Cases/Musculoskeletal Health

Tennis Elbow Asking for A Second Steroid Injection — Free SCA Practice Case

Woman with tennis elbow asking for a second steroid injection

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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

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Materials for Candidate

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Patient Profile

Full Name

Nicola Pascoe

Age

47 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I had a steroid injection in my right elbow four months ago and it helped for six weeks. The pain is back and I have a big job booked. Can I have another today?"

Medical Records

●PMH: Nil significant. No diabetes.
●Medications: Ibuprofen 400 mg, occasional, over the counter.
●Allergies: NKDA.
●Social: Plasterer. Non smoker.

Recent Notes

●GP, 4 months ago: Right lateral elbow pain. Tender over lateral epicondyle, pain on resisted wrist extension. Lateral epicondylitis. One corticosteroid injection given at her request. Advised to rest.

Patient Script

For the friend playing the patient role

Character Overview: You are Nicola Pascoe, a 47 year old plasterer. You have worked for the same small plastering firm for eleven years. The firm is run by Wendell, and you are the one he usually puts on the ceilings. You live with your husband Terry, who works shifts, and your two children have left home. You have had a sore right elbow (your dominant arm) for about six months. You had one injection in it four months ago from a doctor at this practice. It was brilliant for about six weeks and then the pain crept back. You have a big job starting in ten days, a whole barn conversion, about three weeks solid, with a deadline for the buyers. You want another injection today so you can get through it. You are practical, quick talking and cheerful on the surface, but you sound worn out, and your voice tightens when the job or Wendell comes up. You never use a medical label for the condition.

Opening Sentence: "Hi, thanks for seeing me. I had an injection in my right elbow a few months back and it was brilliant for about six weeks, but the pain's crept back. I've got a massive job starting in ten days and I really need my arm working, so I was hoping I could come in and have another one today."

History if Asked (Data Gathering Phase)

●Where and what it is like: "Right on the outer point of my elbow, with an ache down the top of my forearm. It's a dull, grinding ache and I get a jolt when I grip hard."
●Compared with before the injection: "Same place, same sort of pain as before. It's about as bad now as it was before the injection."
●How it started (if asked): "Gradually, about six months ago. No fall, no knock. I just noticed it getting worse over a few weeks."
●What sets it off: "Squeezing the trowel, wringing out the sponge, lifting a bucket of water, carrying bags of plaster. Ceilings are the worst because my arm's out in front and up in the air for hours. Mixing plaster with a paddle on a heavy drill really sets it off. Stefan, our labourer, does that when he's there."
●How bad it is, and night pain (if asked): "About six out of ten at work and about two when I'm resting. It doesn't wake me up."
●The injection and what happened after (if asked): "I had one injection four months ago. It was sore for a couple of days, then it kicked in and I was a lot better for about six weeks in all. Then it crept back over three or four weeks and it's been as bad as before for about two months now. No problems after it, and my skin's fine."
●What she has tried since (if asked what she has done about it): "I take ibuprofen tablets now and then, a couple of times a week. I tried a chemist's elbow strap for a few days but it was fiddly under my sleeve so I stopped. The doctor last time said to rest it, but I only managed a long weekend."
●Physiotherapy or exercises (if asked): "No. Nobody mentioned physio and I've never done any exercises for it."
●Grip and everyday jobs (if asked): "It feels weaker, but that's because it hurts when I squeeze. I'm not dropping things because of numbness or anything like that. I can still do everything, it just hurts."

Ideas, Concerns, Expectations

Gating note: Nicola does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks the injection simply wore off and needs topping up, like a service. "It worked brilliantly last time, so it's just worn off, hasn't it? My mate Cormac gets his done a couple of times a year, no bother." She thinks resting is pointless.
●Concerns: Her main worry is the job and what hangs on it. "If I let Wendell down on this one I don't know where it leaves me. He's always been fair, but it's the biggest job we've got, and if I'm off we only get the basic sick pay." If the doctor explores further, a quieter fear comes out: "What if it's something torn and it never gets better? I'm 47. If I can't plaster I don't know what I'd do."
●Expectations: She came expecting an injection today. "I was hoping to pop in this afternoon and have it done."

