November 2016 Journal Club Case

[nhoover17]

Patient is 54 yo female equine veterinary technician with chief complaint of gradual onset of L medial wrist pain over last two months and gradual onset of L lateral elbow pain > 1 year. Pt reports driving motorcycle to work 30-60mins each way daily, and usually goes to barn to tend to horses and ride on days off from work. Pt reports tending/grooming horses 5-6 days per week. Pt reports (-) findings on Xrays and previous treatment consists of Rx naproxin which has decreased lateral elbow irritation. Pt denies shoulder/neck/back/R UE symptoms. Pt reports occasional N/T in L hand w/ riding motorcycle >60 mins but is able to relieve with taking hands off handle bars and moving hand/wrist.

Pain Level:
Current: 0/10
Best: 0/10
Worst: 3/10 in L elbow after prolonged time in extended position on handle bars

PMH:
Hx of breast cancer

Aggs:
Brushing teeth/hair w/ L hand, turning key, opening a jar, grooming horses produces L med wrist pain immediately, but subsides w/ stopping activity.
Bending L elbow after riding motorcycle w/ arms extended >30mins produces L lat elbow pain but goes away in a few minutes w/ mvmt.

Eases:
Heat application eases wrist pain
Naproxin eases elbow pain

Severity: min-mod (low level of pain 3/10 at worst, does not prevent pt from performing work/recreational tasks, pt reports using R hand for hair/teeth brushing)
Irritability: min-mod (immediate onset of wrist pain w/ provoking activities but eases quickly, >30mins onset of elbow pain but eases in a few mins)
Nature: L TFCC, L CET
Stage: Chronic
Stability: unchanging

Objective:
Csp: Full ROM in all direction, no syx provocation w/ active/passive/resisted/quadrants
Shoulder: Full ROM in all directions, no syx provocation w/ Active/passive/resisted testing
Elbow: Full ROM in all directions, no provocation w/ active/passive/resisted/quadrants
Wrist/Hand:
AROM: full ROM in all directions, no pain
PROM: full ROM in all directions, no pain
Resisted:
(+)wrist pain w/ ulnar deviation (1-2/10)
(+) elbow pain w/ wrist ext (1-2/10)
PAM: WNL, no pain w/ elbow med/lat glides, radioulnar glides, ulnar distraction. no pain w/ med/lat wrist glides, proximal/distal carpal AP/PA
MMT:
(+) Abductor digiti minimi: 4/5; wrist pain (1-2/10)
TTP:
(+) L CET at lateral epicondyle
(+) medial wrist distal to ulna
Special Tests:
(+) TFCC compression test
(+) table lift test
(+) wrist WB test

Tx
Day 1: STM crossfriction at CET, manual resisted ecc wrist ext
Follow up: addition of TFCC compression taping, grip strength assessment and elbow lateral glides w/ active contraction gripping.

HEP:
Ecc wrist ext
wrist flex/ext stretching, elbow flex/ext stretching

PICO
For a 54 yo white female with physically demanding job requirements, will Lateral elbow taping reduce pain w/ movement after prolonged static positions?

Discussion Questions:
What other screening tools/tests would you use for this pt presentation?
What other objective measures would you test/did I leave out?
What Tx strategies have you used for lateral epicondylalgia or TFCC dysfunction?
How do you manage chronic pain and overuse type injuries in patients who do not have the option to take rest/time off work duties?
Have you utilized taping techniques for these or other body regions?
Was it beneficial?
Should shoulder strength/conditioning be included in progression of tx program?

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[Scott Resetar]

Cool case, Nic.

1. Does she have any previous history of episodes of LE? People can often have recurrent cases. Is this her dominant arm?

2. Any change in activity level recently? Riding motorcycle more often vs previously, working more hours?

3. I can see that you made the decision not to do a neuro screen day 1, which is reasonable, given that I would also probably have tingling in my hands after riding a motorcycle with wrist extended for an hour, but I would like to see if ULNTTs, spurlings, compression, reproduce any of her pain or tingling in the hand.

4. Any pain with direct palpation of the triquetrum or lunate? Any “piano key” sign present? she may have TFCC dysfunction, but could also have damage to other carpal ligaments.

