Although most chiropractors focus on spinal conditions, especially lower back pain, neck pain and cervicogenic headaches, many patients present with other neuromusculoskeletal conditions involving the extremities. In this article, you will be challenged to perform a differential diagnosis and develop a treatment plan for a patient with an elbow condition that responded poorly to chiropractic management. Hopefully, you will become aware of the need to be precise with the diagnosis of elbow conditions prior to performing manual medicine procedures.
History of Present Illness
A male patient, 55 years of age, presents with a chief concern of, "My elbow hurts." He points to the area of the lateral epicondyle as the area of the pain. This pain has been bothering him for the past seven months. The pain increases while using his laptop. He notices some aching discomfort during the night that wakes him. He can produce sharp pain if he presses near the elbow.
He fell and dislocated his left elbow 10 years ago. Fortunately, his elbow self-reduced and he healed without disability, but he experienced pain for 12 months following the injury.
The patient does not recall any specific cause of the pain and denies any recent falls or other specific injuries. Upon further questioning, he does admit that eight months earlier, he was charged with caring for his son's large Doberman, which required walking of the dog several times per day. This large, strong and playful creature loved to play with other dogs. Hence, he would frequently attempt to dash off, which would jerk the patient's left arm.
The severity of the aching pain is 3-4/10, and the sharp pain is 8/10. The condition seems to be getting worse for the past three months. He denies seeing a doctor, but admits he has been using a counterirritant that provides some relief of the ache.
Physical Examination
The patient appears healthy, alert, cooperative, well-nourished, and a good historian. Observation does not reveal any cicatrix, discoloration or edema of the left elbow. It appears like the opposite elbow.
Palpation of the left extensor carpi radialis longus and brevis reproduce sharp pain; palpation of the right elbow does not elicit pain.
Active and passive ROM are painless and without restrictions. Resistive extension of the wrist does produce pain in the left extensor brevis muscles.
Cozen's test produces mild discomfort in the left extensor radialis longus and brevis muscles. Mill's test is negative for lateral epicondylar pain. Abduction and adduction tests do not demonstrate pain or signs of instability in the elbows.
Assessment
- Chronic strain of the extensor muscles of the left elbow with resultant myofascial pain syndrome
- Mild lateral epicondylosis of the left elbow
Treatment Plan
- Soft-tissue treatments to reduce pain
- Tennis elbow support band to be worn when walking the dog or performing extensive laptop work
- Ultrasound therapy to reduce pain and improve circulation to muscles
- Three treatments per week for two weeks and then re-evaluate status
Problems at Follow-Up
The initial treatment was performed with no adverse reaction. Unfortunately, when the patient presented for the second of the six treatments, he was livid. He asked, "What did you do to me?" He had awoken at 3 a.m. the morning after the initial treatment with severe throbbing pain in the left elbow. He was unable to sleep and paced around the house until it was time to shower and go to work. Severe pain also occurred when he attempted to use his laptop.
Can You Solve This Dilemma?
Now, you must solve this dilemma by correctly answering both of the following questions:
1. Which condition would cause such a painful adverse reaction to conservative myofascial care?
a. Lateral epicondylosis
b. Myofascial pain syndrome
c. Radial tunnel syndrome
d. Lateral epicondylitis
If you picked C, you are correct.
2. What was not performed correctly?
a. Did not specifically identify the painful tissue
b. Did not rule out radial nerve compression at the radial tunnel
c. Did not perform the resisted middle-finger extension test
d. Did not perform a three-part neurological examination to test for neurological deficits
e. All of the above
If you picked E, you are correct.
Clinical Pearls
- Palpation of the radial tunnel, which is located 5 cm distal to the lateral epicondyle, will reproduce the CC pain. Determining the exact location of the pain in the forearm is the primary step in evaluating for RTS. The main clinical feature of RTS is a localized tenderness over the radial nerve 5 cm distal to the lateral epicondyle. Patients typically report aggravated pain at nights that may interfere with sleeping. The pain can also become more severe when increased traction is applied to the nerve by extending the elbow, pronating the forearm or flex-ing the wrist.1
- An orthopedic test is most often a provocative maneuver that reproduces the patient's chief concern (pain with stretching, compressing or contracting) in order to identify the involved (pain generator) tissues. If you have not reproduced the patient's chief pain concern and identified the pain generator, then a working diagnosis is not possible.
- Management of compressed neural tissue normally involves reduction of surrounding fluids and decompression of the superficial branch of the radial nerve and/or the deep radial branch of the same nerve. Hence, soft-tissue treatments, compression bands and heat are contraindicated. It has been my experience that 7-10 days of NSAIDs and restriction of compressing activities are salubrious in these cases.
- Diagnosis is the key to successful treatment of neuromusculoskeletal conditions.
Reference
- Moradi A, et al. Radial tunnel syndrome: diagnostic and treatment dilemma. Arch Bone Jt Surg, 2015 Jul;3(3):156-162.
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