Case
- 48 y.o. lawyer
- Lateral epicondyle w/ radiation into the forearm
- Onset 2 weeks ago after doing DIY using hammer |
- Sharp, aching & burning
- 7/10 at worst, 2/10 at best
- Progressively getting worse
- Timing: elbow stiff in morning, aware of it most of the time but worse w/ certain activities |
- AF: gripping & lifting (e.g. briefcase) or shacking hands
- RF: Rest & ibuprofen |
Physical Examination Findingscal
- Very loose handshake, R elbow appears slightly swollen compared to L w/ no obvious deformity |
Reflexes
- 1+ biceps & triceps bilaterally
- 2+ brachioradialis bilaterally |
ROM
- AROM: Cx pain & restriction on R rotation
- PROM: R resisted pronation + extension caused pain on R lateral epicondyle
- Grip strength: caused pain on R lateral epicondyle |
Myofascial & joint findings
- Tight extensors
- Tender & containing trigger points on R
- Restricted radial head |
Discussion
Working Dx:
- Wrist extensor tendinopathy (aka lateral epicondylalgia / tennis elbow) |
Hx:
- Acute onset associated with repetitive use
- Some signs that it could still be inflammatory (tendonitis)
→ at 2 weeks duration it'll be moving towards a tendinosis (degeneative) |
What suggests this isn't a wrist extensor strain / sprain?
- Relieved by ibuprofen |
What suggests this isn't a radial nerve entrapment?
- Character of pain isn't neurological
- Mechanical aggravating & relieving factors
- PROM findings suggest complaint is muscular |
What suggests this isn't RA?
- Clear mechanical onset
- No symmetrical synovitis of the small joints of the hands & feet |
What suggests this isn't elbow arthropathy?
- Elbow OA most commonly affects the radiocapitellar joint
- Pain is at the lateral epicondyle
- Clear mechanical onset
- ROM findings which suggest muscular involvement |
Risk factors for poor prognosis:
- Worsening pain
- Prevented from exercising & performance of activities of daily living (ADLs)
- Aggravated by simple use (grip) |
Learning outcomes
Dx of elbow pain
- Posteior: [1] Olecranon bursitis - inflammation of the bursa sac [2] Triceps tendinitis - inflammation of the tendon [3] Radial head fracture [4] Osteoarthritis - DJD
- Anterior: [1] Biceps tendinitis - inflammation of the tendon [2] Elbow flexor tendinitis - inflammation of the tendons [3] Ulnar collateral ligament (UCL) injury - medial ligament injury (throwing athletes) [4] Osteochondritis dissecans (OCD) - piece of bone & cartilage within the elbow breaks loose
- Lateral: [1] Tendinopathy of wrist extensor origin (tennis elbow) - inflammation of the tendon [2] Radial tunnel syndrome - compression of radial nerve as it passes through the forearm muscle [3] Lateral ulnar collateral (LUC) ligament- lateral side ligament injury
- Medial: [1] Golfer's elbow (medial epicondylitis) - inflammation of the tendon [2] Ulnar nerve entrapment - ulnar nerve compression as it passes through cubital fossa [3] Medial collateral ligament (MCL) injury - medial side ligament injury |
Pathophysilogy of tendinopathy
- Overuse: microscopic damage that the body is unable to repair quickly enough
- Age-related changes: tendons becoming less elastic & more prone to injury, degenerative changes
- Mechanical stress: e.g. repetitive motion throwing a ball can cause stress on tendon of the shoulder & lead torotaor cuff tendinopathy
- Inflammatory response: tendon tissue is damaged, triggering inflammatory response, aka pain & swelling in affected area
- Genetic factors: e.g. certain genes have been associated w/ increased risk of developing achilles tendinopathy
- Other: diabetes & rheumatoid arthritis |
Difference between tendonitis and tendinosis
- Tendonitis: (tendinitis) acute condition that results from inflammation of the tendon; caused by overuse, repetitive motion, or injury; symptoms: pain, swelling, & tenderness in the affected area;treatment: rest, ice, compression, & elevation (RICE), as well anti-inflammatory medications, mechanical therapy, & sometimes corticosteroid injections{{nl]]- Tendinosis: chronic condition that results from degeneration of the tendon tissue; caused by repetitive motion or overuse over long period of time, w/o adequate time for rest & recovery; doesn't involve significant inflammation; symptoms: pain, stiffness, & weakness in the affected area; treatment: manual therapy to strengthen the affected area & improve flexibility, shockwave therapy, platelet-rich plasma injections, or surgery (severe cases) |
Management
6 week plan:
- Heat/ice to relieve pain
- Rest the arm & avoid aggravating sports/work
- Consider using orthosis (wrist brace)
- Analgesia for symptom relief: paracetamol or topical NSAIDs (ibuprofen gel)
If no response to treatment after 6 weeks:
- Reassess pt & consider alternative Dx
- Manual therapy: stretching & strengthening exercises for the wrist & forearm extensors, eccentric muscle training, massage, & ultrasound therapy |
What are clinical prediction rules?
- CPRs help guide clinical decision-making by providing standardised approach to pt assessment & management
- Based on research & statistical analysis of clinical data to identify patterns & factors that are associated w/ specific diagnoses, outcomes, or responses to treatment |
Clinical prediction rule, success probability managing pts w/ lateral epicondyalgia using mobilisation w/ movement & exercise
- Score of 0-4 indicates low success probability
- Score of 5-7 indicates a moderate success probability
- Score 8-10 indicates high success probability |
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