Cases/Musculoskeletal Health

Elbow Pain Worse On Gripping — Free SCA Practice Case

Electrician with elbow pain worse on gripping

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Gary Middleton

Age

46 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've got this nagging pain on the outside of my elbow. It's worse when I grip things or use my tools. Can I have a steroid injection to sort it?"

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Gary, a 46-year-old self-employed electrician. For about six weeks you have had pain on the outer aspect of your right (dominant) elbow, worse when gripping tools, turning a screwdriver, or lifting. It is affecting your work. You have read online that a steroid injection is a quick fix and you want one so you can keep working. You are practical and a little impatient — you cannot afford much time off. You will engage with alternatives if the reasoning is explained.

Opening Sentence: "Hi Doctor. I've had this pain on the outside of my right elbow for about six weeks. It's worst when I grip my tools or turn a screwdriver — which is my whole job. I've read a steroid injection sorts it quickly, so that's really what I'm after, to keep me working."

History if Asked (Data Gathering Phase)

●The pain: "On the outside of the elbow, a nagging ache that flares to a sharp pain when I grip or lift. It can spread a bit down the forearm."
●Onset/cause: "Came on gradually over about six weeks. No single injury. My work's all gripping, twisting, repetitive stuff — I reckon it's from that."
●Aggravating/easing: "Worse gripping, turning things, lifting the kettle even. Better when I rest it, but I can't rest it with my job."
●Function/work: "It's really affecting my work — hard to hold tools all day. I'm self-employed, so time off costs me."
●What he wants: "A steroid injection, ideally — I've heard they work fast."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Gary believes a steroid injection is a quick, definitive fix and the best option for getting back to full work fast. "In my head an injection is the quick fix — job done, back to work."
●Concerns: His real concerns are being able to keep working and earning and how long this will drag on. "My worry is my livelihood — I can't be off, and I need to know how long this'll last."
●Expectations: He expects a steroid injection today. "I came expecting you'd just give me the injection."

If Asked — Examination and Differential Screen

The patient answers these only when directly asked; on video he can perform guided movements.

●If asked to localise the pain / point to it: "Right here, on the bony bit on the outside of the elbow, and just below it."
●If asked about pain on gripping / resisted wrist extension (guided): "Yes — gripping and bending my wrist back against resistance really sets it off." (Consistent with lateral epicondylitis.)
●If asked about neck pain or pins and needles/numbness in the arm/hand: "No neck pain, no pins and needles or numbness." (Screens for referred/nerve causes.)
●If asked about locking, giving way, or swelling of the joint: "No locking or giving way, no real swelling."
●If asked about trauma or a fall: "No injury or fall."
●If asked about medial (inner) elbow pain: "No, it's the outer side, not the inner."
●If asked about hobbies/other repetitive activities: "Just the work really — it's very hands-on."

Responses to Management (The Negotiation Phase)

●If the Doctor diagnoses tennis elbow and explains the natural history: "So it's tennis elbow? How long is this going to take to get better?" (The tested point is explaining lateral epicondylitis and its self-limiting but often prolonged natural history.)
●If the Doctor manages expectations about steroid injection — the key point: "But everyone says a steroid injection fixes it fast. Why won't you just do that?" (The tested point is honestly explaining that injections give short-term relief but poorer long-term outcomes, so they are not first-line.)
●If the Doctor recommends activity modification and physiotherapy: "Rest it? Physio exercises? But I can't stop working — what can I actually do?" (The tested point is practical activity modification and exercise-based management tailored to his job.)
●If the Doctor offers analgesia and a brace: "Would painkillers or a support help me get through the working day?"
●If the Doctor arranges follow-up/examination: "Do you need to look at it properly in person?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Lateral Epicondylitis (Tennis Elbow)

●Lateral epicondylitis causes pain over the lateral epicondyle, worse on gripping and resisted wrist extension, from repetitive overload of the forearm extensor tendons (occupational or sporting). It is a clinical diagnosis (tenderness over the lateral epicondyle; pain on resisted wrist extension).

Natural History

●It is usually self-limiting but often slow to resolve (months, sometimes up to a year). Setting realistic expectations is central to the consultation.

Managing Expectations About Steroid Injection

●Corticosteroid injections provide short-term pain relief but are associated with poorer long-term outcomes and higher recurrence. They are not first-line, and patients requesting them should have their expectations managed with honest explanation of the evidence.

First-Line Management

●Activity modification/relative rest, physiotherapy with progressive/eccentric strengthening exercises, analgesia (topical or oral NSAIDs), and a counterforce brace/epicondylitis clasp are the mainstays.

Occupational Considerations

●For manual workers, give practical, tailored advice (tool/technique modification, pacing, ergonomics) and consider a fit note or graded return where necessary — balancing recovery with livelihood.

Differential Diagnosis

●Consider and exclude cervical radiculopathy/referred pain, nerve entrapment (radial/posterior interosseous), medial epicondylitis (golfer's elbow), and intra-articular pathology — screen for neck pain, paraesthesia, locking, and swelling.

Escalation

●If conservative measures fail, revisit options — a considered corticosteroid injection (limited role) or specialist referral — placing injections in their proper, limited context.

Common Candidate Mistakes in This Case

●Acceding to (or flatly refusing) the injection request: rather than explaining the evidence and placing injections in their limited role.
●Setting no or unrealistic expectations: promising a quick fix, or failing to prepare him for a slow recovery.
●Advising unrealistic rest: ignoring that he is a self-employed manual worker.
●Omitting physiotherapy/exercises: the mainstay of effective management.
●Not screening the differential: missing referred/nerve causes or other joint pathology.

Free MRCGP SCA practice case for GP registrars covering Elbow Pain Worse On Gripping — Musculoskeletal Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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