Clinical signs in elbow pain.

Javed et al’s guide to the management of elbow pain1 is disappointing on several fronts including its support for the myth that only tennis players get tennis elbow,2 but especially in its description of the clinical signs of this condition and golfer’s elbow. The essence of examining a joint is to distinguish between conditions of the joint proper and those of the muscle and tendons that move it. ‘Active’ and ‘passive’ movements do not achieve this because both move the joint. It is necessary to test isometric resisted movement to separate these possibilities. If resisted movement is painful, it must be the muscle/tendon being stretched that is the source of the pain (because the joint itself is not moving). Thus tennis elbow produces pain on resisted supination, especially when trying to extend the wrist as well. This is because the lateral epicondyle is the origin of the common supinator muscles that extend and supinate the wrist. Similarly, pain on resisted pronation and wrist flexion is characteristic of golfer’s elbow. The authors do mention the wrist, but could perhaps have given more emphasis to the fact that patients with carpal tunnel syndrome often complain of pain that extends up to the elbow and beyond. Finally the authors’ advice for workrelated problems is dismissive, especially in the context of a problem that affects the patient’s livelihood. Problems with workstation geometry are common and can often be helped by an occupational therapist or even by the simple expedient of changing mouse hand for a while.