Epikondylit

In medial epicondylitis, which of the following resisted movements would you expect to be painful?a.Wrist flexion and supinationc.Wrist extension and supinationb.Wrist flexion and pronationd.Wrist extension and pronation

B

Extracorporeal shock-wave therapy can be used in the treatment of epicondylitis as a means to:A. improve ROMB. build forearm strength.C. promote the natural healing processD. stretch the extensor tendon.(Ch. 9 Fitzgerald)

C. promote the natural healing process

What is the most commonly involved muscle/tendon in lateral epicodylitis?

Carpi radialis brevis.

What is the most common musculotendinous attachment involved in lateral epicondylitis?

Extensor carpi radialis brevis

What is lateral epicondylitis also known as?

Tennis elbow[Extension of wrist causes pain]

Olecranon bursitis is usually due to _________________ or trauma

chronic irritation (like elbows on the table)

Pt. presents to office with complaint of elbow pain, states they have pain with handshakes and grasping things, point to the outside aspect of the elbow. What would NOT be appropriate first line treatment?a. NSAIDsb. Physical therapyc. Corticosteroid injectiond. Surgery

d (pt has lateral epicondylitis always try at least one shot, PT and NSAIDs even before referring to ortho)

The medial epicondyle is the origin site for the wrist ___________.

flexors

When should you refer for lateral epicondylitis?

A. If the patient does not improve after 1 month of the following, then refer:1. One steroid injection.2. PT.3. NSAIDS.B. If the MRI shows a tear.

In lateral epicondylitis, which of the following movements are painful?a.Stretch into wrist flexion and supinationc.Stretch into wrist extension and supinationb.Stretch into wrist flexion and pronationd.Stretch into wrist extension and pronation

B

Which of the following injuries occurs from overuse and affects the origin of the pronator teres, flexor carpi radialis, and the flexor carpi ulnaris?A) Lateral epicondylitisB) Medial epicondylitisC) Medial valgus stress overloadD) Carpal tunnel syndrome

B) Medial epicondylitis Correct

Initial treatment of lateral epicondylitis includes all of the following except:A. rest and activity modificationsB. corticosteroid injectionsC. topical or oral NSAIDsD. counterforce bracing.(Ch. 9 Fitzgerald)

B. corticosteroid injections

Lateral epicondylitis (tennis elbow) typically results from repetitive (flexion/extension) ________________ (backhand shots), but can also be idiopathic.

extension

a person with lateral epicondylitis would have pain with resisted wrist __________ and __________

extension and supination

the tendon of this muscle is always involved in lateral epicondylitis

extensor carpi radialis brevis

(lateral/medial) epicondylitis is usually chronic inflammatory changes of the musculotendinous attachment of the common extensor group, most commonly extensor carpi radialis brevis

lateral (same pathophys for medial but with flexor)

what tendons (2) are most often involved with medial epicondylitis?

pronator teres, flexor carpi radialis

A 13-year-old boy is brought into the urgent care clinic by his father with a complaint of swelling around his right elbow. He is in 8th grade football and has been lifting weights, despite having just started puberty. He has no significant past medical history and recalls no specific incident of trauma to the elbow. On exam, the patient has a soft swelling around the posterior of the elbow. He has no redness or warmth and minimal pain. He is nontender over the bony prominences of the ulna, radial head, and humorous. What disorder of the elbow is the most likely diagnosis?(A) Arthritis(B) Olecranon bursitis(C) Epicondylitis(D) Rheumatoid nodules

(B) Olecranon bursitisSudden and repetitive trauma often causes swelling and inflammation in the bursa. In this case, the repetitive injury of inappropriate weightlifting led to the accumulation of fluid in the bursa sac.Arthritis is not a correct response. Degenerative joint disease is usually seen in older people and is caused by degeneration of the cartilage of the joint. Any swelling is felt in the grooves between the olecranon process and the epicondyles. The swelling usually feels boggy and is very tender. Although epicondylitis is also often associated with repetitive motion in sports, there is no swelling involved. There is, however, a great deal of point tenderness over the medial epicondyle in tennis elbow and golfer's elbow. Rheumatoid nodules are subcutaneous nodules, which develop along pressure points on the extensor surface of the ulna. They are firm and nontender. They are associated with longstanding rheumatoid arthritis or acute rheumatic fever.

