Elbow Pain History Taking – OSCE Guide

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Taking a comprehensive pain history is an important skill often assessed in OSCEs, and musculoskeletal problems are commonly used for this. This guide provides a structured framework for taking a history from a patient with elbow pain in an OSCE setting.

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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.

Fracture

With a fracture, there is usually a significant trauma in the history that has caused the fracture. There often is pain, bruising, 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 fluid, allowing easy movement of the elbow joint. This area can become inflamed, causing olecranon bursitis. Inflammation can be caused by infection (i.e. 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 fluctuant. Movement is usually painless at the elbow joint unless the joint is put in full flexion.

Tennis elbow (lateral epicondylitis)

Tennis elbow is inflammation of the tendons 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 affected. 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 inflammation of the tendons 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 affected.

There is medial epicondyle tenderness which may radiate. Wrist flexion 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.

Gout

This is a kind of arthritis that is caused by monosodium urate crystals developing in the joint. Usually, this affects more distal joints such as the toes (particularly the first metatarsophalangeal joints), ankles, knees and fingers. Lower limb joints are more commonly affected than upper limb, however any joint could be affected.

The onset of symptoms is rapid, with significant pain, swelling and redness in the joint. Symptoms are usually unilateral.

Pseudogout

This may present the same way as gout but is more likely to affect the wrists and knees. With pseudogout, calcium 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 affected.

Symptoms include chronic elbow pain and stiffness worse with activity or weight bearing. The range of movement reduces as osteoarthritis advances and there may be loss of extension and flexion at the elbow with pain at the ends of the range of movement of the joint.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic systemic inflammatory disease. It is usually symmetrical with bilateral symptoms; small joints of the hands are typical sites but it can occur in any joint.

Usually, the whole synovial joint is inflamed with soft tissue swelling. Pain is usually worse at rest, with early morning stiffness 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 flag symptoms include an unexplained lump 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 fingers.

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 fingerbreadths distal to the lateral epicondyle. Resisted thumb and index finger extension can cause pain.

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient, including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

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Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

• “What’s brought you in to see me today?”
• “Tell me about the pain you’ve been experiencing.”

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:

• “Ok, can you tell me more about that?”
• “Can you explain what that pain was like?”

Clarify any unclear comments they make, for example:

• “Could you let me know what you mean by weak?”

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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:

• “Where exactly is the pain?”
• “Can you point to where the pain is?”

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 fingerbreadths distal to the lateral epicondyle).

Onset

Clarify how and when the pain developed:

• “When did the pain first start?”
• “Did the pain start suddenly or develop gradually?”
• “What were you doing when the pain started?”

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 specific characteristics of the pain:

• “How would you describe the pain, e.g. burning, stabbing, aching?”
• “Does the pain come and go, or is it constant?”

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:

• “Does the pain spread elsewhere?”

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:

• “Are there any other symptoms that seem to be associated with the elbow pain?” 

Some symptoms that you may want to specifically ask about include:

• 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 differentials. For olecranon bursitis, the area may be tender and hot and feel fluctuant. In 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 inflammation of the whole synovial joint with associated soft tissue swelling. There is usually early morning stiffness for more than one hour. On the other hand, in osteoarthritis, symptoms include stiffness that worsens with activity or weight bearing. The range of movement reduces as osteoarthritis advances, and there may be loss of extension and flexion at the elbow.

In a fracture, there is often bruising, swelling, physical deformity of joint, abnormal movement of the joint and loss of function.

Red flag symptoms for 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 fingers or ring fingers.

Gout and pseudogout are usually associated with swelling and redness in the joint.

Time course

Clarify the time course of the pain and whether it occurs in discrete episodes or is continuous:

• “Does the pain come and go, or is it always there?”
• “How long does the pain last for?”
• “Has the pain always felt the same, or has it changed over time?”
• “Is there a particular time of day you notice the pain occurs?”

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 affected. Rheumatoid 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:

• “What were you doing when the pain started?”
• “Does anything make the pain worse?”
• “Does anything make the pain better?”

