Diff Dx Lab Case Studies

Presenting Complaint: 58 YO female with right shoulder pain

History:
O: several months ago, lifting milk carton out of fridge, been getting worse
P: Better with rest; worse when working arms elevated or lifting objects to the side
Q: Dull, achy, sharp at times, particularly when lifting objects to the side
R: No pain elsewhere, does not radiate
S: 2/10 at rest, 6/10 when first occurred, 4/10 when lifting objects to the side
T: dull/achy most of the day, doesn’t change with time of day, only activity

Ortho/Neuro:
-Empty can test (supraspinatus test): positive
-Painful but normal active ROM; painful but normal passive ROM
-Drop test: positive; all other shoulder ortho tests painful but negative

Diagnosis: Supraspinatus Sprain

Presenting Complaint: 48 YO male with left shoulder pain

History:
O: Started about 4 weeks ago, not sure exactly when, got worse, then improved somewhat, still
hurt but less
P: Worse when moving shoulder, better when resting
Q: Achy to sharp at first, dull/achy now, difficulty moving shoulder
R: No pain elsewhere, does not radiate
S: 4 or 5/10 initially, 2/10 now
T: Was constant when first noticed, still fairly constant, occasionally pt wont notice it as much

Ortho/Neuro:
-Painful reduced active and passive ROM
-All other shoulder ortho test painful but negative

Diagnosis: Frozen Shoulder aka Adhesive Capsulitis- Not 100% positive, but pretty sure since it
got worse then improved

Presenting Complaint: 24 YO male with forearm pain

History:
O: about 4 weeks ago, been slowly getting worse, no particular event caused it
P: better with rest, worse when throwing (plays softball regularly), also worse holding object for
extended periods of time (demonstrate by placing elbow in flexion as if to hold a book or phone up
to read it)
Q: achy in forearm, tingling into 4th and 5th digit
S: 0/10 right now, if asked 3/10 at worst
T: occurs 3-5 days per week, time of day varies, lasts for an hour or so
Ortho/Neuro:
-Normal ROM throughout upper extremity, sxs increased with passive maximal elbow flexion
-Tinel’s test positive
-Phalen’s test negative

Diagnosis: Ulnar Entrapment

Presenting Complaint: 36 YO male plumber with elbow pain

History:
O: began about a week ago, been getting worse, not associated with a specific event
P: better with rest, worse with motion, particularly opening hand and extending wrist
Q: intense achy at rest, more sharp when moving, particularly extension of fingers or wrist
R: goes into the back of the forearm a little during extension motions
S: 2/10 at rest, 5 or 6/10 during extension motions
T: present most of the day and most days of the week

Ortho/Neuro:
-Painful palpation of the lateral epicondyle
-Pain with Cozen’s maneuver; pain with Mill’s maneuver
-Painful but normal active and passive ROM, painful resisted extension of wrist
-Inability to perform chair lift test due to pain, all other elbow ortho tests have pain but not
positive

Diagnosis: Lateral Epicondylitis

Presenting Complaint: 28 YO male construction worker with elbow pain

History:
O: began about 2 weeks ago, been getting worse, not associated with a specific event
P: Better with rest, worse with motion, particularly gripping and hammering at work
Q: Intense achy at rest, more sharp when moving, particularly gripping hang or flexing wrist
R: no pain elsewhere, does not radiate
S: 1/10 at rest, 5 or 6/10 during flexion motions
T: present all the time

Ortho/Neuro:
-Painful palpation of medial epicondyle
-Pain with reverse Mill’s maneuver
-Painful but normal active and passive ROM, painful resisted flexion of wrist
-Reduced grip strength; all other elbow ortho tests have pain but not positive

Diagnosis: Medial Epicondylitis

Presenting Complaint: 31 YO male with right knee pain
History:
O: Comes and goes; had it for many years after injuring knee in high school (doesn’t know what
was injured, no specific diagnosis was given or can be recalled)
P: Worse when using stairs or running up/down hills; better with rest and icing
Q: Dull and achy but sharp at times
R: no pain elsewhere
S: 0/10 right now, if asked: usually 2/10 but sometimes 4/10
T: 2-3 days a week, intermittent throughout the day, usually best in the morning

Note: if asked about specific location of pain, point to medial patellofemoral joint space

Ortho/Neuro:
-Waldron’s test produces pain and crepitus during the last 20 degrees of extension, no pain at full
squat
-Observation of knee extension notes difference in patellar tracking for right v. left
-Crepitus felt when palpating patella during knee motion
-All other ortho tests of the knee are negative/normal

Diagnosis: Patella femoral arthralgia, usually medial… Some previous injury without rehab. See
tracking at last 20 degrees of extension.

