Monday, February 4, 2008

Case of the Week - Medial Epicondylitis

Patient: 40 year old male, office worker

Complains of bilateral medial elbow pain with a duration of the last several weeks. Pain has steadily increased with increased time spent bicycling. All symptoms are greater on the right. Patient is right-handed. Some bilateral medial tingling in the forearms. No reported loss of grip strength. No shoulder or neck pain. Ice, tiger balm and OTC anti-inflammatories relieve only temporarily. Patient is concerned he will not be able to continue his exercise program and compete in an upcoming event due to pain.


All findings greater on right than left. Bilateral mild edema at the medial elbows. Tight and tender medial and anterior forearm muscles (Flexor carpi radialis and ulnaris, palmaris longus, pronator teres) especially at the common flexor tendon insertion. Mild tight and tender distal triceps tendons. Active range of motion within normal limits, but painful if stressed in extension and supination (elbow straight with hand facing out). Neurological testing for deep tendon reflexes, muscle strength and sensation were within normal limits. Palpation of the elbow joints was impeded by regional swelling. The shoulder and wrist joints were within normal limits bilaterally.


Here is a website that may be helpful in visualising the area. Bear in mind that this is an orthopedic website and typically recommends less conservative treatments than we perform. The picture in this post is from this website also and is provided by the Mayo Foundation.

This patient is suffering from a unique form of medial epicondylitis, commonly known as golfer's elbow. As you can see, there is no mention of the patient playing golf. Also, golfer's elbow is usually only present on the dominant swinging arm, not both arms. In this case, the inside of the patient’s elbow, the medial epicondyle, is irritated and inflamed because the muscles that attach to the area are being over-stressed. The patient has increased the amount of time he spends bicycling. With increased time on a bicycle, the wrists fatigue and the elbows are forced to absorb the shock to the arms from the handlebars. Due to a lack of fore-arm-specific strength training, the muscles of the patient’s wrist and forearm have become over-tight and swollen, causing pulling on the bone of the elbow, the ulna. This causes significant pain, especially during activities where these muscles are used, such as during the swing of a golf club. Because the patient needs to maintain a rigorous training schedule on the bicycle, our treatment will focus on pain-management until after his up-coming event. After the irritation of training rides is removed, the patient will be ready for the focal strength training and muscle re-balancing he needs to prevent this injury in the future. It should be noted that his examination showed the tingling he was feeling to be non-neurologic in origin. This means that he feels tingling, but it is not caused by a nerve problem. Often this sort of symptom is caused by the tension in the surrounding muscles and is relieved when the muscles relax.


After several weeks of therapeutic massage and chiropractic manipulation for the elbows, the patient experienced a significant reduction in symptoms and was able to continue training for and to eventually participate in his event. Since then, the patient continues to experience mild discomfort in his forearms, but only a few days per week, and only when he has performed an irritating activity. He is working on strengthening his forearms and stretching the over-tight muscles in his arms. When he over-stresses the area, ice relieves the symptoms. He continues to improve and our hope is that he will be in great condition for next year’s event.

Exercise of the week:
Soup Can Exercises - Hold the arm at the side of the body, with the elbow bent at 90o and the thumb facing the ceiling. Hold a can of soup in the hand. Move the wrist into flexion, that is bending the wrist to bring the can closer to your stomach. Now move the wrist into extension, that is bending the wrist back as far as it can go. These flexion/extension exercises are a great way to start re-strengthening your fore-arm after an injury. If you are strong enough, add gravity to your exercise: for flexion, hold the arm in the same position, but palm-up. Bend the wrist to bring the can closer to the stomach. For extension, turn the hand over so the palm is facing down. Bend the wrist back. Try starting with 10 reps on each side and see how your arm muscles feel!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
Suggestion of the week:
Stretch at your Desk! Most of us work with our hands in one way or another. Whether you are working as a laborer and use a shovel, or work at a desk and use a keyboard, your arms are busy. The muscles that keep your hands doing what they do are anchored in the forearm, mostly at your elbow. With that in mind, take a 40 second break every hour or so. Hold your right arm straight out in front of you and use your left hand to bend your right wrist down. Feel the stretch across the top of the forearm. Then turn the right arm over and use the left hand to pull the right hand back. Feel the stretch in the forearm. Repeat this on the left arm. Hold each position for 10 seconds, and breathe while you hold. This takes a total of 40 seconds. You CAN find time for stretching! And you’ll feel better and more productive to boot!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
See the following pictures for explanations of the exercises and suggestions of the week:

Stretching the forearms - Beginner

Stretching the forearms - Advanced

Strenghtening the forearms


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