If Asked: Medical History and Medications

Gating note: Nicola answers each of these plainly when the doctor asks about it.

●Health and medicines: "Nothing really. No indigestion or ulcers, no asthma, no kidney problems, never been told my blood pressure is high, and I'm not diabetic. Just the ibuprofen from the chemist, 400 milligrams, a couple of times a week, and it doesn't upset my stomach. No allergies and no other tablets."

Social History and Lifestyle Impact

●Work: Employed plasterer, about eight hours a day on site, with trowel work in her right hand, buckets of water, 25 kilo bags and overhead ceilings. Stefan, the labourer, is 20 and works with her three days a week.
●The job (if asked about it): "The barn conversion starts in ten days, three weeks solid. Wendell's got a deadline with the buyers, so if I can't do the ceilings he'll have to get an agency plasterer in, and I'll be the one who let him down."
●Money and sick pay (if asked): "The firm only pays the basic sick pay, and it's nothing like my normal wage. We'd manage for a bit, but not for weeks."
●Flexibility (if asked whether anything could move or whether Wendell would give her extra help or time): "Wendell's swapped people between jobs before when they've told him early enough. I've never actually asked him for anything. He could put another plasterer on the walls or give me a second labourer on the ceilings. Stefan could do more if I asked, but he's still learning."
●Impact and lifestyle: "I'm tired and sore by the evening. Terry says I'm snappy." A couple of glasses of wine at the weekend. Never smoked.

If Asked: Associated Symptoms

●Neck pain, pins and needles, numbness or tingling in the arm or hand, weakness separate from the pain: "No, my neck's fine, nothing like that, it's only weak because it hurts."
●Swelling, redness, heat, fever or feeling unwell, a lump: "No, it looks normal and I feel fine in myself."
●Locking, clicking, giving way, inner elbow, shoulder or wrist pain, a fall, knock or injury, weight loss or night sweats: "No. It moves fine and it's only the outside of the elbow."
●If asked to press the elbow, squeeze or do any test herself on camera: Declines politely. "I wouldn't know how to do that properly and I'd feel daft. If you need to examine it, I can come into the surgery." She is relieved if the doctor arranges it.

Responses to Management (The Negotiation Phase)

●
If the doctor declines or defers the injection, or explains that injections give short term relief but do worse over the longer term:
- ●Reaction: Deflated and tense, pressing once or twice without aggression. "But it worked last time. Why wouldn't it work again?" If told the evidence: "So was the last one a waste of time?" She settles if told it gave real relief and the pattern is a known one. If the first injection is criticised, defensive: "He was only doing what I asked him to." If a later injection is left as her choice, relieved: "That's fair enough. After the job, maybe."
●
If the doctor explains how long it usually takes to settle, or whether it will keep coming back:
- ●Reaction: Dismayed at first. "Months? I can't be like this for two years." She calms if told most people improve well before that. "Will it keep coming back every time I do a big job?" She is reassured to hear it can recur but usually does not once it has settled.
●
If the doctor advises rest or time off, gives general advice such as "avoid gripping", or asks which jobs she could hand over:
- ●Reaction: On rest, flat and tense: "That's not possible. The barn's the biggest job the firm's got on, and Wendell's counting on me for the ceilings." On "avoid gripping", exasperated: "Plastering is gripping. What do you want me to do, hold the trowel in my teeth?" When asked what she could change, she thinks aloud and becomes practical: "Stefan could do all the mixing and carrying. I could do the ceilings first thing and the walls later. And I suppose I could ask Wendell for another pair of hands." She settles on two or three changes. On a fit note: "It won't make up the money, but I'd take one."
●
If the doctor suggests gel, paracetamol, a strap or a brace:
- ●Reaction: "Is the gel better than my tablets?" On a strap: "I tried one before and it was fiddly. Does it actually work?" She will try one again if told the evidence is limited but it may take some strain.
●
If the doctor suggests physiotherapy or exercises, or mentions a scan or a specialist:
- ●Reaction: Sceptical about time. "I haven't got time for appointments three times a week, I'm on site all day. Can I do the exercises at home or on site? So it won't sort me out before the barn?" She agrees to try if shown how it fits around work and told it works slowly. On a scan or specialist, anxious: "Do I need a scan? Would I need an operation?" She settles if told why neither is needed at this stage.
●
If the doctor gives vague safety netting, such as "come back if it gets worse", or asks when she will be seen again:
- ●Reaction: "Worse how? It hurts every day. What would actually mean I need to be seen quickly?" On review: "I'm flat out for the next month. Can we do it after the barn?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Nicola has lateral epicondylitis (tennis elbow), a tendinosis of the common extensor tendon, driven by repetitive gripping, heavy manual work and vibrating tools. She wants a repeat of a treatment that worked briefly, on a deadline, and the evidence now points away from it. The tested skills are explaining the natural history, putting injections in their limited place, and giving activity and exercise advice a plasterer can follow.
●Model plan: name the problem, explain that it usually settles over months, decline to give or book an injection on request while keeping the door open for a later informed choice, advise cutting back aggravating tasks with specific changes for her job, offer simple pain relief and a strap, start exercises or physiotherapy, review at about six weeks, and give a specific safety net.
●Also acceptable: examining her in person before advising, or deciding on the history alone, since the same pain with no red flags is reasonable to act on. NICE Clinical Knowledge Summaries (CKS, tennis elbow, October 2025) advise reassessing if pain has not responded to initial treatment.
●Alternatives: cervical radiculopathy, radial tunnel syndrome (often worse at night), elbow osteoarthritis, septic or inflammatory arthritis (hot, swollen joint) and, rarely, malignancy. Imaging is only for persistent diagnostic uncertainty.

