The posterior fat pad sign on a lateral elbow X-ray is one of the most important radiological findings in trauma — it represents haemarthrosis displacing the fat pads from the olecranon and coronoid fossae, and is present in 90% of occult elbow fractures (fractures invisible on standard X-ray). In adults, a visible posterior fat pad with trauma should be treated as a radial head fracture even if no fracture line is visible on X-ray. Management: collar-and-cuff sling, analgesia, orthopaedic review in 1–2 weeks (repeat X-ray often shows fracture at 10–14 days when periosteal callus forms). Failing to treat fat pad sign as an occult fracture is a well-recognised medicolegal issue. Cubital tunnel syndrome (ulnar nerve compression at the medial elbow) is the second most common peripheral nerve entrapment after carpal tunnel syndrome — it causes ring and little finger paraesthesia and, in advanced cases, weakness and wasting of the intrinsic hand muscles (hypothenar wasting, interossei wasting, claw hand).

The anatomical localisation of elbow pain is highly diagnostically specific — the elbow has distinct compartments and structures, and pain in different regions points to different pathologies. Lateral epicondyle pain = extensor origin tendinopathy (tennis elbow). Medial epicondyle pain = flexor origin tendinopathy (golfer's elbow) ± cubital tunnel syndrome. Posterior swelling = olecranon bursa (separate from the joint). This anatomical precision means that a careful examination of exactly where the pain is, and what movements reproduce it, is the most important diagnostic tool — more informative than investigations in most cases. The key examination finding for tennis elbow (Cozen's test) takes 5 seconds: place two fingers on the lateral epicondyle and ask the patient to extend the wrist against resistance — reproduction of lateral elbow pain is a positive test with 85% sensitivity.

Tennis elbow is not an inflammatory condition — histological studies consistently show angiofibroblastic tendinosis (degeneration and attempted disorganised repair) rather than inflammatory cells. This has important treatment implications: anti-inflammatory treatments (NSAIDs, corticosteroid injection) address the wrong pathology. Corticosteroid injection for tennis elbow provides rapid short-term pain relief (superior to physiotherapy at 6 weeks) but is associated with significantly worse outcomes at 1 year and higher recurrence rates than physiotherapy or watchful waiting (NICE 2016 review). The current recommendation is to offer physiotherapy (eccentric exercises, deep friction massage) and watchful waiting as first-line, reserving corticosteroid injection for exceptional circumstances. This represents a significant shift from historical practice.

Olecranon bursitis aspiration is a key diagnostic and therapeutic procedure — it differentiates septic bursitis (requires IV antibiotics and repeated aspiration or surgical drainage) from traumatic or gouty bursitis (managed conservatively). The aspirated fluid should be sent for MC&S (culture), cell count, and crystal microscopy simultaneously. Septic bursitis typically shows WBC >10,000/mm³ and positive Gram stain in 60% of cases; culture is positive in 85%. The most common organism is Staphylococcus aureus (80%). Empirical treatment while awaiting cultures: flucloxacillin 500 mg QDS (covers staphylococci) or co-amoxiclav if polymicrobial concern. MRSA-suspected (healthcare worker, previous MRSA): doxycycline 100 mg BD.

Distal biceps tendon rupture requires early orthopaedic assessment — surgical repair within 2 weeks produces significantly better long-term supination strength and functional outcomes than delayed repair or conservative management. After 2 weeks, tendon retraction and adhesion formation makes surgical repair progressively more difficult. The clinical features are classic: sudden pop at the anterior elbow during forceful elbow flexion or supination (e.g., lifting a heavy box), followed by weakness of elbow flexion and supination and a visible deformity (Popeye sign — biceps muscle belly displaced proximally). The Hook test is specific: the examiner hooks a finger under the bicipital tendon at the elbow — if the tendon cannot be hooked, it has ruptured. Any patient with suspected distal biceps tendon rupture should be referred to orthopaedics urgently, not managed conservatively by default.

The evidence against corticosteroid injection for tennis elbow represents one of the most significant recent guideline shifts in MSK primary care. The landmark RCT by Coombes et al. (2013, Lancet) demonstrated that corticosteroid injection produced significantly worse outcomes at 1 year compared to physiotherapy alone or placebo injection — patients who received steroid injection had higher recurrence rates, greater global deterioration, and worse functional outcomes at 52 weeks despite better short-term pain relief at 4 weeks. NICE and RCGP guidelines now recommend against steroid injection as a routine treatment for tennis elbow. This requires active de-prescribing of an established GP practice — explaining to patients why the previously offered steroid injection is no longer recommended requires good communication skills. The SCA examination may specifically test this communication scenario.

Topical NSAIDs (diclofenac gel) have equivalent efficacy to oral NSAIDs for peripheral MSK pain (epicondylitis, OA of superficial joints) with dramatically lower systemic side effects — GI toxicity, renal impairment, and cardiovascular risk are all significantly reduced. NICE recommends topical NSAIDs as first-line analgesia for peripheral MSK conditions before oral NSAIDs. Voltarol 1% gel (diclofenac diethylamine 1.16% equivalent) is available OTC and on prescription. Application frequency: apply 4 times daily (QDS) or BD–TDS depending on formulation. The Voltarol 12-hour gel (2.32% diclofenac) requires BD dosing only, which improves adherence. Provide occupational advice at every consultation for work-related epicondylitis — returning a patient to the same job without addressing the causative ergonomic factor results in immediate relapse.

The Tyler Twist exercise (using a rubber bar/Flexbar) is the best-evidenced single exercise for lateral epicondylitis — it produces eccentric loading of the wrist extensors in a functionally relevant pattern. The original Tyler study showed a 72% reduction in pain at 6 weeks. Instructions: hold the bar vertically in both hands, twist the bar with the affected hand (wrist extends eccentrically against the bar's resistance). This is available for patients to view via YouTube. Most physiotherapists include this as part of a broader programme. Two-handed backhand technique coaching is the most effective sports-specific prevention strategy for tennis elbow — teaching a single-handed player to switch to a two-handed backhand eliminates the primary eccentric loading mechanism of the extensor origin during tennis. This is a recommendation from BASEM (British Association of Sport and Exercise Medicine) guidelines.

Compartment syndrome following elbow fracture or dislocation is a rare but devastating complication — the forearm is the second most common site for compartment syndrome (after the leg). It presents with the 5 P's: Pain (disproportionate, unrelieved by opioids), Paraesthesia (early — indicates ischaemic nerve), Pallor, Paralysis (late), Pulselessness (very late). The compartment pressure threshold for fasciotomy is 30 mmHg (or within 30 mmHg of diastolic BP). Any patient in a cast who reports worsening pain + tingling must have the cast removed and be assessed for compartment syndrome immediately — do not give more analgesia and wait. This is a medicolegal emergency with a narrow window for limb salvage.