COHF 004: Client presents with bilateral epicondilitis with pain after crawling during an exercise class.

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Today, we’ve got the episode 004. We’re gonna be talking about bilateral epicondylitis. So the case presentation with this is, we found the right side was worse when we were looking at the bilateral epicondylitis. There was pain onset following a high volume crawling exercise class. Pain present for six weeks prior to the session and was unresponsive to other treatments.

Evaluation Parameters

Right side was worse than left

Pain onset following a high volume crawling exercise class

Pain present for 6 weeks prior to session and unresponsive to Osteopathic treatment

Pain occurs on straight arm loading which radiates to a small degree and bicep curls

Findings:

Pain on finger extension/wrist extension/straight arm long head biceps loading

Slight dysmteria to left paravermis CB at the shoulder

MMT (manual muscle test)

Bilateral glut medius weakness

Right teres major – hurts elbow

Right minor weakness teres minor

Bilateral Radial extensors

Bilateral brachialis creates pain

Reduced tone in brachialis bilaterally

Peripheral immune – bacteria to Small intestine and stomach, linked to hypothalamus, pineal, thyroid, pituitary, left adrenals, left reproductive, pancreas and spleen.

Right pain linked to Pancreas & Spleen reflexes, Left anterior Insular via gustatory thalamus, cranial nerves 9,10

Left pain linked to small intestine and mesencephalon

Let’s Hear From The Council!

David Fleming

I’d be interested in possibly seeing if there’s any reasons as to why the… If there’s any links between the organs and the glands, for example, that might be inhibiting some of the muscles. For example, the supra and infra spinatus may be linked with something going on at the thyroid. It may be causing some cerebral inhibition that means the shoulder can’t stabilize at that level. We just don’t know until we look for these kind of things. So essentially with this case in mind, I would really be first and foremost want to establish if there’s any distinct pain pathways involved.

Jeff Frame

The first thing I would look at after going through that is, understanding better what the actual movement is. When they say crawling, are they doing a traditional infant crawling? Are they doing a reverse crab crawling? Looking at the ergonomics of the activity they’re actually doing, will help us to better understand if this person is being subjective to loads that are one, unusual to what they’re supposed to be. Obviously, since thousands of years ago, humans haven’t walked on all fours, the shoulder and the arms are not used to bearing those kinds of loads.

Stephen King

The first thing that I also noticed at this case is the terminology used with the epicondylitis. I guess there’s a lot of conjecture and literature now whether there is sort of inflammation at play in the tendons. So especially through the early 2000s to the mid 2000s, and looking at some of Cook and Purdam’s work. It suggested it might not have been a great deal of inflammation at play in the tendons. And that still seems to be the thought. But a recent article from 2013, it’s a really good article, sort of on tendinopathy itself, suggests that maybe there is some inflammation present with some sorts of tendinopathy.

Dr. Brandon Brock

We know that this lateral epicondylitis typically is this, monosynaptically and disynaptically, the extensors are just not as great as the flexors. So what happens is you get a decrease in extensor tone, you exceed the load of the muscle itself. So the load itself on the muscle gets shifted off to the myotendinous region, it flares up, and now you hurt. Usually happens at the origin more than it does the insertion. So the first thing I’m gonna do on this is look at the nervous system, and see if I can figure out, is this sort of a raw segmental response?

Dr. Emily Splichal

So again being a podiatrist, it might seem a little bit out of my scope, because we’re dealing with a epicondylitis of the upper extremity elbow. However, I do have patients who do present with this, and they just happen to have foot pathology at the same time. Knowing that the body is completely interconnected and integrated, there’s actually some really good research that supports how foot-to-core stabilization actually happens before shoulder stabilizers activate. And in this specific client or patient, if their shoulder stabilizers are not stabilizing fast enough, then that can transmit down into bicep tendons, the flexors of the hand and wrist, etcetera.

Jessica Sears

Looking at it, we see what the activities that she’s going with as being the cause of it, but it’s looking at what she does in her day to day. What’s her work? Is she in an office environment? Does she have to use her upper limbs more? Depending on what she does, when you’re at desk work or computer work, some postures go with that. But the activities that she’s been doing have probably been the main cause of it. We try and limit those activities, but it’s hard to take back. When it comes to treatment-wise, kind of a little bit as Emily was pointing to, I’d look at the front and back arm fascial lines.

Dr. Mark Wade

I would also wanna be evaluating the postures. I’d be specifically looking at posture quadrants one and two for any kind of postural distortion patterns presenting dysfunction in the kinetic chain. Most likely, we’ll find some anterior rolling of the shoulders, as Jeff just put it. As well as forward head posture. Now, I would use the spinal push test, and it would let me know if there was any kind of postural instability throughout that spine, that may be altering the structure and the function of the kinetic chain, and potentially the musculature.

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