Case Study of Lateral Elbow Tendinopathy

Original Editor - Antonio Cardenas

Title

Case Study of Lateral Elbow Tendinopathy

Abstract

In the following document I would like to present the case of a patient with elbow epicondylitis, which followed a two-week treatment. All case management during this time has been carried out with an approach based in The Lateral Epicondyle Tendinopathy Toolkit [1]

Key Words

Tendinopathy, Manual therapy, Eccentric, Visual analogic scale (VAS), Pain free grip strength ( PFGS)

Client Characteristics

M. Kokolari was a 46 year old, kosovar origin bus driver working in Switzerland for 24 years, his last work like bus driver in the Lausanne region, who presented a three-month lateral elbow pain. He reported that his symptoms were gradual onset after a slight shock to the lateral aspect of his right elbow at work. He reported he was right dominant, in good general health and denied any previous history of similar symptoms.

He couldn´t follow with his regular hours and duties of work and he had been unable to participate in his recreational running and home activities like gardening due to the severity of his symptoms. Symptoms were aggravated by any repetitive use of the lower right arm and hand and relived by rest. There was some residual discomfort, for 2-4, hours following repeated use of the right wrist and hand but otherwise pain was of intermittent nature.

M. Kokolari reported that he had been referred to a physiotherapy service early in the onset of his symptoms. He had received a course of ultrasound and stretches for the writs extensors and been placed on an isotonic resisted wrist extensor strengthening program. He reported that during this treatment it had resulted in a significant increase in his pain and disability and his discontinuance of the treatment.

Examination Findings

Subjectively: The patient complained of pain in the side of his right elbow, and also in the olecranon and radiated into the muscle compartments 3 and 4 extensors. The pain was accentuated in movements of flexion and extension of elbow and wrist extension weathered. As proposed in The LET toolkit we used the VAS for pain rating and in this case M. Kokolari classed his pain on 5/10 averaged over all day.

Objectively Cervical spine: no abnormal posture of the cervical trunk, the palpatory examination was normal and the active mobility is symmetric and with normal ranges in all movements. No neurological signs during the mobility test. Shoulders: no abnormal posture, no signs of muscular atrophy, the palpatory examination was normal and the mobility was symmetric and with normal movement ranges.

Elbows: Right elbow perimeter 10cm below the olecranon process was 24 and 10cm above the olecranon process was 29.5cm. Left elbow perimeter 10cm below the olecranon process was 24 and 10cm above the olecranon process was 29cm.

Palpatory examination: hyperalgesic point in the region of the right epicondyle. Mobility of both elbows is symmetric, but the subject moves with caution his right elbow.

A radiologic examination of his right elbow was made a week after the shock without anomalies in the image

Clinical Hypothesis

Based on data from initial evaluation clinical hypothesis was a latral elbow tendinopathy. To confirm this hypothesis I used the measures recommended in the toolkit, namely the Pain-free grip test[2], Thomsen test and Maudsley test. As a subjective measure Visual Analog Scale was used as mentioned before.

Specific test like recommended in the toolkit were used on the right elbow:

  • Pain-free grip strength (PFGS)[2], first outcome-measure was: 12kg, 13kg and 11 kg.
  • Thomsen Test was positive. Pain intensity was VAS 8 / 10.
  • Maudsley Test was positive. Pain intensity was VAS 7 / 10.

Intervention

For handling this case first the patient was instructed in the handling of cargo, biomechanics and ergonomics elbow. For the management of pain the patient will be asked to keep a diary, writing on it three times a day activities that had caused him pain and classify them according to VAS.

The patient was instructed in a program of isometric exercises which aimed to control pain and the beginning of active strengthening. During the second week of treatment the patient began a program of eccentric exercises as proposed by Stasinopulos et al[3] and completed simultaneously by Tyler eccentric twist wrist extensor exercise as indicated by Tyler et al 2010[4]

Manual therapy was used from the second week with a frequency of twice a week with the following maneuvers used, Mills manipulation, elbow mobilization with movement, and varus thrust manipulation.

After these two weeks of treatment at the clinic, the patient will be asked to continue another two weeks home exercise and subsequent outcome evaluation in the clinic.

Outcome

After the four weeks of follow up the patient experienced a decrease in pain level of more than fifty percent, the Thomsen test was positive with an intensity of VAS 3 / 10 and the Maudsley test was positive too and its intensity was VAS 2 / 10. We also notice an increase in the strength of the forearm muscles measured with the PFGS and the three trials were 23kg, 26kg and 22kg respectively.

Discussion

As mentioned above the handling of this case it has been made following the recommendations of The Lateral Elbow Tendinopathy toolkit from the Physical therapy Knowledge Broker. In this case the key points of the treatment were pain management for the patient, learning proper exercises and manual therapy according to Mills and Mulligans concepts (MWM).

The end result of the outcomes were successful but would have to continue to monitor the case because the not complete disappearance of symptoms.

References

  1. http://physicaltherapy.med.ubc.ca/research/physical-therapy-know ledge-broker/projects/lateral-epicondyle-tendinopathy-let-toolkit//
  2. 2.0 2.1 Stratford P, Levy D. Assessing valid change over time in patients with lateral epicondylitis at the elbow. Clinical Journal of Sport Medicine. 1994;4:88-91.
  3. Stasinopoulos D, Stasinopoulos I. (2006) Comparison of effects of cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (bioptron light) for the treatment of lateral epicondylosis. Clinical Rehabilitation. 2006; 20(1): 12-23.
  4. Tyler T, Thomas G, Nicholas S, McHugh M. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal Of Shoulder And Elbow Surgery. Sep 2010; 19(6): 917-922.