Case of the Week 7-15-12: The Elbow Bone is Connected to the Knee Bone | Modern Manual Therapy Blog

Case of the Week 7-15-12: The Elbow Bone is Connected to the Knee Bone

This week's COTW was a good example of regional interdependence that resolved in a few short visits.


History: The patient is a 37 yo male with complaints of severe left elbow pain, felt "deep in the joint" with only golfing and end range elbow flexion with self overpressure. Onset occurred about 1 year ago and was felt during his first time golfing for that season. He was able to finish, but the elbow pain got progressively worse. He rested, and noticed his complaints unchanging since then. Other than golf, which he does not get to do very often due to his family and work commitments, he mainly notices the complaints ONLY with end range overpressure (not sure why he repeatedly tested this). He was otherwise not limited in any ADLs. PMH significant for left knee lateral release several years ago.

Objective:

Observation of golf swing showed decreased trunk rotation and hip rotation on the left.

Myofascia: mod restrictions along lateral upper arm, triceps, anconenus, biceps, anterior radial bony contours.


The SFMA results were actually found on the third visit, as I locally treated the left arm and worked on trunk rotation a bit.

Assessment: 

Treatment 1: IASTM to lateral upper arm, biceps, triceps, radial bony contours. Humero-ulnar distraction with extension and then held MWM with overpressure into flexion. This significantly decreased his elbow complaints. He was instructed on self humero-ulnar distraction for HEP to be performed hourly and to avoid repeatedly checking for pain (other than pre and post self treatment).

Treatment 2: Pt reported at least 75% reduction in end range elbow pain. I performed IASTM to his thoracic paraspinals, and performed MWM to improve thoracic rotation. I added IASTM and FR to the anconeus while the patient actively performed elbow flexion. He left with no pain at end range OP elbow flexion,

Treatment 3: The patient was told to practice swinging, he still had end range elbow "strain" but not severe pain. I observed his swing and noticed his rotational deficit. 

SFMA results

DN for MSR to the left, mod loss
breakouts:


  • trunk rotation to left upper and lower DN, mod loss
  • hip IR DN on left, mod loss
  • tibial rotation DN, mod loss
  • ankle df, mod loss on left
Locally, the elbow had normal extension with bony end feel passively, painful (empty) end feel with flexion before end range, which sharp pain at end range flexion overpressure. 


I added IASTM on the ITB, hamstring/gluteal junctional area, gastroc, lateral tibia bony contours, and MWM to the hip and tibia. Thoracic IASTM was again performed and followed with thrust manipulation.

Hip IR, tibial IR, and trunk IR were now FN. MSR to the left was FN. He was told to practice his golf swing again and it was completely Sx free!


Discussion: After his knee surgery, he had PT, but no 1:1 attention, mainly bike riding, etc. His hip and tibia were pretty locked up. A lack of thoracic rotation did not help either. The weakest link in his chain just happened to be a mobility joint, or the elbow. His swing with a lack of left hip IR, left tibial IR, and trunk rotation caused excessive mobility at his elbow. The elbow joint "restrictions" were most likely left over from golfing for years with those restrictions, causing some microtrauma. He even said his entire swing felt easier to perform. We are seeing him 2 more visits to perform a bit more manual on his left lower quarter and trunk. In the meantime, hopefully he gets a chance to get out there and golf. Oh, and he was given repeated hip IR, tibial IR MWM, and open book exercises for his trunk rotation.


6 comments:

  1. Great case! I just wanted to express how grateful I am for your posts. As a new graduate, your blog has strongly influenced the way that I practice and approach patients with difficult presentations. Thank you!

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  2. Good post E! I like the fact that you used micro trauma and weakest link at end of post. I have been using these terms like they are going out of style lately with pts! I think they are able to understand this as it is a layman explanation. As I wrote you back on my post, it can be difficult to express to the patient the whole body can be involved and don't necessarily need to just treat the focal area of pain. Some can think you are 'out there'. These terms are better than me singing, 'the hip bone is connected to the knee bone...'

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  3. Thanks HV! Figured you would like this coming off of your last written case! Yeah, singing is not my forte either.

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  4. Thanks Tom, that's my hope that these COTWs help other clinicians gain insight on potential similar presentations.

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  5. I agree with Tom! Another great example of the importance of involving the whole kinetic chain...

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