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Cathy is a 42-year-old employee on the housekeeping staff at a local hospital.
Cathy presented with pain at the lateral epicondyle of the right elbow.
This was the result of a sprain/strain of the right forearm and elbow,
which occurred while lifting an unexpectedly heavy trash bag filled with books
and periodicals, instead of the usual crumpled pieces of paper.
Whenever Cathy used her right arm to lift an
object of any appreciable weight, such as a 6 oz tumbler of iced tea or heavier,
she experience pain from the lateral epicondyle down into the right hand and
simultaneously up to the right shoulder.
Since
the pain pattern for scaleni muscles fit Cathy’s pain almost to a “T”, I
did ROM testing for active myofascial trigger points in the scaleni muscles.
Of all the tests I did, the scaleni cramp test was the only one that
proved negative. All the rotator
cuff muscles, coracobrachialis and anterior deltoid were positive for active
myofascial trigger points as demonstrated in the Backrub and Hand to Shoulder
Blade tests.
Both
tests were also painful at the extensors of the right forearm when supinating
the hand and forearm. The Handgrip
test was positive for trigger point activity in the brachioradialis and
extensors of the right hand and fingers. Testing
of pronation and supination against resistance was positive for active
myofascial trigger points in the supinator and pronator teres, respectively.
This
evaluation indicated to me that the right epicondyle pain was the result of
continuous subclinical trauma to most of the musculature from the shoulder
girdle to the hand. Lifting the unexpected weight of books and periodicals in a
trash bag was simply “the straw that broke the camels back.”
When
Cathy first came in for treatment, she stated that her pain was as much as an
8/10. By the sixth treatment, the
pain never rose above a 4/10.
During those 6 treatments, continued release of active myofascial trigger points
in the entire right arm, coupled with a home exercise program, was successful in
decreasing the intensity of Cathy’s pain.
Although
the 6 treatments reduced the right epicondyle pain by 50%, it seemed there was a
piece of the puzzle I had not yet discovered.
After much discussion and inquiry, I learned that Cathy not only slept
face down, but also with her right arm overhead, under the pillow and with her
elbow flexed to approximately 90°. This
position keeps the brachioradialis, biceps brachii, pronator teres and extensors
shortened, thereby perpetuating the pain.
After
discussing various methods to change her sleep position, it was agreed that
Cathy would sleep with her right arm inside a T-shirt instead of through the
normal arm opening. This would prevent her from sleeping with her arm in the
usual position that was perpetuating the pain.
A week later, Cathy returned with very little pain during normal daily
activities, including lifting.
There was still pain upon palpation at the right lateral epicondyle, but pain no
longer traveled up to the shoulder and down to the hand.
Although
I was not able to relieve all of Cathy’s pain using Myofascial Trigger Point
Therapy, I was able to greatly decrease her pain and return her to nearly normal
function. Since the muscles were
shortened and contracted, due to myofascial trigger points, a long time before
the actual injury, the chance of inflammation at the attachment of the tendon to
the periosteum of the lateral epicondyle was considered.
I sent Cathy back to the referring physician to be evaluated for the
possibility of injection of an anti-inflammatory to resolve the remaining pain.
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