5. Love the idea of adding grip assessment next session and trying some lateral elbow glides.

6. I think the research out there for LE strongly supports thoracic and/or cervical manips! However due to her history of breast cancer, I would be hesitant, and would stick to mobilizations. On that note, cervical PPIVMs and PAIVMs should be assessed at next session.

7. Hard to deal with “blue flags” like inability to stop these repetitive actions at work. I like your idea of taping or bracing for her. She might benefit from a neutral wrist splint for a while to see if that allows any improvement in pain, at which time she can continue to slowly load the LE to improve tendinopathic changes.

8. On shoulder strengthening – articles presented during weekend 2 support shoulder and scapular strengthening for LE, so it would be interesting to see if she has any gross changes in shoulder strength.

9. In my short time treating I have had 1 or 2 LE cases, and both were independent with their home program after a few weeks and were discharged. I think that LE takes a long time to improve to 100% and patients can get impatient with therapy sometimes. Thoughts?

10. Never taped the elbow or wrist. A quick google yields this cool TFCC taping technique: https://www.alphasport.com.au/news/post/triangular-fibrocartilage-wrist-taping-technique/

Is this what you were going to try the following session?

[nhoover17]

1. this is her dominant arm, and she did not report previous hx of LE.
2. No change in current riding time or work hours
3. I have yet to be able to reproduce her tingling and per her report it doesnt happen often or with any consistency based on activity, but I agree, I should have done a neuro screen at the beginning of care.
4. no pain with palpation of the lunate or AP/PA glides of lunate. She reported her familiar wrist pain with triquetrum glides on her first visit but none since then.
6. I can add in PPIVMs and PAIVMs but I avoided manips secondary to hx of cancer.
7. Yea, the hardest part is that she has relatively low severity and irritability and she doesn’t let it get in the way of her work. We’ve talked about using bracing, splinting, and/or taping to decrease the stress of repetitive motions while working.
8. Over the last 2-3 sessions with her, I have added in some shoulder/scap motor control training and some graded UE CKC exercises to address proximal stability and see if that has an effect on elbow/wrist symptoms.
9. I have done some education on this kind of thing taking a while to heal as it didnt get this way over night, in an effort to decrease any frustration or impatience. She has been very receptive and willing to try things. she is now self-applying her wrist tape as needed.
10. After some unsuccessful literature searches, I did resort to the goog and found a similar technique to the video you sent. She has 0/10 wrist pain when taped.

[Justin Bittner]

Interesting case Nic.

What other screening tools/tests would you use for this pt presentation?
I think doing a neurodynamic screen would be appropriate for her. We discussed in the UE weekend about the potential radial nerve involvement in lateral elbow. Anecdotally I have seen this be the case for a few patients I have had with lateral elbow pain. I also think it is appropriate since she reported N&T. Was the N&T in the entire hand or did it fit a neural distribution. Were you able to reproduce her N&T in the clinic? Do you think it was more from the sustained cervical position of sustained shoulder/elbow position? Or potentially form the sustained pressure over gyon’s canal? I think I may have performed sustained cervical positions with OP since it takes 30 minutes to bring on the N&T (although it sounds like you did this). I think I may have performed PAs in the cervical and thoracic spine to look for symptoms reproduction depending on time I had.

What other objective measures would you test/did I leave out?
I would have checked grip and pinch strength but you went back and got that 2nd visit.

What Tx strategies have you used for lateral epicondylalgia or TFCC dysfunction?
I have yet to see a TFCC lesion in my lengthy career but have seen several lateral epicondylagia patients. I have used radial ulnar nerve mobilizations. I think in your patients case that it will be very important to address wrist mobility as restrictions here may be leading to increased tissue stress at the lateral epicondyle. I have also found eccentric loading and thoracic manipulations be useful.

How do you manage chronic pain and overuse type injuries in patients who do not have the option to take rest/time off work duties?
I think what you did is appropriate. Finding a way to either modify their work to decrease tissue stress or providing them with ways to modify their body to reduce sx (in this case you used taping techniques).