A 21 year old female college javelin athlete presents with complaints of pain on the inside of her elbow. Her pain seems to be worst when throwing, especially towards the end of her throw. She also has some "tingling" of her 4th and 5th fingers. What do you suspect she has and what is one physical exam test you can do?

*DDx: Medial Epicondylitis, likely with cubital tunnel involvement.*Test: Golfer's Elbow Test.

A 45 year old carpenter presents with pain on the outside of his elbow. He doesn't recall any injury, but it is worse when grasping his hammer, lifting heavy objects, and even handshakes. What is your primary differential diagnosis and what test can you do to test for it?

*Ddx = Lateral epicondylitis.*Test = Tennis Elbow Test.

What should you always rule out if there are signs and symptoms of medial epicondylitis? What symptoms might suggest this and what test can be performed to rule it out?

*Must rule out cubital tunnel syndrome.*Suggested by 4th and 5th digit parasthesias.*Order electromyography [EMG] and nerve conduction study [NCS].

What is medial epicondylitis?

*Tendinitis of the common flexor tendon at the medial epicondyle of the humerus.*Usually due to chronic inflammatory changes.

A 32 year old male complaining of right elbow pain. The patient complains of weak grip and slight tingling in his right hand. The pain is presented on the medial side of the elbow, which leads to the belief that this is Medial Epicondylitis. What tests would you use to diagnose for Medial Condylitis>a. + Mills Testb. + Cozen's Testc. + Reverse Mills Testd. - Reverse Cozen's Test

+ Reverse Mills Test

A 28-year-old male comes to your clinic complaining of elbow pain. Upon palpation you find that his pain is localized on the medial side of his elbow. His pain started 2 weeks ago and is now noticing weakness in his grip strength. He needs to increase his strength, so he will be able to compete in his put-put tournament next weekend.

- Medial Epicondylitis

What imaging studies can be ordered to evaluate for lateral epicondylitis? What might be seen on each?

1. Elbow X-ray (AP, lateral, and oblique views) = might see bone spurs.2. MRI = might see calcifications in the tendon, osteophytes, or partial tearing.

What is the treatment plan for lateral epicondylitis?

1. Physical therapy, stretching, and strengthening of musculature.2. NSAIDS.3. Elbow strap and/or wrist brace.4. +/- Steroid injection.5. Surgery if fail conservative management for at least one year.

What physical exam findings would you expect with lateral epicondylitis?

1. Point tenderness at the lateral epicondyle.2. Pain with wrist/digit extension [positive tennis elbow test].3. Weakness.

What physical exam findings do you expect with medial epicondylitis?

1. Point tenderness at the medial epicondyle.2. Pain with wrist/digit flexion [positive golfer's elbow test].3. Weakness.

What are some common history findings with lateral epicondylitis?

1. Repetitive activity.2. Pain at lateral epicondyle.3. No mechanism of injury.4. Pain with handshakes, grasping objects, and lifting.

What is the history behind a medial epicondylitis?

1. Repetitive activity.2. Pain at medial epicondyle.3. No mechanism of injury.4. Pain with wrist/digit flexion and pronation.5. 4th and 5th digit paresthesias if simultaneous cubital tunnel syndrome.

Why is early protection needed following the diagnosis of lateral epicondylitis?A) The patient is in a high degree of pain and movement worsens the painB) The elbow is inflamed and movement will cause more inflammationC) Excessive tissue scarring and random collagen fiber alignment would limit normal motion and function of the elbow and wristD) Active and passive range of motion (ROM) exercises for the elbow and wrist are needed from the splinted position

C) Excessive tissue scarring and random collagen fiber alignment would limit normal motion and function of the elbow and wrist Correct

A 32 year old female patient presents with pain in the lateral portion of her right elbow. The pain started about a month ago and was fairly mild but has been increasing in intensity over that time. Recently she said she is having difficulty gripping her tennis racket and has given up playing due to the pain. You decide to test the elbow by holding her elbow in the bent position with your thumb over the point of pain. You have her extend her wrist back while you apply resistance. This movement replicates the pain. What test did we use and what is the likely diagnosis?a. Mills test; Lateral Epicondylitisb. Middle Finger Extension Test; Pulled Elbowc. Cozen's Test, Pulled Elbowd. Cozen's Test, Lateral Epicondylitise. Reverse Cozen's Test, Medial Epicondylitis

Cozen's Test, Lateral epicondylitis

Young tennis player presents with difficulty picking up items and weakness gripping. You notice point tenderness over the lateral epicondyle that increases in intensity with resisted wrist and finger extension. What tests would you perform and what is the diagnosis?a. Reversed Cozen's test, Lateral epicondylitisb. Reversed Mills, Medial epicondylitisc. Middle finger extension test, Pulled elbowd. Cozen's test, Lateral epicondylitis

Cozen's test, Lateral epicondylitis

what should you rule out when patient presents with symptoms of medial epicondylitis?

