Elbow tenosynovitis (lateral and medial epicondylitis or tendinitis) and primary reason for failure to heal. A case study example.

Lateral epicondylitis and medial epicondylitis of the elbow, or the more common terms, tennis and golfer’s elbow (respectably) can be very difficult problems to resolve for a number of reasons. While guided self treatment can often times be effective, the failure rate of individuals with this diagnosis is more common than most others musculoskeletal problems. One of the primary reasons for this is the individual’s unwillingness to modify their provocative behavior(s) which is perpetuating the problem or the individual feels that they truly cannot modify the offending behaviors (which are usually repetitive in nature). The classic example of “not being able change destructive activity” is a person who works in an occupation which requires repetitive use. Examples in a work environment may be data entry with a keyboard (or use of a mouse,) or something like the repetitive activity required by a meat cutter. Keep in mind, there are a plethora of examples, which I couldn’t possibly touch on.

I was reminded of this difficulty with a recent patient of mine. Despite the best efforts to resolve this disorder (right lateral epicondylitis), there was abject failure until the patient was able (willing) to cease the offending activity(s) for eight weeks. She was spending between 6 and 10 hours per day entering data using a mouse which was highly repetitive. Despite her instructions to rest and to avoid provocative activity, she continued to engage in it (data entry with her mouse). The irritability became so intense, that formal physical therapy had to include use of an Ionto – patch with dexamethasone, a steroid, for 12 sessions total. Her problem in particular was so severe, that there was restriction of right elbow and forearm accessory joint movement which had to be addressed directly. She also presented with a palpable spasm of the right common extensor tendon musculature particularly the extensor carpi radialis brevis. This too had to be addressed with manual physical therapy procedures.

Because this problem was so intractable (again primarily due to her unwillingness to change her behavior, including using the mouse with the left upper extremity), I suggested that in the future the best way to avoid this problem would be use of dictation- command program. I personally use and strongly recommend a Dragon NaturallySpeaking program. She could verbally enter the data instead of using the mouse or keyboard with use of a dictation program.

The outcome of this patient’s tenosynovitis of the right lateral epicondyle was excellent. Her outcome was only due to the fact that she finally disengaged from the offensive activity for eight weeks while continuing to work on resolving the acute and then subacute stages of this diagnosis. She is currently in what is termed as chronic-resolution phase of recovery in which there is no longer pain with use of the right hand and wrist, she no longer requires oral or anti-inflammatories, the common extensor tendon complex muscles and tendons are no longer irritated and painful with palpation. Furthermore, she is able to tolerate light stretching of the involved muscles and tendons without any provocation of pain.

At this stage, she no longer requires formal physical therapy sessions with me, but she does require further maturation of the microscopic scar tissue where the inflammatory process was occurring. She currently is engaged in targeted eccentric loading of the right extensor digitorum longus and extensor carpi radialis musculature of the right elbow-forearm. She will engage in this activity for another 12 weeks while she is weaning completely off of her elbow strap.

Elbow tenosynovitis, whether it’s of the medial or lateral epicondylitis, is one of the more difficult musculoskeletal diagnoses to resolve. In my experience, one of the primary reasons for this is either the individual’s unwillingness (or perceived inability) to stop the offending behavior. I cannot stress strongly enough for this diagnosis, the absolute importance of ceasing the offending behavior or behaviors for up to three months, and possibly more if this is chronic (present longer than six months). The best medical and paramedical treatment intervention will fail without the patient’s compliance on this critical aspect of recovery. I want to stress to any individual dealing with this problem that although they are seeking attention from their physician and/or physical therapist, that this process has to be collaborative in nature for success. While ultimately a structured program and guidance will be given by the clinicians, active and collaborative participation of the individual is the only way to ensure long-term success. This is especially true with a self –guided regimen.

 

Dr. Michael J Malawey, PT

 

 

 

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