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5002 Case 2 Cheat Sheet by

Tendinopathy of the wrist extensor origin (aka tennis elbow)


- 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
- 1+ biceps & triceps bilaterally
- 2+ brachi­ora­dialis bilate­rally
- 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


Working Dx:
- Wrist extensor tendin­opathy (aka lateral epicon­dyl­algia / tennis elbow)
- 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)
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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