Cubital tunnel syndrome (Wartenburg test

10. Risk factors for lateral epicondylitis include all of the following except:a) repetitive liftingb) playing tennisc) hammeringd) gout

D

14. Pateints with medial epicondylitis typically present with:a) forearm numbnessb) reduction in ROMc) pain on elbow flexiond) decrease grip strength

D

Patients with medial epicondylitis typically present with:A. forearm numbness.B. reduction in ROM.C. pain on elbow flexion.D. decreased grip strength.

D decreased grip strength.

A 35 YO male golfer presents with pain over the medial aspect of the elbow which is worse when driving the ball. On examination, there is tenderness on palpation, just distal to the medial humeral epicondyle. The reverse cozens test is (+)Diagnostic Tests: No tests were done.A) Triceps TendinitisB) Nursemaids ElbowC) Little league elbowD) Medial EpicondylitisE) Occult Elbow FractureF) Lateral Epicondylitis

D) Medial Epicondylitis"Golfers Elbow"- Repetitive strain injury of the common flexor origin in the elbow.- Presents with pain over the medial humeral epicondyle- Reverse Cozens test will be (+)- Rest and Ice followed by U/S are helpful

Patients with lateral epicondylitis typically present with:A. electric-like pain elicited by tapping over the median nerve.B. reduced joint ROM.C. pain that is worst with elbow flexion.D. decreased hand grip strength.

D- Decreased hand grip strength

A 45-year old female presented to the clinic with ongoing severe pain in her dominant (right) elbow, that had become increasingly debilitating over the previous 18 months. There was no acute injury to the elbow and the patient was a typist by profession. The pain had become constant and she had difficulty typing, handwriting, gripping and raising her arm. The lateral and posterior aspects of the elbow were especially focally tender. Throughout the 18 months, periods of minor relief were gained with the use of non-steroidal anti-inflammatory drugs

Diagnosis: Lateral Epicondylitis

Why is early protection needed following the diagnosis of lateral epicondylitis?

Excessive tissue scarring and random collagen fiber alignment would limit normal motion and function of the elbow

Lateral Epicondylitis is usually due to chronic inflammatory changes of the musculotendinous attachment of the common extensor group at lateral epicondyle of humerus.

Extensor carpi radialis brevis

A 54 YO male tennis player presents with pain in the lateral aspect of the right elbow. This pain is worse when he attempts a backhand shot. On examination, there is marked tenderness just distal to the lateral humeral epicondyle. Mills is (+)Diagnostic Tests: No tests were done.A) Triceps TendinitisB) Nursemaids ElbowC) Little league elbowD) Medial EpicondylitisE) Occult Elbow FractureF) Lateral Epicondylitis

F) Lateral Epicondylitis"Tennis Elbow"- tender lateral epicondyle- (+) Mills and Cozens test- Rest, Ice, compression using a tennis elbow wrap with U/S are helpful- advice on change of tennis racket and wrist strengthening exercise will be helpful

When would you order an MRI to evaluate lateral epicondylitis?

Failure with conservative treatment.

What is medial epicondylitis also known as?

Golfer's (little league) elbow[Flexion of wrist causes pain]

Which of the following statements represents the BEST recommendation that an athletic trainer could provide to a tennis player suffering from lateral epicondylitis?

Hold the racquet less tightly and limit the number of backhand strokes

The patient is a 42-year-old factory worker who has been complaining of right lateral elbow pain for the last month. He experiences pain at rest, during work activities and during ADL's. He works on an assembly line and is required to tighten bolts on pieces of machinery. The patient has full AROM and PROM and pain with resisted wrist extension and supination. Pain is also present with passive wrist flexion and pronation when the elbow is extended. No swelling is present. He is tender to palpation at the lateral epicondyle and approximately 2" distal to this structure.Based on this info, what is a likely diagnosis for this patient?

