Is today’s chiropractic practitioner identified as a suitable specialist for the referral of complex medical problems? While many of my chiropractic colleagues will answer yes, will these same colleagues take full responsibility for coordinating treatment? The following case report serves as an example of how to take responsibility and work within the medical referral system to maximize outcomes.
History of the present illness: The patient is a pleasant 52-year-old man with a chronic history of radicular pain with resultant surgeries. His current symptoms involve both elbows at the lateral aspects; right greater than left with significant pain that extends down the forearms. He is right-handed.
There is a report of chronic loss in left grip strength that appears stationary at this time. The quality of the elbow pain is burning and aching. Provocative: pronation of upper extremities; turning or twisting a door knob, opening a jar. Palliative: becomes somewhat tolerable with pain medication. There is radiation of pain from the bilateral lateral epicondyle upper extremity toward the forearms.
Past medical history: History is significant for intrabody cervical fusion, discectomy at spinal levels C5-7. The patient reported permanent disability of an industrial nature in 1996 involving the lumbar spine, knee and both wrists. He was provided a combined disability rating of approximately 75 percent. He was employed as an electrician when suffering this industrial injury. There was a litigated automobile accident with subsequent complaints involving the head (concussion), neck, and left hand (compound fracture); metacarpals, radius and ulnar required pinning.
Operations or injuries: Intrabody cervical fusion, discectomy at spinal levels C5-7 secondary to reported MVA. CTS bilateral, and percutaneous pinning left hand/forearm.
Medications: Opiate agonists to control pain.
Examination and Review of Records
Height/weight: Patient’s height is 5’ 10.” Weight is 166 pounds.
General postural inspection and gait: There is asymmetry of the head, shoulders and trunk with unequal amplitude of arm movement on locomotion. There are well-healed surgical scars: bilateral anterior wrists linear, and semicircular anterior cervical. Purposeful painful withdraw on handshake.
Chiropractic motion palpation: Paraspinous myospasm at right pronator teres, right forearm extensors, hypertonicity at left shoulder girdle; infrascapular, subscapular and intercostals region, extraspinal listings indicate a loss of posterior to anterior accessory joint movement of the right radial head in pronation. There is significant point tenderness over the right lateral epicondyle.
Percussion: Negative carpal testing.
Neck: Trachea midline. No masses. Thyroid shows no enlargement or tenderness. No lymph node enlargement. Previous scar noted with extension position of carriage.
Neurological and orthopedic: II-XII cranial nerves intact. No nystagmus or vertigo. No pedal edema, no calf tenderness on squeeze test, distal pulses equal. Seated deep tendon reflexes: +2/4 symmetrically using the Wexler Grading Scale. There is no palpable pain of the ulnar nerve in its groove. Circumferential measurements unremarkable. Cervical spine range of motion 35/45 presents in early extension phase of posture. Right carpal crepitus noted on deviation motions.
Record review: Special imaging cervical spine 10-16-2008 (taken at medical center) reveals cervical spondylosis lower cervical. There are no recent studies available of the upper extremities.
Right lateral epicondylitis and to a lesser extent left lateral epicondylitis.
Status post intrabody cervical fusion, discectomy at spinal levels C5-7.
Possible recurrent CTS left upper extremity secondary to adhesions.
The elbow is exposed to numerous traumatic events that can lead to joint injury and dysfunction. A common cause of elbow problems is muscle activity across the joint. Lateral epicondylitis results from such activity of the wrist extensors. The extensor mass, especially the deeply located extensor carpi radialus, rubs and rolls over the lateral epicondyle and radial head during forced contraction of the muscle. The forced contractions of the muscle group tugs on the origin, resulting in microtears of the tendon and a pulling away of the periosteum.
This is a very painful elbow condition with a typical pain pattern extending down the forearm, following the extensor muscle group, and featuring point tenderness over the lateral epicondyle. The patient reports that medication makes this pain tolerable.
The patient reported use of an elbow brace in the past, and still has this brace. I recommended he reapply a type of a counterforce brace; once patient is compliant in 24-hour use, the intensity of the pain should subside. This brace supports the injury by controlling the internally generated muscle forces by diminishing the expansive capabilities of the extensor muscle group while allowing an unimpeded arc of motion. This reduction acts to decrease the generated force of the muscle contraction at the epicondyle, decreasing point tenderness.
This brace will be weaned away over the remainder of the rehabilitation program. Chiropractic adjustments shall be applied at the extensional regions to assist pain-free joint range of motion and improve kinematics. Consider as an alternative to surgical management for the lateral epicondyle and radiohumeral joint.
Should palliative procedures fail, patient should follow up with an orthopedist for corticosteroid injections, plain-film radiography of the elbow and evaluation of the right and left probable failed or re-current CTS. (If the perceived left wrist grip weakness becomes a functional issue, return to primary for orthopedic evaluation.) I do not feel that there exists any ulnar neuritis or peripheral nerve entrapment, such as PINS, requiring any transposition procedures, or any failed cervical spinal procedure with radiculopathy.
Recommendations and Outcome
Counterforce strapping RUE. Palliative intervention with physical therapy modalities; 12 sessions total (2-3 times a weeks for 4-6 weeks). Technique: diversified non-force technique, diversified extremity. The patient was discharged after 12 sessions with good control following chiropractic care.
This patient’s story isn’t really unusual; we all expect a few more aches and pains as we grow older. After all, aging and wear and tear go together. What’s different about this patient is that staying active after his spinal cord injury meant even more wear and tear on his arms and shoulders. Studies have shown that arm and shoulder pain is more frequent among spinal cord injuries survivors than in the non-disabled population.
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