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A 27-year-old left-handed male presents with left elbow pain (medial aspect) of several months duration that has gradually worsened. The patient can recall no specific injury but notices that the pain increases after working a full day as a carpenter and after playing racquetball. His sleep is not disturbed unless he sleeps on the involved arm. The patient reports no numbness or tingling in the left arm but that his pain does occasionally radiate down the inside of the forearm. Further questioning revealed that the patient has not had this condition before and that his past family and medical history are both unremarkable. The patient went to see his physician who prescribed a course of anti-inflammatory medications and physical therapy.

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What is your best working hypothesis at this stage?

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This patient’s history seems to indicate an overuse injury to the left elbow, possibly medial epicondylitis.

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Which structures attach to the medial aspect of the elbow?

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The middle and superficial layer wrist flexors and extrinsic finger flexors attach to the medial aspect of the elbow by way of the common flexor tendon.

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What movements/actions would you expect to exacerbate this condition?

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This condition is likely to be aggravated by means of resisted wrist flexion and forearm pronation as well as wrist extension with passive supination and ulnar deviation.

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The physical examination reveals the following:

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  • The left proximal anterior forearm is warmer to touch than the non-involved side. There appears to be no visible swelling and girth measurements are equal bilaterally.
  • Active range of motion: wrist flexion at 55°, wrist extension at 50°, pronation at 80°, and supination at 80°. Cervical, shoulder, elbow, and finger active range of motion are all within normal limits.
  • Increased pain with resisted wrist flexion (4/5 for strength) and with forearm pronation (4/5 for strength). All other resisted tests were negative for pain and weakness.
  • The cervical spine was cleared.

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Was your best working hypothesis confirmed following the physical examination?

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The working hypothesis for this patient is medial epicondylitis of the left elbow.

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Having made a provisional diagnosis, what will be your intervention?

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How would you describe this condition to the patient?

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How would you explain the rationale behind your intervention to the patient?

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What activities and positions would you advise the patient to avoid? Why?

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How will you determine the intensity of your intervention?

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Describe the method of applying transverse friction massage for this ...

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