Lateral Elbow Pain in a Warehouse Picker: Tendinopathy or Radial Tunnel?

Lateral epicondylalgia typically produces pain at the ECRB origin, pain with resisted wrist extension, and pain with gripping, and it may be reproduced by stretching the wrist extensors. Radial tunnel syndrome produces a deep ache distal to the lateral epicondyle, often over the supinator, and is provoked by resisted supination, resisted middle finger extension, or repeated pronation-supination. Both can coexist, which is why this case is not a simple recall question. The most important findings are the point of maximal tenderness, the provocation tests that reproduce the patient's familiar pain, and the absence of sensory loss. The pain 4 cm distal and the positive resisted supination and middle finger extension raise suspicion for radial tunnel involvement. I would not rely on one test. I would also screen the cervical spine and check grip strength and pain behavior. The next step is a focused clinical impression with referral for further evaluation if radial tunnel is suspected.

I would start by reducing the provocative load rather than eliminating all work. He needs to modify repetitive gripping, use larger handles or a cart, alternate tasks, and take short frequent breaks. A counterforce brace may help symptoms but does not replace load management. Stretching alone can aggravate a reactive tendon and does not build capacity. I would begin isometric wrist extension and grip work at a tolerable intensity, then progress to slow eccentric or heavy-slow-resistance wrist extensor exercise as symptoms allow. I would monitor pain during and after sessions, using a rule that pain should settle quickly and not increase the next day. I would avoid aggressive stretching into pain and avoid repeated provocative gripping without recovery. The goal is to build tolerance while modifying the work demands, not to rest until pain-free.

I would refer if he develops sensory loss, weakness beyond pain inhibition, worsening pain despite load management, or if radial tunnel syndrome is strongly suspected and does not respond to conservative care. I would also refer if there is no meaningful improvement after a reasonable trial of four to six weeks of graded loading and ergonomic change. For work, I would advise him to stay on modified duty if possible rather than stop entirely, because complete rest deconditions the arm and does not address the work demands. I would specify temporary restrictions such as limiting repeated forceful gripping, using both hands, reducing box weight, and avoiding sustained wrist extension. I would communicate with his employer or occupational health service using objective findings. The decision to refer is based on the pattern and trajectory, not on a single painful test.