Lateral Epicondylitis

Tonya, a 36 year old woman comes into your office and presents with pain in her elbow, which started after playing tennis three days prior. You palpate the elbow and the patient reports tenderness on the lateral aspect of the elbow but not the medial side. You do a few more tests and notice the patient is positive for the Cozens test, Mill's test, and middle finger extensor test.What is more than likely wrong with Tonya's elbow?A) Overly tight extensor muscles in the wrist that need to be properly stretchedB) Lateral EpicondylitisC) A torn Lateral Collateral LigamentD) A torn Annular Ligament

Lateral Epicondylitis

A 45-year-old woman with elbow pain. She reports that the pain began a few weeks ago and affects the lateral aspect of the left elbow. The pain improves with rest and is aggravated while playing tennis or holding a cup of coffee. On physical exam, there is tenderness upon palpation of the lateral epicondyle. Pain is elicited with resisted wrist extension while the elbow is fully extended. What is the most likely diagnosis?

Lateral Epicondylitis (Tennis Elbow)

A 35-year-old right-handed male construction worker comes to the clinic because of right elbow pain. Physical examination shows 5/5 muscle strength bilaterally, 2+ radial and ulnar pulses, and intact sensation throughout the right upper extremity. Increased pain at the lateral aspect of his elbow is produced with resisted wrist extension. A plain radiograph of the elbow is normal. Which of the following is the most likely diagnosis? A. Cubital tunnel syndrome B. Elbow osteoarthritis C. Lateral epicondylitis D. Medial epicondylitis E. Olecranon bursitis

Lateral epicondylitis

A 43-year-old female patient presents with complaints of left elbow pain which she reported having for about a year. The patient described the onset of elbow pain as gradual and attributed it to her previous work as an electronics assembler, where she spent the day pulling out plugs. Over time the pain had worsened to the point where it hurt all of the time. Although the patient had tried a course of anti-inflammatories, they had been discontinued due to an adverse reaction. The patient has since been placed on light duty at work with a lifting restriction of 10 lb. The patient reported no previous history of elbow pain and her past medical and surgical history were unremarkable.

Lateral epicondylitis

Patient complains of pain over lateral epicondyle or outer aspect of lower humerus, which increases with resisted wrist extension, especially with elbow. Hand grip is often weak on affected side. Elbow ROM usually is normal.

Lateral epicondylitis

A patient comes in and describes pain over the lateral epicondyle that radiates down the posterior surface of the forearm. The pain is often felt when they try to open a door or lift a glass of water. What condition is this patient suffering from?

Lateral epicondylitis (Tennis elbow)

A 35-year-old factory worker presents to your office for evaluation of pain in his left arm. He denies any acute trauma or injury. His job involves inspecting jars, and he has to test the opening and closing of the jar lids. He denies fever or chills. On physical examination, there is no swelling over the elbow. You palpate the olecranon process, and he has tenderness on the left lateral epicondyle but not on the medial epicondyle. Based on this information, what is your most likely diagnosis?

Lateral epicondylitis (tennis elbow)

Which of the following injuries occurs from repetitive overuse and affects the common wrist extensor origin of the extensor carpi radialis longus and brevis, and extensor digitorum and digiti minimi?A) Lateral epicondylitisB) Medial epicondylitisC) Medial valgus stress overloadD) Fracture of the distal humerus

Lateral epicondylitis Correct

Patients with __________ usually present with a history of (trauma inducing) repetitive activity, a complaint of pain at the medial epicondyle, no mechanism of injury, and pain with wrist/digit flexion.

Medial Epicondylitis

A 47-year-old man with right-sided elbow pain. He describes the pain as sharp and worsens when performing arm curls or playing golf. He denies any direct trauma to the elbow. On physical exam, there is tenderness upon palpation of the medial elbow. Pain is elicited with resisted wrist flexion while the elbow is fully extended. What is the most likely diagnosis?

