Ortho Examination 5

Station 5

It hurts but the new living room colour is to die for….

Start the Timer and Begin

Intro

Candidate introduces self with full name and role

Identifies patient with 2 pieces of information - eg name and date of birth

Adheres to appropriate infection control measures

Gains consent for examination then adequately exposes the patient's elbow

Look

Please ask the candidate to examine a real model/actor. Please prompt the candidate to verbalise what they are inspecting for.

Inspects elbow anteriorly - nil abnormality

Inspects laterally - nil abnormality.

Inspects posteriorly - nil abnormality

Comments on any 4 elements of visual inspection of:
no varus or valgus deformity
no erythema / rashes
no bruising/swelling
no contraction
no scars
hands are pink in colour

Compares the elbows bilaterally

Feel

Full marks

Screens for temperature change - nil

Palpates the brachial pulse - good volume

Palpates the lateral epicondyle - significant point tenderness on palpation of the extensor tendon insertion point

Palpates the olecranon - nil tenderness

Palpates the medial epicondyle - nil tenderness

Palpates the cubital fossa including the coronoid process of the ulnar and the radial head - nil tenderness

If the candidate attempts a full shoulder or wrist exam then move them along by stating “you do not need for perform a shoulder / wrist exam”.

Move

Full marks

Active Movement

Tests elbow flexion - full range of motion (RoM)

Tests elbow extension - full RoM

Tests elbow pronation - full RoM

Tests elbow supination - full RoM

Passive Movement

Passive movement - feels for crepitus in the elbow joint on passive movement - nil

Special Tests

Performs any special test for lateral epicondylitis - all are painful:
Resisted wrist extension Test
Cozen’s Test
Mill's Test
Maudsley’s Test

Candidate concludes by offering a distal neurovascular exam and exam of the joint above and below

Examiner Instruction

At this point please direct the candidate to move on to diagnosis and management.

Diagnosis and Investigation

Main differential - Lateral Epicondylitis (please inform the candidate of the correct answer if incorrect and allow them to proceed to explanation).

Candidate enquires into the patients current ideas of what the condition might be / their current understanding of epicondylitis

Candidate clearly explains the diagnosis without use of medical terminology

Candidate contextualises the diagnosis by using examples of the patients pain and their recent activty (e.g. painting)

Candidate enquires as to further questions and uses chunking and checking to ensure patient understanding

Management

Ignore management in final marks

Candidate recommends avoidance of aggravating activities (painting)

Candidate recommends pain relief e.g Paracetamol and Ibuprofen

Candidate recommends any other therapy of;
Elbow tendonitis splint
Physio
Steroid injections
Senior discussion

Submit for Scoring

Summary

Lateral epicondylitis or “tennis elbow” is a condition characterised by pain and tenderness at the lateral epicondyle of the humerus. This is the site of origin for the common extensor tendon of the forearm. It is usually caused by repetitive wrist extension, such as tennis or repetitive manual labor (like painting!). Diagnosis is primarily clinical and the need for further investigation is guided by the likelihood of alternative diagnoses such as osteoarthritis of the elbow (which would require XR). As with the rotator cuff exam in the shoulder, special tests like Cozen's, Mill's, and Maudsley's tests are important as they can help clinically distinguish epicondylitis from other differentials. In clinical practice the lateral tenderness really is clear!

Management includes rest, NSAIDs, physical therapy, and activity modification, with invasive treatments like corticosteroid injections or surgery considered for chronic, refractory cases. Prognosis is generally good with conservative management. In Hayley’s case, she made her husband paint the rest of the house and she recovered very well with simple pain relief and some rest.

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Station Written by: Dr Benjamin Armstrong

Peer Reviewed by:

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Ortho Examination 5

Station 5

Candidate Instructions

Setting:

Name: Hayley Matterson

Tasks:

Simulated Patient Instructions

Briefing

Opening Statement

Appearance and Behaviour