Presenting Complaint: 28 YO female with wrist pain after a fall

History:
O: Fell two weeks ago, FOOSH, immediate pain, Xrays at ER are negative
P: better with rest, worse with motion, particularly when gripping something
Q: Sharp initially, now dull ache at rest,, intense ache with motion/gripping
R: No pain elsewhere, does not radiate
S: 6/10 initially, 2/10 at rest, 5/10 at worst
T: pain most of the day, most days of the week

Ortho/Neuro
-Watson’s test positive
-Palpation of snuffbox does not elicit additional pain
-All other ortho tests of the wrist are painful but not positive
-Imaging: scapholunate space is 3mm

Diagnosis: Laxity of Scapholunate Ligament

Presenting Complaint: 36 YO male with left knee pain
History:
O: pain started while playing football with friends 2 days ago, immediate pain, felt a pop
MOI: left leg planted, friend fell on lower leg and buckled knee inward
P: nothing really feels much better, not moving helps some, difficult to put weight on left leg but
can do it, movement hurts
Q: sharp initially, achy now at rest, sharp if moving knee, especially if pressed from the outside
R: No pain elsewhere
S: 3/10 currently; if asked 6/10 when onset occurred, 5/10 with motion of knee
T: Constant pain since onset, doesn’t vary much, has slowly improved since onset
Note: if asked about specific location of pain, point to medial aspect of knee joint

Ortho/Neuro:
-Painful active and passive ROM, mildly reduced due to pain
-Valgus stress test produced pain, gapping of joint medially, and apprehensiveness of patient
-Thessely’s test positive, Lachman’s test painful but no excessive motion, all other knee ortho tests
are painful but otherwise negative

Diagnosis: MCL Tear… Triad = MCL, Medial Meniscus, and ACL

Presenting Complaint: 32 yo Male With Headaches

History:
O: Started about 6 mo ago, no precific event at time of onset
P: Better with rest, worse when moving head
Q: Achy to sharp
R: Frequently associated with upper mid-neck pain
S: Range from 2-5/10
T: Occasional, usually later in the day and lasts for a couple hours, if has one when going to bed, it
is gone by morning
Note: Only provide if asked further about onset – Seemed to start after having been involved in
collision playing hockey, no direct head trauma but neck was sore afterwards.

Ortho/Neuro:
-Neck ROM produces mild discomfort at end-range but is otherwise normal
-C-Spine ortho testing is (-); neuro exam shows no deficits; palpation reveals mild tightness and
tenderness in middle and upper cervical musculature; restricted segmental motion found at C2
and C5
-CN exam is normal; ophthalmic exam indicates no changes in ICP

**Group Consensus: Cervicogenic headache

Presenting Complaint: 71 yo Male with Neck Pain
History:
O: Had it on and off for many yrs, has gotten progressively worse over last 10 yrs
P: Worse at end ROM of neck and with flexion and extension
Q: Dull, achy neck pain
R: Occasional pain into both arms (sharp, shooting in nature), also complains of hand clumsiness
S: Neck pain rates 2/10 at best, 4/10 at worse
T: Neck pain worse in morning when first wake up, improves quickly after waking and getting
going; present most days

Ortho/Neuro:
-Mildly reduced active and passive ROM with pain at end range; cervical compression reproduced
bilateral arm pain; other cervical orthos are painful but (-)
-Neuro tests show diminished sensation along lateral forearm and digits 1, 2, and 3; reduced
proprioception of IP joints in hands; MSR of biceps 2+, Triceps 1+, Brachioradialis 1+, Finger
flexion 3+; reduced muscle strength in elbow flexion and extension, wrist flexion and extension,
and finger extensors, otherwise normal

**Group Consensus: Because of the bilateral nature and the UMN lesion and LMN lesion, this is
just a classic Myelopathy. It is rare to have and probably comes from the degeneration of cervical
spine.

