s t a r t e d ?”
“ D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?”
“ D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?”
These questions can help identify a potential cause for the patient’s symptoms. Olecranon bursitis may cause no pain unless
the joint is put in full
against resistance produces pain in golfer’s elbow. Resisted thumb and index
syndrome.
Severity
Assess the severity of the pain by asking the patient to grade it on a scale of 0-10\:
“ O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?”
Septic arthritis, gout and a fracture are likely to cause signi

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s c a u s i n g t h e e l b o w p a i n ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t , a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

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Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Systemic symptoms

Fever
Rigors
Lethargy
Unintentional weight loss
In septic arthritis, most patients have a fever and other associated symptoms such as rigors. Rheumatoid arthritis can also
cause systemic features, such as malaise and fatigue.
With advanced sarcoma, there may also be red

Skin symptoms

Skin rashes or lesions
Palpable lumps in the area
Sarcoma may present as an unexplained soft tissue or bony lump that is increasing in size. Rheumatoid arthritis and septic
arthritis may be associated with erythema over the joint. It is also important to ask about wounds, as while septic arthritis
usually reaches the joint via the blood, it can be spread directly through a break in the skin.

Neurological symptoms

Numbness
Pins and needles
Weakness
Tennis elbow and golfer’s elbow usually have normal sensation in the upper limb, but there may be reduced grip power in both.
Cubital tunnel syndrome may include an ulnar distribution of reduced sensation in the hand and hand weakness. The patient
may have noticed that tapping over the cubital tunnel (around the medial epicondyle) produces a numbness or tingling
sensation in the little

Vascular symptoms

" I s t h e r e a n y p a l e n e s s o r c o l d n e s s t o t h e u p p e r l i m b ?"
A fracture could have caused disruption to the usual blood supply of the limb resulting in these symptoms above.
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Symptoms in other joints

" A r e a n y o t h e r s m a l l o r l a r g e j o i n t s t h a t a r e a
Rheumatoid arthritis can occur in any joint, but it typically a
Gout usually a

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition,
including hospital admissions.
It is important to know whether the patient has experienced similar episodes of elbow pain before and, if so, whether they
have sought medical attention. This may be reassuring if they have been investigated and received a diagnosis.
However, in this situation, it is essential to maintain an open mind about the current presentation. Firstly, they may be presenting
now with a new condition. Secondly, the initial diagnosis may have been incorrect, and you may be able to correct it with the
new information in front of you.
Examples of relevant past medical history
Having another autoimmune condition or having a family history of conditions like rheumatoid arthritis, may increase the
chance of a patient having rheumatoid arthritis.
It is helpful to know if a patient has conditions such as chronic kidney disease or peptic ulcer history, as this would be
considered when prescribing.
Recent procedures on the joint might increase the chance of getting septic arthritis as a complication of this intervention.

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
If they are taking analgesia for their pain then it also worth asking if they are getting adequate pain relief from their current
dose, and how long they have been using it for.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r p a i n s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
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Relevant drug history
Some of these questions might be useful in assessing the risk of side e
function or peptic ulcers from long-term, high-dose NSAID use. NSAIDs that patients might be taking include ibuprofen
or naproxen. If someone is over 65, this risk of side e
Ways to reduce this risk include o
prescribing a proton pump inhibitor with an NSAID for protection against peptic ulcer risk, or o
to monitor if their renal function has been a
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Family history

Ask the patient if there is any family history of joint problems
“ I s t h e r e a n y f a m i l y h i s t o r y o f a n y j o i n t o r b o n e c o n d i t i o n s , f o r e x a m p l e , r h e u m a t o i d a r t h r i t i s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If there is a suspicion of a sarcoma (e.g. an increasing swelling or mass, bony pain or night pain) you could ask\:
" I s t h e r e a n y f a m i l y h i s t o r y o f s a r c o m a ( a t y p e o f b o n e c a n c e r ) ?"
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”

Explore the patient’s social history to understand their social context, assess the impact of the patient's symptoms on their
life and identify potential risk factors for elbow pain.
It can also help you determine if the patient needs other support for activities of daily living that they might no longer be able to
do due to their symptoms.
General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Ask about the impact of symptoms\:
" H o w h a v e y o u r s y m p t o m s i m p a c t e d o n y o u r l i f e ?"
" I s t h e r e a n y t h i n g y o u
" I s t h e r e a n y t h i n g y o u a r e h a v i n g t o a v o i d d o i n g n o w ?"
" I s t h e r e a n y o n e e l s e a t h o m e w h o c a n h e l p y o u w i t h t h e t h i n g s y o u h a v e h a d t o s t o p d o i n g f o r n o w d u e t o y o u r s y m p t o m s ?"
" A r e y o u r i g h t o r l e f t-h a n d e d ?"
" D o y o u d o a l o t o f m a n u a l w o r k , o r d o y o u h a v e t o u s e y o u r h a n d s a l o t f o r w o r k o r h o u s e h o l d t a s k s ?"
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These questions can also help you identify a potential cause. Tennis elbow and golfer’s elbow often occur in middle age with a
history of overuse of forearm muscles, and commonly, the dominant upper limb is a
Osteoarthritis risk factors include being over 50 and having a physically intense job or playing sports. Radial tunnel syndrome is
associated with repetitive upper limb activities.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for septic arthritis.
Occupation
Ask about the patient’s current occupation\:
Assess the impact of the elbow pain on their ability to work.
Clarify their job role and identify tasks that increase the risk of elbow injury (e.g., repetitive movements, heavy lifting).

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

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https\://app.geekymedics.com/osce-guides/history/elbow-pain-history/ 9/1011/13/24, 8\:09 PM Guide | Elbow pain history
Source\: geekymedics.com
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