SLIDE 1 = A 70-year old golfer with osteoarthritis (OA) complains of elbow pain
Our case study is a seventy-year-old golfer with osteoarthritis who is suffering from elbow pain. The following slides discuss the types of osteoarthritis, how the condition may be linked to the elbow, as well as other pathologies that may cause elbow pain and the treatments for these. Then based on our differential diagnosis, we will discuss the treatment options available and any contraindications or precautions that would need to be taken before the patient could go ahead with treatment.
SLIDE 2 = What is osteoarthritis?
OA is a joint disease characterised by the breakdown of hyaline articular cartilage, but the pathological processes involved, also changes the underlying bone, synovial membrane and other soft tissue structures such as ligaments and tendons (Bultink & Lems, 2013).
It is considered that there are two types of OA (primary and secondary), although the distinction between the two forms are not always clear. Secondary has also been referred to as post-traumatic and this type is a result of any trauma to the elbow joint (Biswas, Cohen & Wysocki, 2013).
Primary OA is defined as having an unknown cause and mechanism where there is no previous pathology. This type of osteoarthritis is mostly associated with aging (Castañeda & Jimenez, 2009).
Secondary OA is caused by predisposing conditions which is a factor that can be a pathological condition, physiological state or habit. Predisposing conditions may include hypermobility, trauma to the joint or instability resulting in excess joint stress (Castañeda & Jimenez, 2009).
SLIDE 3 = Is osteoarthritis linked to the elbow?
Osteoarthritis usually affects the weight-bearing joints, such as the hip and knee therefore it is less common at the elbow (which is a non-weight bearing joint).
The disease has a strong association with ageing, being rated as the 4th leading cause of chronic disability. It gets diagnosed in around 40% of people over the age of 60 years old (Wu et al., 2018). Due to their age and the high risk of developing OA, it could be that the patient is suffering with OA in the elbow which could be the cause of their elbow pain.
Primary osteoarthritis of the elbow usually affects males between the ages of 45-65 years old who have a history of heavy use of the extremity, such as manual laborers, weight lifters and throwing athletes (Kokkalis, Schmidt, & Sotereanos, 2017). We are unaware of the case studies gender or what their background is, but they could have had a strenuous job such as a labourer, which would have caused significant wear and tear to the elbow structures due to repeatedly lifting and carrying heavy objects. Research by Chammas in 2014 found that although the elbow is a non-weight bearing joint, it is subjected to considerable forces 3 times the weight of the body during heavy labour. Repeated trauma at these joints due to the high forces experienced, could have led to the development of secondary osteoarthritis in this patient.
SLIDE 4 = Other pathologies that cause elbow pain:
Elbow injuries in golf are more common in amateurs than professionals. A study also found that the elbow is the most affected region in amateur golfers (Cabri, Sousa, Kots, & Barreiros, 2009).
Elbow injuries usually result from striking an object other than a golf ball, such as heavy rough (long thick grass) as the golf club can become entangled creating a large deceleration of the clubhead through impact, this results in high strain across the forearm flexors (Cohn, Lee, & Strauss, 2013).
Two of the most common elbow problems in golfers are lateral epicondylitis (also known as tennis elbow) and medial epicondylitis (also known as golfers’ elbow) (Cohn, Lee, & Strauss, 2013). Epicondylitis is a common upper-extremity musculoskeletal disorder that usually affects people between the ages of 40–60 years. Tennis elbow is more commonly associated with overuse while golfers’ elbow usually results from sudden deceleration of the clubhead.
Tennis elbow is most common in the lead arm, due to repetitive contraction of the extensor carpi radialis brevis when gripping the club too tightly. The extensor muscles are very active at impact to help stabilize the wrist, consequently the lead elbow experiences high stresses across the extensors. If the case study has old grips on their clubs then they may be gripping too tightly due to fear of the club slipping from their hands. Alternatively, replacing the worn-out grip could have changed the width of it which led them to adapt by gripping too tightly, contributing to the development of tennis elbow.
Golfers elbow typically involves the trailing arm in golfers and most commonly occurs as a result of trauma, such as hitting the ground at impact. At ball impact, the flexor muscles have an activity burst to 90% capacity to stabilize the wrist. If the case study experienced this then they could be suffering from acute or chronic golfers’ elbow.
More than 80% of golf injuries have been related to overuse, this may be as a consequence of gripping the club too tightly. This is particularly common in amateur golfers due to poor technique.
In sport, the concern with an overuse injury is that it may go onto develop into a stress fracture. According to Dugan and Weber (2007) a stress fracture is a partial fracture to bone that occurs as a result of repetitive submaximal loading in the absence of acute trauma. Overtime, if not removed, this repetitive loading will exceed the adaptive capacity of bone and result in a stress fracture.