Medial Epicondylitis (Golfer's Elbow

A 27-year-old left-handed male presents with left elbow pain (medial aspect) of several months duration that has gradually worsened. The patient can recall no specific injury but notices that the pain increases after working a full day as a carpenter and after playing racquetball. His sleep is not disturbed unless he sleeps on the involved arm. The patient reports no numbness or tingling in the left arm but that his pain does occasionally radiate down the inside of the forearm. Further questioning revealed that the patient has not had this condition before and that his past family and medical history are both unremarkable. The patient went to see his physician who prescribed a course of anti-inflammatory medications and physical therapy.

Medial epicondylitis

A 32 year female presents to the office with complaints of elbow pain when gripping to pull herself up when rock climbing. On physical exam she has a - Tinel's, - Speeds but a questionably positive Yergason's. She also has a pain with palpation of ulnar aspect of the elbow, resisted pronation and forced wrist flexion. You diagnose the patient with which of the following:Biceps TendonitisCubital Tunnel SyndromeLateral EpicondylitisMedial EpicondylitisPosterior Interosseous Syndrome

Medial epicondylitis

A patient presents with medial elbow pain after building a brand new deck at his cabin. He reports forgetting to purchase screws prior arriving at the cabin and instead had to use a hammer and nails. He reports exacerbation of the pain following 9 holes of golf. He initially paid for 18 but had to quit due to pain and weakness on gripping his clubs. Based on the information given, what is the most likely diagnosis?

Medial epicondylitis

Patient complains of pain over medial epicondyle or inner aspect of lower humerus. Pain worsens with wrist flexion and pronation activities. Local epicondylar tenderness, elbow pain, forearm weakness, pain aggravated by wrist flexion, and pronation activities with decreased grip strength and full ROM occur.

Medial epicondylitis

_____________________is an overuse injury affecting the wrist flexor tendons that originate in the medial epicondyle. Occasionally the pronator teres and flexor carpi radialis muscle are also injured..

Medial epicondylitis

Pain of the elbow where the tendons of the forearm muscles attach to the medial epicondyle is referred to as what?

Medial epicondylitis (Golfer's Elbow)

A 16-year-old young man comes to your clinic presenting with medial elbow pain and tingling in his hand. He states that it started after a weekend-long video game tournament. He says that taking pain medication helps, but it returns, and it's important that his arm improves so that he can play in another tournament next weekend. Your orthopedic testing validates your diagnosis. What is the condition your patient is suffering from? Name the nerve involved and which test you performed.A. Lateral epicondylitis, Mill's test, UlnarB. Medial epicondylitis, Cozen's test, MedialC. Medial epicondylitis, reversed Mill's test, UlnarD. Lateral epicondylitis, Cozen's test, Medial

Medial epicondylitis, reversed Mill's test, Ulnar

A patient frequently rests their elbow on their desk and uses their hand to hold up their head while looking at their computer screen and has developed pain and swelling in their posterior elbow. Which conditions is MOST consistent with the patient's history and presentation?Myositis OssificansLateral EpicondylitisCubital Tunnel SyndromeOlecranon Bursitis

Olecranon Bursitis

A 49-year-old computer programmer with right elbow swelling for the past few months. The swelling has worsened and became more painful over the last week. He works 12 hours a day and spends a lot of time at his desk keyboarding and working with his mouse. On examination, he has no fever. There is a red and tender swelling of the right posterior elbow. What is the most likely diagnosis?

Olecranon Bursitis (Scholar's Elbow)

Your patient was pitching and felt tingling in their pinky and ring finger. Their flexors are really tight. You perform a Reversed Cozen test. What other test could you perform and what is the possible diagnosisA. Mills Test/Medial EpicondylitisB. Reversed Mills Test/Lateral EpicondylitisC. Reversed Mills Test/ Medial EpicondylitisD. Middle finger extension test/Lateral Epicondyliti

Reversed Mills Test/ Medial Epicondylitis

__________ is a way to detect irritated nerves. It is performed by lightly tapping over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.A. Tinel's signB. Valgus stress testC. Varus stress testD. Tennis elbow testE. Golfer's elbow test

Tinels sign

A 23 YO body builder present with pain at the tip of his elbow after his weight lifting exercises yesterday. There isn't tenderness in his right olecranon fossa which is worse on extension from a flexed elbow position.Diagnostic Tests: No tests were done.A) Triceps TendinitisB) Nursemaids ElbowC) Little league elbowD) Medial EpicondylitisE) Occult Elbow FractureF) Lateral Epicondylitis

Triceps Tendinitis- tenderness over the insertion of the triceps on the olecranon- Repetitive injury to the tendon of the triceps- Presents with pain over the insertion of the tendon of the triceps- Rest, Ice followed by ultrasound will be helpful

What nerve should you be cautious of if administering an injection or surgery for medial epicondylitis/golfer's elbow?

