MSK scenario 2 (Golfers elbow) Flashcards
What additional questions would you ask this pt?
- have you experienced problems with this area before?
- locking after trauma?
- persistent or progressive loss of ROM after trauma
- unexplained swelling or warmth (inflammatory)
- drug history, times, doses and side effects
- any daily activities aggravate? avoid these in the session
What would you include in your objective assessment?
- Clear other joints
- wrist
- shoulder
- cervical spine
- thoracic spine - Observation:
- posture and willingness to move, any guarding
- deformities, look at symmetry
- swelling or heat (inflammation, arthritis)
- muscle wasting - ROM
- flexion, extension, pronations, supination
- is it limited - joint stiffness
- test for passive end feel - spongy (soft-tissue),
hard (bony), none (ligament integrity)
- feel for crepitus as you move the joint (osteoarthritis)
- apply overpressure on passive movements - Special tests
- medial epicondylitis test:
- pt standing with 90 degrees elbow flexion. fixate humerus and palpate medial epicondyle. passively supinate pts forearm and extend pts wrist and fingers and fully extend the elbow.
- positive test: pain or discomfort on medial aspect of the elbow.
- valgus stress test: (ulna collaeral ligament instability)
- pt standing, the elbow is placed in 20° to 30° of flexion with the forearm supinated. palpate the ulna ligament (between olecranon process and medial epicondyle) and a valgus stress is applied (external rotation)
- positive test: pain on the medial aspect of the elbow
- Tinel’s test:
- identifies an irritated nerve through a percussive or tapping technique.
- The therapist should locate the Ulnar nerve that is seated in the groove between the olecranon process and the medial epicondyle, the Ulnar nerve is then tapped on repeatedly by the index finger of the therapist.
- positive test is shown by a tingling sensation in the ulnar distribution of the forearm and hand distal to the tapping point
What are your alternate hypotheses?
- Medial collateral ligament instability:
- pain on the inside of the elbow.
- a sense of looseness or instability in the elbow.
- unable to throw overhead, but this pt can throw but it aggravates the symptoms.
- unlikely as he has reduced hand grip, so suggests it would be a tendon problem rather than ligamental
- he has no tingling or numbness so unlikely to be ligamental - C6/C7 cervical radiculopathy
- radiate pain, paresthesia, numbness, or weakness into the arms
- minimal association between the medial epicondylitis and the cervical spine has been proposed.
X-rays can be used to rule out fractures.
What is your primary hypothesisis and explain to your pt
Medial epicondylitis elbow - golfers elbow
Usually a tendinous overload injury of the flexor-pronator tendon. Occurs with repetitive wrist extension and forearm supination. Can occur as a result of high-energy valgus forces created by overhead throws. Pain is usually accompanied by a weakness of handgrip.
Muscles involved:
- pronator teres: pronates forearm
- flexor carpi radialis: flexes wrist and hand
- palmaris longus: flexes wrist and hand
- flexor carpi ulnaris: flexes wrist and hand
What is the DASH score and what does the 9.2 results tell you?
The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a 30-item questionnaire that looks at the ability of a patient to perform certain upper extremity activities. This questionnaire is a self-report questionnaire that patients can rate difficulty and interference with daily life on a 5 point scale.
The score test ranges from 0 (no disability) to 100 (most severe disability).
DASH fomula: ([(sum of n responses)/n] -1)(25)
His score of 9.2 shows his injury can be considered a low impact disability as it does not interfere with his ADLs.
This patient’s DASH score shows that his pain is aggravated by activity, especially those that produce a force through his arm. It impacts on his social activities which he previously stated was tennis, and pain occurs on the medial side, suggesting golfers elbow.
What outcome measures would you use for this pt?
DASH score repeated after treatment
Maximal grip strength using a hand dynamometer
Upper extremity functional index - 8 item questionnaire used to determine the impact of upper extremity disorders on the function
Explain the treatment you would give this pt
The main aim is to relieve pain and reduce inflammation. Non-surgical treatment is divided into 3 phases:
Phase 1:
- pt must stop all offending activities immediately
- do not stop all activity - can cause atrophy
- begin with PRICE - protection, rest, ice, compression, elevation
- ice the affected elbow several times a day - improves vasoconstrictive and analgesic effects
- a period of night splinting is adequate
Phase 2:
- the first goal is to establish full, painless writ and elbow ROM. this is soon followed by stretching and progressive isometric exercises
- exercises should first be done with a flexed elbow to minimize the pain
- as ROM and strength return to the elbow, concentric and eccentric resistive exercises are added to the rehab programme
- the final part of this phase is a simulation of sport or occupation of the pt
Phase 3:
- assess pts equipment and/or technique once they have returned to their sport.
Exercises:
- isometric wrist strengthening (flexion)
- whilst seated rest forearm on a table with palm up
- press opposite palm into affected hand
- bring affected hand up against resistance
- repeat 15 times
- progress onto a weight
- repeat for extension - resisted wrist flexion
- whilst seated place forearm on table with hand hanging over the edge, palm up, holding a weight
- slowly lower hand and raise
- 1-3 sets of 15 reps
- repeat for extension - Golfers elbow stretch
- aims to stretch the wrist flexors in the forearm (flexor carpi radialis and ulnaris and palmaris longus)
- extend affected arm in front with palm facing up
- use opposite hand to pull fingers and wrist down
- hold for 30 seconds. repeat for 2-5 reps