An olecranon stress fracture is when the bony tip of the elbow is fractured due to stress. This type of fracture is commonly caused by overuse of the elbow. We are unsure as to how frequently the case study plays golf, but if they are playing too often without significant recovery time then this could have led to the development of an olecranon stress fracture (Mauro, Hammoud, & Altchek, 2011).
SLIDE 5 = Differential diagnosis (DDx)
In order to differentiate between pathologies, a detailed subjective and objective assessment should be conducted by where the patients range of movement is tested and potential pathologies are ruled out or confirmed using special tests.
Tennis elbow is the most common pathology for this case study due to research stating that amateur golfers experience tennis elbow, five times more frequently than golfers’ elbow (although we are assuming that our case study is an amateur golfer). If the case was suffering from tennis elbow, they are likely to complain of pain located on the lateral epicondyle. The pain can vary from intermittent and low-grade pain, to continuous and severe pain, which may cause sleep disturbance (Vaquero-Picado, Barco, & Antuna, 2016). If the golfer plays frequently, they could have developed tennis elbow as the most common mechanism of injury is overuse due to gripping the club too tightly. If the player doesn’t have a coach or plays alone, there may be no one to notice that they are gripping the club too tightly and consequently the player could have spent years putting too much strain on the flexor muscles. Furthermore, if the player does have a coach they may have advised them on ways to improve their technique which may have led the player to grip the club tighter, both of which could have resulted in a tear.
A sports therapist could test for tennis elbow by palpating the lateral epicondyle and performing special tests which include passive, isometric and active resisted movement through the full range from full wrist extension into full wrist flexion with the forearm in pronation. If the athlete experiences pain in the lateral epicondyle during these manoeuvres, this indicates a positive test.
When testing ROM, it is important to note whether the pain is present at the end of range or throughout the movement. Many patients who are in the early stages of primary osteoarthritis of the elbow, most commonly complain of pain at the end ranges of flexion and extension, rather than at mid-range due to osteophyte impingement (Biswas, Wysocki, & Cohen, 2013). As the condition progresses, pain is usually experienced throughout the arc of motion and therefore results in loss of movement at the end of flexion and extension (Biswas, Wysocki, & Cohen, 2013). This research suggests that sports therapists should specifically focus on testing active, passive and resisted flexion and extension to help to differentiate between osteoarthritis and other pathologies.
OA is less likely to be the cause of pain at the elbow due to it being a non-weight bearing joint. However, if the player is suffering from OA in other joints (such as the hips or knees) then they may be subconsciously adapting their golf swing to reduce the stress placed on these affected joints, consequently affecting their technique and resulting in tennis elbow. They could be distracted by their pain levels, which could also lead to a fault in technique, increasing their risk of injury.
If the case study experienced trauma which led to pain on the medial side of the elbow opposed to the lateral side, then it is more likely that their diagnosis is golfers’ elbow and not tennis elbow. Without more information from the case study we are unable to conclude this, however we would test for golfer’s elbow using the following tests. These tests can be done passively, isometrically or actively against resisted movement through the full range from full wrist flexion into full wrist extension with the forearm in pronation. If the athlete experiences pain in the medial epicondyle during these manoeuvres, this indicates a positive test.
While a stress fracture could have developed from overuse, we can’t be sure as there is limited research into stress fractures in golf which relates to the presenting case (Lee, 2009). However, if trauma occurred by where the case study fell directly onto the olecranon then this could have resulted in a fracture. A fracture should not be ruled out because if it goes untreated (without rest) it will not have time to heal and the person may be vulnerable to re-injury. If a stress fracture to the olecranon was suspected, you would refer to a GP as X-ray can be used to diagnose it.
SLIDE 6 = Treatment for tennis elbow
Mccoonnell has proposed the use of kinesiology taping for tennis elbow as it can reduce pain, improve muscle function and restore functional movement patterns (Shamsoddini & Hollisaz, 2010). The use of a taping technique may help to facilitate the compliance to exercise rehabilitation programmes by reducing the client’s pain (Zaky, 2013). When specifically relating k taping to golf, it can be used to improve grip strength to reduce aggravating the condition further, as well as correcting the players faulty technique to reduce the risk of reinjury caused by gripping too tightly (Zaky, 2013). However, this may not be a suitable treatment if the player has acute tennis elbow, as this encourages them to continue to play golf and not rest which could aggravate their condition further.
One of the most commonly used treatment methods for tennis elbow management is progressive stretching exercises (Jones, 2009). Eccentric exercise can also be used to strengthen tendons and stimulate mechanoreceptors to produce collagen. This mechanism is key as it helps aid the recovery of injuries (Jones, 2009). Culinane et al. concluded that all groups containing eccentric exercise reported decreased pain, improved function and grip strength. However, the majority of consistent findings support the inclusion of eccentric exercise with other therapies, for improved outcomes in patients with tennis elbow (Cullinane, Boocock, & Trevelyan, 2014).