Have you utilized taping techniques for these or other body regions?
I have used taping for a few patients with knee pain for patellar fat pad unloading. Also for 2 patients providing scapular position awareness.

Was it beneficial?
My success with these techniques have been about 50/50. That may be because I’m not proficient at these techniques but I feel 50% success with taping is not too bad. What have other people found as far as success with taping?

Should shoulder strength/conditioning be included in progression of tx program?
I know there are several studies (not RTCs or case control studies) that have shown relief of lateral elbow symptoms with only periscapular and shoulder strengthening exercises. If I have found weakness in my patient’s with lateral elbow pain, I implement scapular strengthening exercises. Whether or not that is the actual reason for relief of symptoms, I’m unsure because of all the other manual and exercise being performed. I’m not sure of any studies using shoulder and scap strengthening for wrist pain but I think it is appropriate if deficiencies are found.

[nhoover17]

So general consensus so far is that I should have included more of a cervical component and from what I have researched during her care, I would agree.

I have implemented the MWM techniques in clinic with some success, although she is not really in pain during our visits so that has been hard to gauge success other than subjective report of decreased episodes of pain after prolonged hands on handlebars time. I gave her the MWM w/ a belt for self-mobs at home and she didnt like it/didnt find it an effective use of her time so we discontinued that for her HEP.

The initial wrist taping was so effective during her work day activities that she actually commented “I wish there was a way to tape my elbow like we did my wrist”, which led to researching elbow taping techniques.

Another question for you guys:
In these kinds of chronic pain pt’s, How are you structuring your goals and outcomes? Some of the literature (the Vicenzino article included) suggests that these pt’s may take up to a year to get better. Obviously not efficient for us to see them twice a week for a whole year.
What should be the goal for success and d/c without the patient thinking we’re abandoning them or running out of reimbursable visits?

[August Winter]

Nic, thanks for posting the case. It’s nice to talk about a wrist/hand case.

What other screening tools/tests would you use for this pt presentation?
Scott and Justin already hit on the neurodynamic testing and further cervical testing, but I just wanted to highlight the need to (eventually) perform PAIVM assessment of the C spine. As Aaron talked about last weekend, what might seem like a slam dunk peripheral pathology may actually have a spinal component that simply isn’t revealed by normal cervical screening.

What other objective measures would you test/did I leave out?
I think I would have liked to see you include a functional reassessment sign within your exam. Having the grip strength is great, but try to reproduce the every day movements that bring on at least her wrist pain would be good to track your progress and get patient buy in.

What Tx strategies have you used for lateral epicondylalgia or TFCC dysfunction?
I have only ever informally treated a family member for LE, but they did well with a lateral glide self mobilization. If you find good treatment effects in clinic with your MWM lateral glides then it likely would be a good option for home. Like Scott said and like what some research says, if this is already a chronic condition then the progress might be slow anyways, and finding good self management strategies may be the focus of your treatment for the elbow.

How do you manage chronic pain and overuse type injuries in patients who do not have the option to take rest/time off work duties?
It might be hard to recreate some of her work duties in the clinic, but like Justin mentioned it might be beneficial to analyze and modify her body mechanics with particular motions or positions (like on her motorcycle).

Have you utilized taping techniques for these or other body regions?
I have not used taping for either of these conditions. I was actually just taught a similar taping technique for the infrapatellar fat pad that I plan on using in the coming week.

Should shoulder strength/conditioning be included in progression of tx program?
I think if she has deficits in these areas then you definitely should address them. She has a physically demanding job and a hobby in horseback riding that requires a lot of strength in the shoulder. Even just managing the tack and cleaning the horse requires significant stability and endurance in the entire scapular girdle and UE, and if she has deficits proximally then she may be compensating with excessive elbow and wrist motion/contraction.

[nhoover17]

August, see response to Justin’s post, that was in reference to both of you

[Erik Lineberry]

I would have also completed a neuro screen for this patient, everything else looks pretty good screening-wise. With her history of motorcycle riding I initially thought that Guyon’s canal syndrome may be involved, so I might have added Phalen’s, Tinel’s and palpation of guyon’s canal. I also may have added ULTT to your objective measures. I have not taped this region of the body, but I have for the AC joint, medial arch, and PFPS. I have found some success with these techniques, but I try to make sure to explain to the patient that the taping should be a short term solution while we find ways to improve symptom free performance of their activities.