Natural History and What to Tell Her

●CKS describes tennis elbow as self limiting. Most people improve within 3 to 6 months, and about 80 to 90% have significant improvement within 12 to 24 months even without formal treatment. A safe message is that it usually settles over months rather than weeks. It can come back (8.5% within two years in one cohort), but most people who recover stay recovered.
●Factors linked with a worse outcome include high baseline pain, longer duration before treatment, neck or shoulder pain, recurrent episodes, the dominant arm and manual work. Nicola has several, so recovery may be slower, but that does not mean it will not happen.
●Her unspoken fear is that her trade is over. State that recovery is the usual outcome, without promising it in time for the job.

Corticosteroid Injection: What the Evidence Shows

●CKS (October 2025) now says do not offer a corticosteroid injection, because it may give short term relief but is associated with worse outcomes at 6 months. If one is offered, discuss the adverse effects and long term implications.
●The best known trial (Coombes and colleagues, JAMA 2013, 165 adults) compared corticosteroid with placebo injection. At one year complete recovery or much improvement was 83% against 96%, and recurrence was 54% against 12%. Physiotherapy made no significant difference at one year.
●Injections do work early (71% recovered or much improved at 4 weeks), so Nicola's six weeks of relief followed by return is the pattern the evidence predicts. The first injection was not a mistake, and the first doctor should not be criticised.
●CKS complications include tendon weakening or rupture with repeated injections, a pain flare in the first 24 to 48 hours, skin changes, rare ulnar nerve injury, and recurrence in up to 50%. An injection cannot be given over video, so it would need a face to face appointment.

If She Still Wants an Injection

●The clearest answer is not to give or book one on request, explain why in plain terms, and say that the question can be revisited if the plan has not worked.
●A candidate who, after that discussion, agrees to a later face to face appointment so that she can make an informed choice, ideally alongside exercises and load changes, is within guidance. One who books an injection at her informed request after that discussion is not a fail, although it is a weaker answer.
●Giving, booking or promising one without first explaining the worse outcomes at about six months and the higher recurrence is the error, for example to end the argument. So is refusing without giving any reasons.

