Download ELBOW CASE STUDY 1 Task 1: Subjective Site Lateral area of R

ELBOW CASE STUDY 1
Task 1: Subjective
Site
Stage
Severity
Stability
Nature
Irritability
Progression / Rate
Regular / Irregular Pattern
Diagnosis
Lateral area of R elbow: Possibly CEO, musculotendonous
junction, Radiohumeral joint, Superior radioulnar joint, Radial
N, Bursa
Chronic- 6/12
Moderate 6/10 worst, 4/10 best
Unclear-requires testing
Mechanical (eases with rest) on Chemical (night pain, 4/10 best)
Mild (settles in 4-5mins)
Worsening. With Rx should recover 60% over six weeks (
Bisset et al 2006), definitely improved over 12 weeks (esp w
cortisone). Spontaneous recovery in 2 years.
Regular
Lateral Epicondylalgia (Tennis elbow)
Joint possibly implicated
Hypothesis/ Differential Diagnosis
Hypothesis
1. Extensor
tendinopathy
2. Radiohumeral
synovitis
3. Referred P Cx/Tx
spine
4. Increased Neural
tension
5. Ms imbalance
Positive Evidence
Age 35-50
P location
Mechanical nature of P
Aggravated by gripping/
eased by avoiding gripping
Deep, dull ache-tendon
Occupational overuse
syndrome-typing
Overuse-incr. Training
Morning stiffness <15 mins
P location
Deep, dull ache
Morning stiffness <15 mins
Chemical element of P
Overuse-incr. Training
Age
Occupational overuse
syndrome-typing
Deep P
P worsens with activity
TASK 2: Ax
Observation:
Posture: Tragus alignment with acromion
Negative Evidence
Chemical element of P
No neurological signs i.e.
weakness, altered sensation
Carrying angle: normal 9-14*
Resting position of upper limbs (ULs).
+ve: Forward head posture, protracted scapulae, hypertrophy-increases pull on
shoulder girdle. R arm resting in partially flexed position.
-ve: Tragus aligned with acromion. Symmetrical resting UL pos.
AROM: Assess P, Quantity & quality of movement, compensatory movements, capsular
pattern.
Cx Spine Screen: Rotation, Lateral Flexion, Spurling’s test, Traction
Physiological movements: Flexion: (140*), Extension: (0*), Supination: (85*),
Pronation (70*), Wrist flexion (70?) & extension (80?)
Combined extn, supination, ulnar deviation
+ve: Decr/ Painful elbow flexion and/or wrist extension, supination.
P on Combined extn, supination, ulnar deviation (stretch ms/tenson)
-ve: Full, Pain less symmetrical ROM
PROM: Assess P,Quantity & quality of movement, capsular pattern (equal loss of
flexion/extn, supi/pronation).
Flexion: (soft), Extension (Hard), Supination (Firm), Pronation (Hard).
+ve: Incr in jnt ROM, possibly with assoc P. P on exbow extn, wrist flexn, supi, ulnar
dev (stretch).
-ve: Full, Pain less symmetrical ROM
Resisted
Elbow & wrist flexn & ext, Brachioradialis
Combined elbow flexion, wrist extn, pronation, radial deviation
Cozens test: Resist wrist extension w elbow 90*, Resist wrist extension w elbow in
extn, Resist middle finger extn with elbow in extn. Palpation
Pain free grip strength (PFGS)
+ve: P elbow flexn, wrist extn, Brachioradialis, Cozens, PFGS
-ve: No P
Accessory Movments-Perform if hypo/hypermobile.
Relative contraindications to MT; Irritable condition, worsening.
No need to perform ligament stability tests if stable on AROM, PROM.
Humeroulnar Jnt: Longitudingal traction/Post glide for extn (with/without SB)-if decr
extn
Radiaohumeral Jnt: AP glide to improve extn -if decr extn
Palpation-Leave late in Ax to prevent irritation/compromise other tests
Bony: Medial and lateral epicondyle, Apex of olecranon
Flexion 90* (triangle) extension (in line)
Ms: Pronator teres, FCR, PL, FCU
Medial Biceps expansion
Special Tests
Biomechanical analysis of rowing technique
Workstation assessment
TASK 3- Rx
Short Term Goals:




To educate pt regarding condition, treatment options, and expected outcome
Pt will improve 60% by end of week 6.
To improve/modify rowing technique
To sleep through the night
Long Term Goals


Pt will complete 8 hour shift pain free by end of 6 months
Pt will compete in rowing champs next summer.
Plan
Week 1
Assess work environment
Complete Tennis Elbow questionnaire
Analyse rowing biomechanics
Analgesics/massage
Stretches
PRICE
Brace/strapping
Week 2-6
MWMs-passive, active assisted, then active: Lateral glide or
Grip & glide
Try 6 reps of 6 sec holds, then reassess.
Brace/strapping
Stretches: Incr TERT
Week 6
Consider Cortisone
Increase MWMs into range
Increase stretches TERT
Incorporate some ex into existing PRT programme (both
arms):
Eccentric wrist & elbow extn
Radial & Ulnar Deviation
Triceps extn, Biceps curl
Prone Flys
Single arm rows
Single arm bench press
Evidence
(Vincenzino 2001) 57 % Incr PFGS
following MWMS-lat glide while
gripping 6 reps over two days.
(Bisset et al 2006) PT vs Cortisone vs
wait & see. Cortisone most effective
short term but destructive over long
term if adjunct strengthening not
performed.
(Svernlov and Adolfson 2001)
Ecc control exs improved P & grip
strength 79 % over 12 weeks.