[nhoover17]

Guyon’s canal palpation was no different compared to contralateral side, I probably should have included that.

I agree with your thoughts on pt education, it’s essential to prevent reliance on this kind of thing but, at the same time, if it is going to be the one thing that provides relief, then we may have to toe that line. I think I was drawn to the taping due to her high activity level and inability to take time off. I wanted something that could provide some sort of unloading or rest or decreased stress to the environment.

[Michael McMurray]

Great case Nic.

A few thoughts, I think everyone has mentioned neurodynamics, so I would agree that having a baseline may be beneficial as well as evaluating cervical mobility. What digits/area did the patient report having her numbness and tingling? If not something you address right away, I would be curious if providing her with nerve glides or working along the nerve track affected her symptoms with riding her motorcycle. In terms of chronic management, she has been taping her wrist, but what were her thoughts on utilizing a brace at work in order to unload those structures while working towards symptom free performance? In terms of taping, I have utilized it for patellofemoral pain in the clinic. I have had some success when using it to decrease pain with exercise performance. With scapular strengthening, I feel like challenging her functionally with similar endurance activities she has to do at work and trying to pick up and address deficits may provide distal relief.

Did you have her fill out any functional outcome measures (DASH, QuickDASH, etc.)? This maybe useful in structuring your goals and tracking change over time. Additionally, has she noticed any changes in her symptoms since starting therapy? Re-hashing where she started and changes that have occurred, whether it be the intensity of her symptoms, the duration, or the time it comes on, may be useful to discuss as it may point out positive changes and provide you with an idea of what she would like to be able to do prior to being discharged. As this is a chronic condition, maybe consider seeing her two times a week until you have seen a plateau in care and she is independent with her home exercise program. She may be someone you decide to see once a week or every other week to check up on to monitor and change her exercises as appropriate.

[nhoover17]

She wasnt able to provide specifics of N/T location bc it doesnt happen often and it hasn’t happened in the time that I have been working with her in order to map out the area of symptoms.

Wrist braces are difficult because the nature of her job requires significant sanitization and cleanliness, and a brace is difficult to keep cleaned that often.

I am using a quickDASH with her and she has made great improvement on that since beginning care. She has been 2x per week and we have recently discussed reducing to 1x per week due to her progress and decreased intensity/frequency of painful episodes. Her wrist is virtually painfree but she feels comfortable having it taped at work so she keeps doing that. She is actually going to be gone for the next 2 weeks for Thanksgiving so we will get a good break in her repetitive use and hopefully that will get her over the hump.

[August Winter]

One more question Nic: had the patient tried a counterforce brace for the elbow yet? The reason I ask is that one of our CHT was just talking to me about a patient she was seeing who had LE and was prescribed a brace by her doctor. The brace was worn too tightly and the patient actually did end up getting radial nerve entrapment distally. The CHT was saying that apparently this is not too uncommon. Just something for everyone to keep in mind if your patient comes in with one of these already on their arm.

[nhoover17]

Thanks for the insight man! thats a great little clinical pearl to keep in mind. She has used one of those copper infused elbow sleeves but never a brace.

[Michael McMurray]

That is really interesting August, did the CHT mention what her thoughts were regarding the use of LE braces due to the risk of entrapment? Whether it should be utilized in the short term, or how to educate patients in order to potentially avoid that issue.

• This reply was modified 7 years, 8 months ago by Michael McMurray.

[Michael McMurray]

Did you assess her position (grip/grasp, posture) on the motor cycle?
Did you assess her functional biomechanics with other provocative activities (in the barn)?

Especially in light of very low irritability – Don’t lose sight of the basics (functional provocative testing), ergonomic assessment/advice – related to entire kinetic chain, cervical/thoracic/lumbar posture related to increased tissue stress on the elbow/wrist.

Sorry if I missed that in the discussion.

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