Presenting Complaint: 27 yo Female with Left Arm Pain

History:
O: Don’t recall exact onset, started around a month ago
P: Nothing really makes it better, worse when working (only provide if asked: factory worker
doing overhead and raised arm work)
Q: Achy arm pain generalized to arm; sometimes also has numbness and tingling that tracks along
inside of arm into medial hand and fingers
R: No pain other than arm; pain sometimes tracks along inside of arm
S: 1/10 that increases to 4/10 when arm elevates
T: Occurs most days, particularly at work; exacerbations last for 15-30 mins

Ortho/Neuro:
-Roos’s Test reproduces pain and weakness in arm and hand, Wright’s test exacerbates sx’s;
Adson’s and Halsteads tests do not change sx’s
-Upper extremity active and passive ROM are normal; all other ortho tests are negative
-Neuro eval of upper extreme shows no deficit

**Group Consensus: TOS – So Wright’s test indicates Pec Minor… Adson’s and Halstead’s both
indicate scalenes (so, since those were negative we know it is a pec minor TOS), and Roos’s test is
just a general test for TOS.
Presenting Complaint: 35 yo Female with Headaches
History:
O: Had them off and on since about 13 yoa, most recent one was 2 days ago
P: Dark, quiet environment helps; noise, light, and physical activity makes worse
Q: Sharp pain, often throbbing/pounding; usually on one side or the other encompassing temps
and forehead
R: None
S: 7/10 at worst; 3/10 when milder
T: Lasts for a few hours, occurs every few weeks, usually start early to mid-morning

Note: Only provide if specifically asked – Onset usually preceded by visual disturbance consisting
of blind spots or blurred vision; seems to occur in relation to onset of menses; went nearly 6 mos
without headache during preggo of son

Ortho/Neuro:
-CN exam reveals no abnormalities
-Opthalmic exam shows no evidence of increased ICP
-Exam of neck is normal with no prominent mm stiffness, pain or trigger points

**Group Consensus: Classic Migraine due to hormone imbalance

Presenting Complaint: 32 yo Female with knee pain and visibly swollen knee
History:
O: Immediate onset of pain yesterday while playing bball with friends, tried to make a cut and
knee “collapsed”
P: Nothing makes better; worse with motion
Q: Intense and sharp initially, sharp with motion, now intense achy when resting
R: No pain elsewhere
S: 4 now, 6 initially, and 5 with movement
T: Constant since incident yesterday

Ortho/Neuro:
- (+) Lachman’s test, inconclusive anterior drawer test
- Unable to perform weight bearing knee ortho tests
-Reduced active and passive ROM d/t pain
-All other ortho tests are painful but negative

Diagnosis: ACL tear… Anterior drawer test is inconclusive because of tight hamstrings
Presenting Complaint: 37 yo female with left hand pain
History:
O: Started a couple mo’s ago, not sure when, but getting worse
P: Pain is worse while working (if asked, works in warehouse pushing carts of boxes) and at night;
pain is better with rest, also improves with shaking out the hand as if flicking water off after
washing hands
Q: Achy, sometimes intense; occasional tingling in palm and fingers
R: Occasional forearm achiness; thumb, index and middle finger have occasional tingling
S: 2 now, if asked: 1 at best, and 5 at worst
T: Worse as day goes on and at night; present most days of week

Note: If, and only if, asked about any other complaints elsewhere indicate similar but less severe
symptoms infrequently occur on the right

Ortho/Neuro:
-Tinnel’s test is positive
-Phalen’s test is positive
-Neuro exam demonstrates no abnormal sensation in upper extremity
-*Visual comparison side to side is unremarkable*; left thumb abduction strength was mildly
reduced vs. right

Diagnosis: Carpal tunnel Syndrome

Patient Presentation: Wrist pain on ulnar side

Presenting symptoms: Pain with supination, pronation, ulnar deviation, and pain with axial
loading.

Diagnosis: Pathology of triangular fibrocartilage

Patient Presentation: Facet pain

History: MVC, but previous imaging ruled out any possibility of fracture

Presenting Symptoms: Cervical distraction and compression caused pain. Active and passive
ROM was guarded in cervical spine. There was paresthesia of C6 dermatome. MSR’s were +2.
Upper extremity muscle tests were +5 (all normal).

Diagnosis: Facet sprain/strain (ONLY) from whiplash of MVC. There was an inflammatory
response in cervical spine from the facet issue causing a release of histamine, bradykinis and
substance P and that inflammation is what caused the paresthesia, which is why there was no
neural lesion. –Petrie said this would be something awesome to adjust and help with because
chiros are so great with facets!
 Exam 1 Disorder Highlights

Neck and Neck/Arm

Dermatomes:
 C5: Motor supply to deltoid (shoulder abduction) and biceps (elbow flexion/supination),
biceps reflex, and sensory supply to outer shoulder (axillary nerve)
 C6: Motor supply to biceps (elbow flexion/supination) and wrist extension, brachioradialis
reflex, and sensory supply to outer forearm
 C7: Motor supply to triceps (elbow extension), finger extensors and wrist flexors, triceps
reflex, and sensory supply to middle finger
 C8: Motor supply to finger flexors, no reflex, and sensory supply to little and ring fingers
 T1: Motor supply to interosseous muscles of the hand (abduction/adduction of fingers), no
reflex, and sensory supply to medial arm

Disc Herniation
 Presentation: Complaints of neck and arm pain. Onset often follows neck injury, but could
be insidious. Patient also complains of some weakness in hand. Pain is a deep ache. Some
pts report some relief with hand held behind head
 Evaluation
o Painful restriction in active and passive ROM, often more on one side
o Cervical compression causes neck and arm pain, distraction may relieve pain
o Radiation into medial scapular area is possible
o Neuro testing reveals decreased corresponding DTR, weakness in a related
myotome, and sensory abnormality in related dermatome.
Myelopathy
 Presentation: Complaints of *bilateral* symptoms and clumsiness of hands, difficulty
walking, possible urinary dysfunction, and possible shooting pains into arms
 Cause: Tumor, herniated disc, and spondylotic sources. If compression of nerve roots also
occurs, signs of lower motor neuron problem will surface.
 Evaluation
o Check for presence of pathologic reflexes, UMN signs, and decreases in strength,
proprioception, and vibration.
o Lhermitt’s test utilizes passive flexion and is provocative. A positive response with
SC involvement is shooting pains into arms or legs.

Burner/Stinger
 Presentation: Pt reports with sudden onset of burning pain and/or numbess along lateral
arm with associated arm weakness following a lateral flexion injury of neck/head (eg
lateral “whiplash”). Symptoms usually last only a couple minutes
 Evaluation
o M/C finding is weakness of shoulder abduction, external rotation, and arm flexion
o Both muscle weakness and sensory findings may be delayed, so reexamine in about
a week.

TOS
 Presentation: Pt presents with **diffuse** arm symptoms, including numbness and tingling.
Often pt will describe a path down inside of arm to the little and ring fingers. This is often
made worse by overhead activity.
 Cause: Brachial plexus and/or subclavian/axillary arteries can be compressed at carious
sites as they travel down arm.
 Evaluation
o When scalenes are tested: pt is asked to look either toward (Adson’s) or away
(Halstead’s test) from involved side with the arm in slight abduction.
o Pectoralis Minor: Arm is lifted into abduction and horizontal abduction (wright’s
test).
o A function test is to have pt raise arms above head and repeatedly grip and release
hands (Roo’s test) to reproduce pain.
o Always important to perform neuro eval to differentiate TOS from lower brachial
plexus, nerve root, or peripheral n. entrapment

Facet Referred
 Presentation: Pt will most likely report minor to moderate traumatic onset of neck and arm
pain. Some pt’s onset is insidious. Pt often will draw a line of pain down the outer arm to
the hand. The arm and hand pain do NOT often fit a specific dermatome.
  Evaluation
o Deep tendon reflexes are normal
o Muscle strength is normal or weakness doesn’t fit a specific myotome, and
numbness is often subjective with no objective sensory findings.
o Local pain may be reproduced with cervical compression with neck in extension and
rotation to involved side.

Torticollis
 Presentation
o Congenital: Infant will have a fixed asymmetry of the head that is seen within hours
to weeks of delivery
o Adult version: Pt presnts with painful spask of SCM, causing head to be held in
rotation and sometimes slight flexion.
o Pseudororticollois: Pt presents with the inability to move head in any direction
without pain. Pt reports having awakened with the condition; there is no trauma or
obvious cause. Head is held in neutral
 Evaluation
o If there is moderate to high fever = Meningitis
o Kernig’s or Brudzinsky’s signs would be positive, causing severe pain and/or flexion
of the **lower** limbs on passive flexion of the neck
o Palpation of SCMs and anterior neck for masses is important
o Neuro check for UMN or LMN dysfunction will reveal any medically referable causes

Shoulder

Impingement Syndrome
 Presentation: Shoulder pain worse with overhead activities. Pt often will have a positive
history for a sports or occupational requirement to work in an overhead position.
 Evaluation
o Relief of pain with anterior to posterior support in the apprehension position, the
relocation test
o Subacromial Impingement: Tenderness and pain at anterior joint
o Infraspinatus/teres minor Impingement: Tenderness at posterior joint
o Subcoracoid impingement of Subscap: Tenderness or pain at coracoid process made
worse by passive horizontal adduction
o Traditional tests include demonstration of a painful arc, Hawkins-Kennedy test, and
Neer’s test
Rotator Cuff Tear
 Presentation: Pt is likely to give history of an acute traumatic event such as lifting heavy
weight or fall on outstretched arm. Pt’s usually complain of pain with overhead activities or
weakness in lifting the arm
 Evaluation
o Pt has difficulty raising or lowering the arm actively
o Supraspinatus tear: Empty can test or drop arm test
o Subscapularis tear: Weakness found with the lift-off test

Acute Calcific Bursitis and Tendinitis

 Presentation: Pt presents with severe shoulder pain that increases with any shoulder
movement, either with an insidious onset or subsequent fall or other major trauma
 Calcific tendinitis doesn’t occur in pts under 30 or over 60
 Evaluation
o Pt exhibits supportive posture, holding arm against side to avoid movement. All
passive and active movement is painful.
o If possible, bursa may be palpated by passively extending shoulder and feeling for
AC joint tenderness and swelling

AC Separation
 Presentation: Pt presents with traumatic onset of shoulder pain following either fall on
outstretched arm or a fall on top of shoulder
 Evaluation
o MOI and the pain/tenderness and swelling or deformity at the AC joint are classiv
findings.

Elbow

Lateral Epicondylitis
 Presentation: Pt presents with lateral elbow pain associated with a repetitive sport or
occupational activity
 Cause: Current accepted theory is that initially there is tearing of extensor carpi radialis
brevis (ECRB) origin. Repetitive movements requiring forceful wrist extension, radial
deviation, and supination are the most common causes
 Evaluation
o Tenderness at lateral epicondyle, specifically at origin of ECRB
o Provocative maneuvers are contraction of wrist extensors with the elbow flexed or
extended, and stretching of the wrist extensors with passive wrist flexion with the
elbow extended.
o Pt cant pick up a chair while keeping elbow extended and forearm pronated.
Medial Epicondylitis
 Presentation: Pt present with medial elbow pain following repetitive activity such as
hammering or suing screwdriver. In athletes, the inciting activity involves wrist flexion and
pronation. Pt’s may also complain of pain or weakness gripping
 Cause: Believed to be a tendinopathy of the origin of the wrist flexors and pronator teres
 Evaluation
o Pain is reproduced with resisted wrist flexion and pronation. Passive stretching of
wrist flexors with wrist extension, keeping the elbow straight, may also elicit pain.
o An ulnar neuropathy may coexist with medal epicondylitis. Tinel’s sign may be
positive over the ulnar nerve.

Nursemaid’s Elbow
 Presentation: Pt usually between 2 and 4 yoa. Presents withlateral elbow pain after being
swung by arm or sudden jerking of their arm.
 Cause: Radial head is not fully formed, allowing damage or entrapment of annular ligament
 Evaluation
o Exquisite lateral elbow pain and tenderness in a child without trauma of fall or flow
to elbow.
o Palpation may reveal malposition of radial head

Little League Elbow

 Presentation: Pt is usually adolescent baseball pitcher complaining of either medial or
lateral elbow pain
 Cause: Repetitive valgus stress incurred with pitching causes stretch injury to medial
elbow and possible compression injury to lateral elbow.
 Evaluation
o Tenderness may be at both medial and lateral elbow
o Valgus test may reveal laxity and/or pain.
o Alternating supination and pronation performed actively or passively may cause
palpable or audible crepitus at the head of the radius when osteochondritis
dessicans or radial head damage is present
o Popping, clicking or locking may occur on full range active movement.

Osteochondrosis (Panner’s Dz)

 Presentation: Young male complaining of **unilateral** (dominant arm) lateral elbow pain
and stiffness. Associated sx’s may include clicking and locking. Pt is often in sport several
times a week
 Cause: Osteochondrosis of capitellus is caused by AVN
 Evaluation
o Diagnosis is largely radiographic: Fragmentation or loose body formation is clear
indicator of this condition
o Exam should include passive & active supination & pronation with elbow extended.
Olecranon Bursitis
 Presentation: Pt presents with obvious swelling just distal to point of elbow
 Cause: Single fall on elbow, or more commonly, repeated weight bearing or dragging of
elbow on ground like with wrestling causes irritation and swelling.
 Evaluation: Goose-egg sized swelling at the elbow is difficult to miss.
 Must distinguish between an infected vs an inflamed bursa
o Infection si more likely when there is an obvious wound near bursitis. Infection will
also be warm and more tender than simple bursitis

Wrist/Forearm

Scapholunate Dissociation
 Presentation: Pt complains of radial or dorsal wrist pain following fall on outstretched
hand
 Cause: Falling onto thenar causes wrist into hyperextension, ulnar deviation, and
intercarpal supination, which forces the capitate between scaphoid and lunate.
 Evaluation
o Standard Stability Test = Watson’s: With pt’s arm relaxed, wrist is taken passively
into ulnar deviation. Examiner presses distal pole posteriorly as he or she passively
moves the wrist into radial deviation. A painful pop or click will occur at proximal
pole
o Xrays: Terry Thomas sign

Triquetrolunate Dissociation
 Presentation: Pt may report a fall on either palmar-flexed or hyperpronated wrist. Some
pt’s present with only dorsal ulnar wrist pain and a nontraumatic history.
 Cause: Stretching or disruption of lunotriquetral ligaments allows palmar subluxation of
lunate
 Evaluation
o Ballottement Test: Test is performed by stabilizing the lunate or triquetrum and
“shucking” or shearing the other bone against the stabilized bone. A painful pop is
considered positive.

Triquetrohamate Instability (Midcarpal)

 Presentation: Pt may present with history of fall or blow to medial side of hand with
hyperpronation. Some pts have wrist pain with no trauma
 Evaluation: Reproduction may occur on either passive or active pronation coupled with
ulnar deviation
Triangular Fibrocartilage Injury
 Presentation: Pt presents with pain on ulnar side of wrist made worse by pronation and
supination.
 Evaluation
o Ulnar deviation, axial loading, and shearing distal to the distal radioulnar joint will
often produce pain and crepitus

deQuervain’s
 Presentation: Complaint of radial wrist pain with history of activities that require either
forceful gripping with ulnar deviation or repetitive use of the thumb
 Evaluation
o Pain is reproduced with resisted thumb extension with the wrist in radial deviation
or with the standard Finkelstein test.

Carpal Tunnel
 Presentation: Complaint of pain and numbness/tingling in palmar surface of thumb and
radial 2 ½ fingers. Symptoms are worse at night. Complaints of climsiness with precision
gripping
 Evaluation
o Phalens or Tinels
o Pinch and grip strength weaker on involved side
o Thenar atrophy may be evident in chronic cases

Pronator Syndrome
 Presentation: Complaint of volar forearm pain. Usually no hx of trauma; however, there is
often a hx of repetitive pronation and wrist flexion such as incurred by carpenters,
assembly line workers, and weight lifters.
 Evaluation
o Lacertus Fibrosus Compression: Provocation with resisted elbow flexion and
supination with max elbow flexion
o Pronator Teres Compression: Provocation with resisted pronation, keeping elbow
extended and wrist flexed
o Flexor Digitorum Superficialis Compression: Provocation with resisted middle
finger flexion

Cubital Tunnel (Ulnar)

 Presentation: Complaint of medial forearm pain and paresthesia into ring and little finger.
Often hx of activities, such as throwing, that medially stretched the elbow
 Evaluation
o Sx’s often reproduced by passive or resisted elbow flexion with elbow in max flexed
position or by Tinel’s sign

Radial Tunnel
 Presentation: Complains of a dull, aching pain over lateral forearm
 Evaluation: Tenderness is distal to lateral epicondyle with weakness of wrist extensors