Studies have shown positive short-term outcomes when using low level laser therapy (LLLT) on patients with tennis elbow. This includes a reduction in pain and increased grip strength (Chesterton, Mallen, & Hay, 2011).
Consequently, a combination of all three treatments may be the most effective option for this patient.
Finally, forearm braces can be used in the management of lateral epicondylitis, as biomechanical studies have shown that bracing has a direct effect on reducing stresses on the origin of the extensor radialis carpi brevis (ERCB) (Jones, 2009).
SLIDE 7 = Contraindications to treatment for tennis elbow
However, taping may not be appropriate for the case, due to their age. This is because a contraindication of taping is parchment like skin (thin skin) which is a common problem in older adults (Kumbrink, 2014). Therefore, we would need to make sure we checked for this condition before applying the tape, if they were a sufferer we would avoid this treatment or apply underlay before the tape to protect the skin.
Particular medical conditions are more common in the elderly. When combining the physiological changes that occur during exercise with age, it can lead to increased risks associated with exercising in this population (Concannon, Grierson, & Harrast, 2012). For the present case, as the participant is 70 years old, it is more important to advise them of the precautions of exercise rather than deeming it a contraindication.
There are a few general contraindications for low level laser therapy however none of these highlight any specific risk for our case, therefore we would just check these prior to beginning treatment.
Before applying the forearm brace, we would check that the person did not have impaired sensation as this would risk us applying the brace too tightly. We would also check for impaired circulation as a brace would reduce their circulation further. If the patient did not have these conditions we would go ahead with the application, ensuring that the brace was not applied too tightly (Leggitt & Jarvis, 2008).
This concludes our presentation. On the next slide is a list of all our references. Thank you for listening.
SLIDE 8 = References
Bultink, I. E. M., & Lems, W. F. (2013). Osteoarthritis and Osteoporosis: What Is the Overlap? Current Rheumatology Reports, 15(5), 328.
Cabri, J., Sousa, J. P., Kots, M., & Barreiros, J. (2009). Golf-related injuries: A systematic review. European Journal of Sport Science, 9(6), 353–366.
Castañeda, S., & Jimenez, S. A. (2009). Primary: Three Subsets with Distinct Etiological, Clinical, and Therapeutic Characteristics. YSARH,39(2), 71–80.
Chammas, M. (2014). Post-traumatic osteoarthritis of the elbow | Elsevier Enhanced Reader. Orthopaedics & Traumatology: Surgery & Research, 100(1), 15–24.
Chesterton, L., Mallen, C., & Hay, E. (2011). Management of tennis elbow. Open Access Journal of Sports Medicine, 2(1), 53–59.
Cohn, M.., Lee, S.., & Strauss, E. (2013). Upper Extremity Golf Injuries. Bulletin of the Hospital for Joint Diseases, 71(1), 32–38. Retrieved from http://presentationgrafix.com/_dev/cake/files/archive/pdfs/103.pdf
Concannon, L. G., Grierson, M. J., & Harrast, M. A. (2012). Theme Issue: Exercise and Sports Exercise in the Older Adult: From the Sedentary Elderly to the master’s Athlete. PM&R,4(11), 833–839.
Cullinane, F. L., Boocock, M. G., & Trevelyan, F. C. (2014). Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clinical Rehabilitation,28(1), 3–19.
Gibbons, J. (2014). A Practical Guide to Kinesiology Taping. Chichester: Lotus Publishing.
Jones, V. (2009). Physiotherapy in the management of tennis elbow- a review. Shoulder & Elbow,1(2), 108–113.
Kokkalis, Z. T., Schmidt, C. C., & Sotereanos, D. G. (2017). Elbow Arthritis: Current Concepts. YJHSU,34(4), 761–768.
Lee, A. D. (2009). Golf-related stress fractures: a structured review of the literature. The Journal of the Canadian Chiropractic Association, 53(4), 290–299.
Leggitt, J. G., & Jarvis, C. G. (2008). Counterforce Brace. In the Sports Medicine Resource Manual (pp. 483–494).
Lum, G., & Yuill, E. (2011). Lateral epicondylitis and calcific tendonitis in a golfer: a case report and literature review. The Journal of the Canadian Chiropractic Association, 55(4), 325–332.
Mauro, C. S., Hammoud, S., & Altchek, D. W. (2011). Ulnar collateral ligament tear and olecranon stress fracture non-union a collegiate pitcher. Journal of Shoulder and Elbow Surgery, 20(7), 9–13
Shamsoddini, A., & Hollisaz, M. T. (2010). Initial effect of taping technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis. Iranian Rehabilitation Journal, 8(11), 24–28.
Wu, Y., Goh, E. L., Wang, D., & Ma, S. (2018). Novel treatments for osteoarthritis: an update. Open Access Rheumatology: Research and Reviews,10(1), 135–140.