History

The typical age of those affected is 40 to 50 years.

Patients most typically report an insidious onset, but they will often relate a history of overuse without specific trauma. Symptom onset generally occurs 24-72 hours after repeated wrist extension activity. Delayed symptoms are probably due to microscopic tears in the tendon.

The patient complains of pain over the lateral elbow that worsens with activity and improves with rest. The patient will also often describe aggravating conditions such as a backhand stroke in tennis or the overuse of a screwdriver.

Pain may radiate down the posterior aspect of the forearm. The patient can often pinpoint pain 1.5 cm distal to the origin of the extensor carpi radialis brevis (ECRB).

Pain can vary from being mild (eg, with aggravating activities like tennis or the repeated use of a hand tool), or it can be such severe pain that simple activities like picking up and holding a coffee cup (ie, "coffee cup sign") will act as a trigger for the pain.

Physical Examination

The following may be noted on physical examination:

Inspection: Very rarely does one notice swelling or ecchymosis.
Palpation: Maximal tenderness is elicited 1-2 cm distal to the origin of the ECRB at the lateral epicondyle.
Pain is increased with resisted wrist extension, with the wrist radially deviated and pronated and the elbow extended
Pain may also increase when the patient attempts to lift the back of a chair with the elbow extended and the wrist maximally pronated.
Resisted extension of the middle finger is also painful secondary to stress placed on the ECRB tendon, as it is preferentially stressed in this position when it must contract synergistically to anchor the third metacarpal, such that extension can take place at the digits.^[9]
Increased pain is noted with resisted supination, gripping hand shaking.
Always examine range of motion (ROM) of the shoulder, elbow, and wrist on the affected side.
Examine ROM and test for crepitus at the radiohumeral joint of the affected limb to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.
If decreased ROM if noted on physical examination, consider obtaining an x-ray to further evaluate the joint.

Differential Diagnoses

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