Ulnar nerve

A 35-year-old male presents with complaints of lateral elbow pain of 4-months' duration. He is a mechanic and has to rotate his arm and elbow constantly. The pain occurs at work and is dependent upon the number of hours operating the machines. Physical exam reveals pain on finger extension directed to the lateral elbow. The likely diagnosis is lateral epicondylitis. Which one of the following treatments has been shown to have a likelihood of a detrimental long-term outcome?A - Evaluate and correct work stationB - Corticosteroids injection aloneC - Placebo injection aloneD - Physiotherapy aloneE - Platelet-rich plasma (PRP)

Your answer is Correct: B - Corticosteroids injection aloneEXPLANATION: This question describes a clinical scenario where lateral epicondylitis has become chronic. Option A is a treatment that is not necessarily proven by evidence. However, clearly there has been no evidence to suggest a detrimental effect. Option B suggests a treatment that historically was the standard intervention for lateral epicondylitis. However, recent data has shown that corticosteroid injections for lateral epicondylitis are associated with worse outcomes at one year than other treatments, including placebo injections. Option C was found to not result in worse outcomes in the studies. Option D is incorrect because physiotherapy does not make things worse at one year. Improvement is uneven. Option E is incorrect, as PRP has not been show to worsen outcome. With some preparations, PRP has been shown to be helpful.

1. A professional golfer consulted a physician about an aching pain in his elbow and along the anterior surface of his forearm. The physician detected extreme tenderness in the region of the medial epicondyle and some pain when the forearm flexor-pronator group of muscles was compressed. The golfer said that the pain usually subsided after he finished his game but that it has gradually become more severe and constant. Radiographs of the elbow were normal.a. What elbow injury do you think the golfer has sustained?b. Using your anatomical knowledge of the elbow and the flexor-pronator group of forearm muscles, what do you think is the mechanism of injury in this case?c. What is the most likely cause of the golfer's pain?

a. The symptoms and signs suggest that the golfer has an elbow injury called medial epicondylitis (golfer's elbow). b. The mechanism of injury resulting in medial epicondylitis is usually medial tension overload of the elbow from repeated microtrauma of the flexor-pronator group of forearm muscles at the common flexor attachment, the medial epicondyle. c. The probable cause of pain in medial epicondylitis is inflammation of the medial epicondyle and common flexor tendon of the flexor-pronator group of the forearm muscles.

1. A 32-year-old woman learning to play tennis practiced daily for approximately 2 weeks. She reported to her coach that she was experiencing pain over the lateral region of her elbow that radiated down her forearm. Familiar with this complaint by beginners, he asked her to hold the tennis racket and extend her hand at the wrist. She felt no pain until he resisted extension of her hand. When he asked her to pinpoint the area of most pain, she placed her finger over her lateral epicondyle. When he put pressure on the epicondyle, she pulled her elbow away because of the severe pain. The coach compressed the common extensor tendon, and she again experienced intense pain.a. What elbow injury has this woman sustained?b. What are the mechanisms of this injury?c. Does this injury occur only in tennis players?d. Where is the discrete point of local tenderness in these injuries?e. Why did the woman experience radiation of pain along the posterolateral aspect of her forearm?

a. The symptoms clearly indicate lateral epicondylitis (tennis elbow), the most common painful condition in the elbow region. b. This elbow injury usually results from repetitive microtrauma of the common extensor origin of the forearm extensor muscles. Lateral epicondylitis represents approximately 70% of all sports injuries in persons 40-50 years of age. c. Lateral epicondylitis also occurs in baseball, swimming, gymnastics, fencing, and golf sports that involve heavy use of the forearm extensors. Lateral epicondylitis can also result from direct trauma to the lateral epicondyle (e.g., a slash with a hockey stick on an unpadded elbow). d. The discrete point of local tenderness in lateral elbow injuries is immediately distal to the inflamed lateral epicondyle. e. As the inflammation of the common extensor tendon develops, pain is referred distally along the extensor tendon.