Case Presentation: Patient presents with bilateral epicondylitis after performing crawling during an exercise class.
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. The pain occurred straight on arm loading which radiated to a small degree into the… And also was radiated with bicep curls. The findings were, there was pain on finger extension and wrist extension, as well as straight arm, long head biceps loading. There was slight dissymmetry to the left, and as well as into the shoulder.
Stephen King presents his thoughts on this case presentation.
Well, I guess 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. This case looks like it is a tendon issue as such. There seems to be an initiating incident. A history of an overload, which is pretty common.
As Emily said, the person may not have been used to tolerating loads to their arm, and that sudden increase in load may have been the factor that has overloaded the extensor muscles. Note that she’s had six weeks of osteopathic treatment. Often, being an osteopath myself, initially osteopathic treatment can be quite passive. And there’s not a heap of research out there for passive treatment and a role in tendinopathy. Not saying it doesn’t have a place and often can be very beneficial in modifying symptoms. But often we need to progress, I think with tendinopathy, to a more active and strength-based approach. So also from the history, I guess, some things that we don’t know. We probably wouldn’t know the person’s current activity level, what sort of tasks they sort of do in their day-to-day life.
And often, we wanna know what they’ve continued in doing, and what sort of things cause their flare-ups and their aggravation. From the assessment, again that tends to confirm that there is a tendinopathy there, with some functional weakness through the extensors, as well as through the shoulder muscles, which indicate that there may be some issues in that whole upper quadrant. Also note from the case that the pain is linked to some reflexes to the pancreas and spleen, which are, I believe, is probably maybe related to Chapman’s reflexes which I must admit, I don’t know a lot about. But there may be a place for that. Odd also, you’re looking at in the assessment having looked at some upper limb tension to see if there’s any neurological involvement, and trying to get some objective measurement using maybe a dynamometer to measure group strength.
So management-wise, at first look at what the person is doing day-to-day and see if we can sort of modify some, ergonomically, some of the tasks they’re doing, as well as having a look at what their current sort of exercise and activity level is. And try not to remove compressive positions, so tendons don’t tend to lock compressive positions. So if we can aim to remove some of the tasks that may be continuing that aggravation, it may help remove them out of that reactive phase. Potentially on top of it, it generates tendon compliance. So initially, I’d probably start with a loading program. So starting, looking at some isometrics for pain relief. Some good research coming out, especially from Ebonie Rio last year, from a PhD paper that they have a really good role in modifying pain symptoms.
I’d then progress to some sorta heavy slow-resistance training to start to build up some strength and help to build the capacity of the tissue. I’d then look to build some more functional strength, so looking up and down the chain. It’s a heavy look, especially through the hips and the shoulders, ’cause they’re big influences and areas that can tolerate a lot of load, that can be good friends to the elbow. And then I’d look to gradually progress back into, and start to pace some of the activities they wanna do. So whether it is getting back into that crawling type exercise, or any other task that they wish to do as well. So I guess the main thing we need to work out is, is it just purely an overload of the tissues and they didn’t have the capacity to do the task that you perform with the crawling exercise? Or whether it was something else in the chains, so the shoulder or whether it was maybe the thoracic spine, hips, or even down to the foot? As Emily said, that could have been just causing the elbow to take the hit and have that extra load through it
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Stephen King B.SC, M.H.SC, MPT
Steve has a unique skill set being qualified as a Physiotherapist, Osteopath, personal trainer and strength and conditioning coach. He is currently a director of the Functional Movement Group and co-creator of The M.A.T (Movement Assessment Tool). He has a keen interest in functional performance testing and using objective data, technology and analytics in his practice. Steve is also a current SMA-Victoria board member and performing research with both the University of Queensland and Victoria University in Australia.