Pain referred to the elbow

Pain referred to the elbow from structures that lie higher up the limb is one possibility. The localization of the pain indicates the segment in which the lesion lies: the lateral aspect of the elbow is formed by the C5 dermatome, the anterior aspect by C6, the inner aspect by T1–T2 and posteriorly by C7.

Pain referred from the elbow

Pain referred from the elbow is uncommon. A lesion at the origin of the extensor carpi radialis brevis may give rise to pain radiating down the posterior aspect of the forearm to the hand as far as the third and fourth fingers. A lesion at the distal bicipital insertion radiates down the proximal and palmar aspect of the forearm. Proximal reference of elbow pain is very rare.

• Where is the pain? The location of the pain is usually closely related to the site of the lesion. When the patient indicates exactly where the symptoms are felt, all causes that cannot produce pain in that area are automatically excluded.

• How did it all start? Did the symptoms start spontaneously or has there been any trauma; if so, what type? If the onset was spontaneous, did it begin suddenly or gradually, or as the result of a particular activity?

• What was the evolution? Was there any change in the location, intensity or frequency of the painful episodes? Did the pain spread and, if so, where to? This may indicate the dermatome and, in consequence, the segment in which the lesion must be sought.

• Is there any functional loss?

• Has the elbow ever been swollen? If the swelling came on after trauma, how soon did it appear? Immediate general effusion is probably the result of a haemarthrosis; gradually increasing swelling usually indicates the presence of synovial fluid. Spontaneous swelling may be the result of an impacted loose body or a rheumatoid condition. Localized swelling may occur in bursitis or in some exceptional cases of tennis elbow.

• What influences the pain? Is the pain constantly present, or does it come on during or after either general or specific activity? In an arthrotic or arthritic joint the maintenance of a particular posture at the extreme of the possible range may become very painful. Release from this position is usually very uncomfortable. ‘Twinges’ when picking up objects (e.g. a telephone or a coffee pot) with an outstretched elbow is a well-known symptom in tennis elbow.

• Are any other joints involved? In rheumatoid-type conditions other joints may be affected.

Passive movements

The passive movements (Fig. 16.1) are used to examine the inert structures: the joint, the capsule, the capsular ligaments and the bursae. It is also clear that, by passively testing the elbow, one also indirectly stretches or pinches muscular and tendinous structures.

The range of movement is ascertained and the end-feel noted.

The four passive tests give the examiner an idea of the behaviour of the inert structures around the elbow. The pattern that is formed suggests a lesion of either the capsular type – arthritis, in the joint between forearm and humerus or in the upper radioulnar joint – or the non-capsular type.