Load Management and Work Advice

●CKS advises resting the arm and avoiding or reducing aggravating work for about 6 weeks while keeping active where possible, and avoiding high force gripping, pinching and vibrating handheld tools.
●Nicola cannot stop plastering, so cut the load, not remove it. Options: her labourer does the mixing and carrying on the days he is there, smaller mixes, shorter spells with breaks, varying tasks, doing the heaviest overhead work early, and asking her boss for extra help or time. The conversation she needs is with her boss, who has swapped people between jobs for others who told him early.
●A fit note is available if she wants one, for example to help her employer arrange cover, but it is not the main tool.

Pain Relief and Bracing

●CKS advises paracetamol or a topical NSAID such as ibuprofen gel first line, topical being preferred over oral for the lower risk of stomach side effects, and consider an oral NSAID if symptoms persist. The evidence is limited.
●Before an oral NSAID, ask about indigestion or ulcers, asthma, kidney problems, high blood pressure and other medicines. Nicola has none and takes ibuprofen tablets without trouble. Advise people using ibuprofen gel to avoid smoking and naked flames.
●A forearm strap or elbow brace can be considered, saying honestly that the evidence for benefit is limited. She stopped using one because it was fiddly, so a different type, or use during the working day only, is reasonable.

Physiotherapy, Exercises, Review and Referral

●Nicola has had no physiotherapy and no exercises in four months. This is the main gap in her care. CKS advises considering physiotherapy if there is no response after 6 weeks, including stretching and strengthening exercises for the wrist and forearm extensors and eccentric training. The evidence is limited, but exercises are simple and low risk.
●In the Coombes trial, physiotherapy helped at 4 weeks but made no significant difference at one year. The honest message is that exercise helps over weeks and does not give an injection's quick relief. In many areas people can self refer to NHS musculoskeletal physiotherapy, and CKS signposts the NHS tennis elbow page, Versus Arthritis and Chartered Society of Physiotherapy videos.
●Review at around 6 weeks, or after the barn job if she cannot be seen sooner.
●CKS advises referral to an orthopaedic surgeon if the diagnosis is uncertain, pain is refractory or function is severely impaired, or symptoms persist despite 12 to 24 weeks of optimal management in primary care. Nicola has not yet had optimal management, so referral now is not indicated.
●Surgery may be considered after 3 to 6 months of failed non surgical treatment, but evidence does not show it to be better than placebo, and it can reduce grip strength, so manage expectations.

Safety Netting

●Hot, red or swollen elbow, or fever or feeling unwell with the arm pain: same day assessment, because this could be a septic or inflammatory arthritis.
●New numbness, pins and needles or weakness in the hand or fingers, or neck pain spreading into the arm: contact the practice promptly, because this points to a nerve or neck cause.
●Locking, a lump or increasing swelling, a sudden change after an injury, or pain waking her every night: contact the practice promptly. Persistent or worsening pain despite the plan: book the review sooner.

Negotiating the Plan Around a Deadline

●Start from her experience. The injection really did help, and wanting it again is reasonable. Use her own pattern of relief and return to explain why it is not the answer now.
●She has two fears, letting her boss down and being finished as a plasterer. Ask about them, say how much is riding on this, and give an honest, hopeful picture.
●Ask what she can hand over or change rather than issuing a list. She has options she has not thought of, and a plan she has chosen is one she will follow.
●When she pushes, give the reason once in plain words and move on to what she can have today. Make exercises worth her time by showing how they fit around work and being honest that they work slowly.

Common Mistakes in This Station

●Giving or promising a second injection to settle the conversation, or declining it with no explanation.
●Telling her to rest for six weeks with no thought for the job, telling her to carry on as normal, or giving generic advice such as avoiding gripping.
●Promising she will be better in time for the barn, or leaving her thinking it will never settle.
●Making no plan for exercise or physiotherapy, so the injection is the only treatment discussed.
●Ordering a scan or referring to an orthopaedic surgeon when the diagnosis is not in doubt and exercise based treatment has not been tried.
●Criticising the colleague who gave the first injection.
●Starting an oral NSAID without asking about stomach, asthma, kidney and blood pressure problems.
●Vague safety netting such as come back if it gets worse, and never exploring what she is afraid of.

Mapped to the RCGP curriculum topic: Musculoskeletal Health.

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