BPHY213 Musculoskeletal Physiotherapy II

Elbow Case 1: S/E Documentation

Miss Teresa Lam works in a bank. She works with the computer all day. In the last few months, she
has been feeling some pain in her right elbow after work. This pain has been getting worse gradually,
being aggravated by prolonged typing. Now it is so bad that her elbow and forearm aches severely
after work. She cannot even lift up a teapot with her right hand. The doctor has just referred her for
physiotherapy.

This is her referral:

Name: Teresa Lam Age: 26

Diagnosis: (R) Elbow Pain x 3 months – aggravated by work, getting worse gradually

Treatment: Physiotherapy please

Date of Referral: 17 Mar 2023

Main problem: Painful (R) elbow and forearm during working with the keyboard and mouse.

Past history:
Similar episodes – very mild occasional (R) elbow pain x 1-2 days for the last 2 years. General
health – good.

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 Teresa
Mary Lam
Wong 26 F

P1
intermittent,
deep, sharp
to
dull ache

Behavior of symptoms:
Aggravating factors:
1. typing for 1hour á pain (5/10) – need to stop and rest for about 10min, then âpain to 2/10
2. lifting a full teapot á pain (7/10) - âpain to 2/10 when putting it down

Easing factors:
Resting, wriggling wrist around, massaging muscles in the forearm

Functional limitation:
Cannot tolerate hours of typing at work;
Unable to play any racket sport, carry objects heavier than 3 kg, e.g. grocery/ cooking pan.

24 hour pattern:
No pain at night, increased pain after a day’s work

Special questions:
X- rays : not taken
Medication: Deep Heat
Social: lives with parents, used to play badminton at leisure time with friends once a week

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 Elbow Case 1: O/E Documentation

Observation: mild swelling around lateral epicondyle and muscle belly of wrist extensors

Physiological Movement Accessory Movement (R)

(R) (L)
Active Passive Active Passive

Shoulder üü üü üü üü

Elbow
Flex üü üü 1300ü üü E/Abd P(3/10) R+
Ext -50 P (5/10) -50 P(5/10) 00ü üü
E/Add P(5/10) R+++
Pron 900ü P (2/10) on OP F/Abd üü
Sup üü üü üü üü F/Add üü

Wrist
Flex 400 P (4/10) 700 P (8/10) 900 ü 900 ü
Ext 800 P (2/10) üü 800ü 800ü
UD üü üü üü üü
RD üü üü üü üü
üü üü üü üü
Hand
üü üü
Cx

Isometric Muscle Testing:

Elb. flexors üü
Elb. extensors üü
(R) Wr extensors P (8/10) in (R) lateral epicondyle

Palpation:
Localized tenderness P (8/10) in lateral epicondyle;
Mild swelling and ↑ swelling in belly of (R) Wr extensors

Strength:
¯ (R) grip strength 80% of (L)

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Discussion:
1. What are the asterisks in S/E and O/E?

2. Prioritize the physical problems of Teresa.

3. What are your short-term goals of physiotherapy?

4. What would be treatment for the first physiotherapy session?

5. How would you evaluate the immediate treatment effect?

6. What could be the protective device prescribed to Teresa?

7. What should be the long-term goal of rehabilitation for Teresa?

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 Elbow Case 1: Follow-up Visit Documentation

Teresa is now attending the 4th treatment session.

S/E:
­ tenderness in (R) elbow for two hours after last Rx but got better gradually. Pain decreased about
30% in general.
O/E:
Observation: mild swelling around (R) lateral epicondyle, ¯ swelling in muscle belly of (R) wrist
extensors

Active Movements:

Physiological Active Passive Accessory Movts

(R) Elbow
E -50 P (3/10) 00 P (3/10) E/Abd P(3/10) R+
Pron 900 P0 P (1/10) at OP E/Add P(3/10) R++

(R) Wrist
F 600 (3/10) 700 P (5/10) at OP
E full mild P üü

Isometric Muscle Testing:

Wrist extension Reproduce pain+++ in lateral epicondyle

Palpation:
Localized tenderness in lateral epicondyle (R)
Mild swelling and increased temperature in R wrist extensor muscles

Strength:
Decreased grip strength (R) – ISQ i.e., 80% of (L)

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Discussion:
1. What are the major changes in S/E and O/E from that of the 1st session?

2. Are there any changes in priorities of the problems?

3. How would you progress your treatment techniques from the 1st to the 4thsession?

4. Is resisted exercise suitable to improve the strength of Teresa’s grip? Reasons?

5. Any advice to Teresa for self-care strategy in preventing recurrence of the elbow problem?

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 Elbow Case 2 – David
David, an 8 year-old boy fell off his skateboard and sustained a supracondylar fracture of (R) elbow.
The fracture was reduced and immobilized in a cast for 3 weeks. He has now been referred to
physiotherapy for “active exercises but strong passive mobilization is not allowed”.

Exercise in the first 3 weeks from removal of immobilization:

Problems:
¨ Very limited active R.O.M. of (R) elbow (70o – 95o, no pain in the elbow)
¨ Atrophy of muscles in (R) upper arm and forearm

Aims of exercise therapy:

Types of exercise:

Repetition & Frequency:

Week 8 after fracture (sign of callus):

Problems:
¨ Limited active R.O.M. of (R) elbow (25 – 105o, no pain in the elbow)
¨ Atrophy of muscles in (R) upper arm and forearm

Aims of exercise therapy:

Types of exercise:

Repetition & Frequency:

Week 12 after fracture:

Problems:

Aims of exercise therapy:

Types of exercise:

Repetition & Frequency: