Each of the common names for the illness addressed in this book is either inaccurate (e.g., using “itis” for a noninflammatory condition), stigmatizes arm use while inaccurately attributing etiology (e.g., tennis elbow), or is too nonspecific for such a specific disease process (e.g., lateral elbow pain). In my opinion, the best disease labels are accurate and descriptive. In this case: enthesopathy of the origin of the extensor carpi radialis brevis (eECRB).

An enthesis is an attachment point of ligament or muscle to bone. eECRB is one of the many enthesopathies that mostly arise and resolve in middle-age. The pathophysiology for these enthesopathies (as well as for tendinopathies such as trigger finger and de Quervain tendinopathy and degenerative changes in the meniscus of the knee) is myxoid degeneration [1]. Myxoid (or mucoid) degeneration is characterized by gelatinous change in connective tissue. There is an increase in extracellular matrix, fewer tenocytes, and less organized collagen. People with eECRB feel like the elbow is inflamed, but the pathophysiology is not inflammatory.

A useful summary of this disease that is easily understood by most patients is as follows:

I suspect that most caregivers—let alone patients—find this “best evidence” summary unexpected, counterintuitive, and unbelievable—at least to some degree. It does not fit our “experience.” We have met patients that have had eECRB for 10 years. We have seen people get better from corticosteroid injections. Many of us have personal experience with eECRB—experience that does not mesh with this best evidence summary.

I cannot give caregivers a “magic bullet” for their patients, but I am confident that I can explain the range of debate and emotion on these issues. There are simple things that we can do better—starting with how we conceive of this disease, what we tell our patients, and which coping strategies we directly or indirectly reinforce with our language and behavior. At a minimum, eECRB is a great paradigm for becoming familiar with the wonderful complexity of the human illness experience.

The best healer for patients with eECRB may be curiosity. The best attitude of caregivers is also curiosity. Most of us are familiar with the selective attention test where 50 % of us miss the gorilla while counting the number of times players pass a basketball. Magicians routinely fool even the most intelligent people using this type of misdirection and sleight of hand. In fact, magicians prefer an intelligent audience because the intelligent are easier to fool. Human intelligence is rooted in rationalization and pattern formation—it is built to get it wrong sometimes in order to come to a decision quickly in an emergency. That is why humans invented science. Be ready for your first impressions to be wrong.

eECRB is a paradigm for conditions that require strict science. Subjective, benign, and self-limited, it is difficult to be sure that anything we do for eECRB is superior to the natural history of untreated disease, the tendency of symptoms to wax and wane and regress to the mean, and the placebo effect.

With all the room for debate in eECRB, there is one thing that is so consistently observed, I think it qualifies as a fact: symptom intensity (e.g., pain) and magnitude of disability correlate most strongly with ineffective coping strategies [4, 5]. Pathophysiology as measured with magnetic resonance imaging or operative findings has little or no correlation with symptoms and disability to date [6].

This may amount to common sense. Humans are built to respond to symptoms—pain in particular—by feeling protective and preparing for the worst. Psychologists measure this tendency in the negative as catastrophic thinking (“Every time I cause pain, I’m keeping it from healing”; “If I don’t do something it will always hurt and I will never be able to depend on my arm”) and in the positive as self-efficacy (“I’ll be fine”; “I’ve had pains like this in the past and it always works out”; “I can achieve my goals even with these symptoms”) [7].