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 flexion. With tennis elbow, wrist extension against resistance exacerbates pain. Conversely, wrist flexion against resistance produces pain in golfer’s elbow. Resisted thumb and index finger extension can cause pain in radial tunnel syndrome.

Severity

Assess the severity of the pain by asking the patient to grade it on a scale of 0-10:

• “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Septic arthritis, gout and a fracture are likely to cause significant pain.

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 fluid throughout the consultation in response to patient cues. 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:

• “What do you think the problem is?”
• “What are your thoughts about what is causing the elbow pain?”
• “It’s clear that you’ve given this a lot of thought, and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

• “Is there anything, in particular, that’s worrying you?”
• “What’s your number one concern regarding this problem at the moment?”
• “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

• “What were you hoping I’d be able to do for you today?”
• “What would ideally need to happen for you to feel today’s consultation was a success?”
• “What do you think might be the best plan of action?

Summarising

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 different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

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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 flag systemic features such as unintentional weight loss and fatigue.

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 fingers or ring fingers.

Vascular symptoms

• “Is there any paleness or coldness to the upper limb?”

A fracture could have caused disruption to the usual blood supply of the limb resulting in these symptoms above.

Symptoms in other joints

• “Are any other small or large joints that are affected in the body?!

Rheumatoid arthritis can occur in any joint, but it typically affects bilateral symmetrical small joints of the hands.

Gout usually affects more distal joints, such as the toes (particularly the first metatarsophalangeal joints), ankles, knees and fingers. Lower limb joints are more commonly affected than upper limb, however any joint could be affected.

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Past medical history

Ask if the patient has any medical conditions: 

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

Ask if the patient has previously undergone any surgery:

• “Have you ever previously undergone any operations or procedures?”
• “When was the operation/procedure, and why was it performed?”

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.

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Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

• “Are you currently taking any prescribed medications or over-the-counter treatments?”

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 effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”
• “Do you think your pain started after you began taking any of your current medications?”

Allergies

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 anaphylaxis).

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Family history

Ask the patient if there is any family history of joint problems

• “Is there any family history of any joint or bone conditions, for example, rheumatoid arthritis?” 

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:

• “Is there any family history of sarcoma (a type of bone cancer)?”

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 really sorry to hear that, do you mind me asking how old your dad was when he died?”
• “Do you remember what medical condition was felt to have caused his death?”

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Social history

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:

• “How have your symptoms impacted on your life?”
• “Is there anything you find difficult to do now?”
• “Is there anything you are having to avoid doing now?”
• “Is there anyone else at home who can help you with the things you have had to stop doing for now due to your symptoms?”
• “Are you right or left-handed?”
• “Do you do a lot of manual work, or do you have to use your hands a lot for work or household tasks?”

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 affected. 

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 profile:

• 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).

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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.

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Editor

Dr Jess Speller

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References

• NICE CKS. Scenario: NSAIDs – prescribing issues. 2023. Available from [LINK]
• NICE CKS. Tennis elbow. 2020. Available from [LINK]
• NICE CKS. Osteoarthritis. 2022. Available from [LINK]
• NICE CKS. Bone and soft tissue sarcoma – recognition and referral. 2020. Available from [LINK]   
• NICE CKS. Gout. 2023. Available from [LINK]
• BMJ Best Practice. Calcium pyrophosphate deposition. 2019. Available from [LINK]
• BMJ Best Practice. Bursitis. 2019. Available from [LINK]
• BMJ Best Practice. Rheumatoid arthritis. 2023. Available from [LINK]
• BMJ Best Practice. Epicondylitis. 2022. Available from [LINK]
• BMJ Best Practice. Osteoarthritis. 2023. Available from [LINK]
• BMJ Best Practice. Septic arthritis. 2022. Available from [LINK]
• Calgary-Cambridge Guide to the Medical Interview – Communication Process. Available from [LINK]
• GP notebook. Septic arthritis. 2023. Available from [LINK]
• GP notebook. Radial tunnel syndrome. 2023. Available from [LINK]
• GP notebook. Clinical features of fractures. 2018. Available from [LINK]
• GP notebook. Olecranon bursitis. 2018. Available from [LINK]

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