Case Studies:

Tennis / Golfer's Elbow

By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.

 

CASE PRESENTATION

A 44-year-old double glazing worker, presented with a complaint of elbow pain. The patient had a 13 months history of the pain in both elbows. He attributed the onset of symptoms to his work. His symptoms were aggravated by a double glazing work (mainly movements of extension and supination at his elbow joints), and relieved by extended this elbow and resting the arms. He initially sought care at a medical facility and received steroid injections (December 2008 and June 2009). Unfortunately, this failed to relieve his symptoms.    

He demonstrated classic signs and symptoms of Tennis elbow. Pain over the lateral elbow, which was described as a dull ache which may become severe, particularly with resisted movements or activity. Focal tenderness at the lateral epicondyle and dorsiflexion of the wrist against resistance (Cozen’s test) reproduced his chief complaint. Gross passive and active range of motionof the elbow joints demonstrated a moderated restriction in extension (-8 degree), all other ranges was full. Upper extremity motor function and strength were intact and results of neurologic testing were unremarkable.    

TREATMENTS

  • Deep tendon friction (DTF),
  • Manipulation of elbow joints followed by cryotherapy
  • Acupuntrue.
  • Elbow support
  • Self-home stretching.

The application of DTF can produce therapeuticmovement by breaking down the strong cross links oradhesions that have been formed, softening the scar tissueand mobilizing the cross links between the mutual collagenfibres and the adhesions between repairing connective tissueand surrounding tissues.Deep tendon friction also produces vasodilatation and increased blood flow to the area. This may facilitate the removal of chemicalirritants and increase the transportation of endogenousopiates, resulting in a decrease in pain.  (Gregoryet al. 2003; Goats, 1994; Walker, 1984).

Manipulation of lateral epicondylitis of the elbow joint was accomplished by  Mills' manipulation, and “the lateral gliding technique” and the marble’s mobilisation. Theaim of these technique is to elongate the scar tissueby rupturing adhesions within the teno-osseous junction,making the area mobile and pain free.(Selvierand Wilson, 2000; Turek,1984). The Mill’s manipulation is performed as follows:  the elbow in extension and the forearm in pronation with a varus thrust at the elbow   The lateral gliding technique is performed as follows: The therapist laterally glides the proximal part of the forearm while stabilising the lateral aspect of the distal humerus. 

The marble’s mobilisation is performed as follows: the elbow in extension and thrust elbow with contacting oracranon. Ice massage (5mins) is performed for analgaesia and inhibiting the inflammatory cascade.  

Acupuncture needle was applied at main points for the affected channel. 4 studies had found that there is a potential role for the use of Acupuncture treatment for tennis elbow as an analgesic. (Brattberg G. 1983, Fink, M., Wolkenstein, E., Karst, M., Gehrke, A. 2002, Haker, E., Lundeberg, T. 1990, Molsberger, A., Hille, E. 1994).

The patient's elbow was alsosemi-immobilized with “Epicondilitis Clasp” during the 3-week manipulative treatment phase. This splint allows flexion and extension of the elbow while preventing supination and pronation motions. The purpose of the splint is to provide an anti-inflammatory effect through relative immobilization of the wrist and elbow (Kaufman, 2000).The patinet also was given the stretching wrist extensors execises.

The treatment was repeated twice per week for 3 weeks & once a week for 2 wks. then, re-examination in 3 weeks.

OUTCOME

After 5 treatments, the patient had a significant improvement. He felt very mild aching during his work & no symptoms when he rests.  There is no symptoms after 3 weeks although there is tenderness on the muscles & aching with the orthopeadic exams.  There is very mild tender point in wrsit extensors in the re-examination after 3 weeks.  

DISCUSSION

Lateral epicondylitis is a common complaint affectingbetween 1% and 2% of the general population. (Verhaar, 1994). It is also the most commonly diagnosed elbow condition and produces a heavy burden of workdays lost and residual impairments (Hong, Duran and Loisel, 2004).Despite this frequency and common and a wide range of treatment options exist,very little evidence exists to guide clinicians.

The most popular methods used include rest, manipulation, non-steroidal anti-inflammatory agents, a counterforce brace/strap orthotic, corticosteroid injectionsand surgery (Alonso-olmedo, 1992).

At a medical facility,corticosteroid injections are common method utilised. Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). However, the existing evidence on corticosteroid injections for the treatment of tennis elbow is not conclusive (Assendelft et al, 1996). Surgery is only required in less than 10% of cases (Gabel, 1999). A well-designed randomized controlled study (Smidt et al., 2002) concluded that for lateral epicondylitis, corticosteroid injections seem to offer immediate and short-term improvement, but more sustained improvement results from physiotherapy. 

In conservative interventions, lateral epicondylitis could be treated with rest, ice, ultrasound, electrical stimulation, manipulation, mobilisation, friction massage,splinting, stretching and strengthening exercise(Sevier & Wilson, 1999). Kaufman (2000) claimed that when the condition is chronic or not responding to initial medical treatment, conservative therapy such as cryotherapy, manipulation and cross friction massage is initiated. Gabel(1999) noted that chronic elbow tendonitis (medial or lateral epicondylitis and triceps tendonitis) are common disorders that, overall, have a good prognosis but, even with optimum management, require a minimum of 3 months to resolve.  

Mulligan (1995) introduced a new concept in manipulative therapy which  has application in the treatment of tennis elbow. This technique – “The lateral gliding technique” involves the therapist's sustaining a lateral glide of the elbow while the patient performs an activity that aggravates pain. The rate of pain reduction with this technique was greater than that for function (Vicenzino and Wright, 1995).

Deep tendon friction  was populased by Storms and Cyriax, and is a from of deep tissue massage deigned to break down scar tissue and adhesion. Turek (1984) and Brutzman et al.(1996) recommended friction massage and stretching in the acute phase of lateral epicondylitis.  

CONCLUSION

A conservative regimen consisting of specific manipulationand mobilisaition of elbow joints, cross friction massage, Acupucnure and splinting provided excellent care for a patient refractory to past medical intervention, especailly when the condition is chronic or not responding to initial medical treatment.

 

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