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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.