13th April. Duration: 6 hours. (2 clients)
My first client was a 34-yr old female was suffering from pain in her elbow. Through questioning and passive/active ROM assessment, I used resistance on her outstretched arm/palm, which reproduced pain on the inside of her elbow, indicating the possibility of medial epicondylitis, a repetitive strain injury (Curti et al., 2021; Wilk et al., 2021). The patient described the pain got worse when she griped things hard and had got worse over the past 2-weeks, and she now has slight pain on the inside of her elbow when going about her normal daily activities (Fig.1). The patient worked long hours on a laptop and liked to keep fit in the gym, where she first noticed the niggle after a few sessions. I also conducted Cozens Test, checking for lateral epicondylalgia, but this test was negative (Karanasios et al., 2021).
She advised she did a repertoire of exercises including wrist curls. I believed this was a degeneration of the tendon perhaps caused by overloading the tendon too quickly. I quickly did more research on elbow injuries and noted similar pain can result from an avulsion fracture or medial collateral ligament (MCL) sprain,however, the patients’ symptoms, did not occur immediately, and there was minimal swelling and no bruising, hence although similar pain is felt, I was confident my diagnosis was correct, but of course only an MRI, would be able to detect tendon tears. I am always cognizant not to provide a 100% positive diagnosis to a patient if doubt remains, however, if no further damage could occur through incorrect treatment, I am comfortable giving a professional judgement with the evidence available.
I advised the client to rest the impacted arm/elbow from any activity that caused pain and avoid gripping/carrying heavy objects for a week to see if the pain started to subside. I provided ice compress for 10-min advising to repeat every hour for a week or as able, and to consider using an elbow brace/ bandage for a few weeks to support it until the pain had subsided. I also advised after 2-weeks to use heat rather than ice on the wound to promote blood flow, and if her GP authorised, the use of NSAIDs may assist. I finished the session advising the client if after 2-weeks the pain had not gone, a visit to her GP would be advisable, or if pain had gone, she could return where we would assess and if suitable, conduct cross friction massage to the tendon to stimulate healing in conjunction with massaging the muscles of the forearm to reduce tension and improve function. If I could have done anything differently with this patient, I would have provided more detail reference form when performing weighted exercises including loading, however the patient was very satisfied with her treatment and advice provided.
Fig. 1 Site of pain in medial epicondylitis (Golfer’s elbow
My second online patient was 50-year-old man who explained he had a sore aching shoulder, which had gradually deteriorated over the past 3-weeks or so, was restricting his movement and more painful at night when he lay on it, causing him to wake up. He described the pain as spreading around his shoulder. Through questioning and assessment, I conducted a passive ROM test observing his mechanical movements as best as I could online; minus his shirt on, and how his pain levels felt when moving his neck and arm in different directions (flexion, adduction & internal/external rotation). I informed the patient, I could not conduct all tests online i.e., strength tests/resistance, but got him to apply some resistance on his impacted arm using his good arm, which although not perfect, did assist to identify some muscular areas with pain. Through further research, I was aware there are potential Red Flags with shoulder pain including: Referred ischaemic cardiac pain Polymyalgia rheumatic etc, hence, decided not to do any more tests online.
The patient advised he did not go to the gym, had not bumped his shoulder, worked in an office, and had never had this pain previously. I was aware, this could be a variety of conditions (impingement syndrome; referred shoulder pain; Glenoid Labrum tear; Surascapylar Neuropathy; Pec Major Tendon inflammation…), however, through questioning, I believed it was more likely to be Frozen shoulder, particularly as the pain was worse at night. I advised the client, he should visit his GP to have it checked out, but I thought it displayed all the signs of being Frozen shoulder (De La Serna et al., 2021; Hand et al., 2008). Whilst conducting this online assessment, I was acutely aware, a wrong diagnosis with a shoulder injury, could have serious consequences, hence I erred on the side of caution. I advised the client if it was Frozen shoulder, I believed he may be in the Freezing stage, which may persist for 2-9 months, followed by Stiffening phase (4-12 months), and finally Thawing phase (5-12 months), and regardless, the treatment would be to try to keep the shoulder moving if not too painful, and once he had been to his GP, we could arrange a mobility programme for him at the clinic if pain allowed. I was not particularly satisfied with this session, as although I believed I had undertaken the correct and safest path for the client, in hindsight, perhaps if I had got him to visit the clinic personally, this would have been a better solution, to offer a more personalised service.
References
Curti, S., Mattioli, S., Bonfiglioli, R., Farioli, A., & Violante, F. S. (2021). Elbow
tendinopathy and occupational biomechanical overload: A systematic review with best-evidence synthesis. Journal of occupational health, 63(1), e12186.
De La Serna, D., Navarro-Ledesma, S., Alayón, F., López, E., & Pruimboom, L.
(2021). A Comprehensive View of Frozen Shoulder: A Mystery Syndrome. Frontiers in Medicine, 8, 638.
Hand, C., Clipsham, K., Rees, J. L., & Carr, A. J. (2008). Long-term outcome of
frozen shoulder. Journal of shoulder and elbow surgery, 17(2), 231-236.
Karanasios, S., Korakakis, V., Moutzouri, M., Drakonaki, E., Koci, K.,
Pantazopoulou, V., … & Gioftsos, G. (2021). Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)-a systematic review. Journal of Hand Therapy.
Wilk, K. E., Ellenbecker, T. S., & Macrina, L. C. (2021). Rehabilitation of the
overhead athlete’s elbow. In Elbow Ulnar Collateral Ligament Injury (pp. 327-356). Springer, Cham.