Clinical presentation in musculoskeletal physiotherapy

Clinical practice in musculoskeletal
physiotherapy(II)
Case presentation
Done by-T.L.Y.Pathirana
D/PST/21/0028

Subjective Examination
• Demographic Data
 Name- Sudesh Gamlath - Occupation – Software engineer
 Age- 32 years old -Working hours- 10 hrs per day normally
 Gender – Male -Civil status -Married
 Hometown – Piliyandala -Dominant side- Right handed( During working both
 Unit – UHKDU hands use)
• Present Complain
 Pain over medial side of the right elbow joint
 Pain on the inside of the elbow when grip something
 Pain occurs when bending the wrist
 Weakness in the wrist
• History of Present Complain
• Onset- gradual from 2 months
• Pain started during weight lifting at gymnasium and worsen with occupation.
• Pain type- localized pain in medial side of the elbow
• Normally he is going to gymnasium and doing exercises like weight lifting, by using upper
limbs throghout 45 minutes per day and 3 days per week.

Pain Assessment
• Onset-Gradual onset since 2 months
• Type of Pain-Localized pain
• 24 hours pattern- Difficulty in falling sleep due to pain
• Aggravating factors- After activity and during activity, lifting weight, using computer
• Releasing factors- Rest
• Pain according to numeric pain scale- 6
 Past medical history- no history of chronic illness or diseases.
 Past Surgical history- no history
 Investigations- Xray- no fractures
 Trauma History- none
 Allergies-none
 Social history- regular smoker,
-during working time on office difficulties in posture maintainence
-socioeconomic status is good
 Family History- Married
-No congenital abnormalities or illness
-Family support is good

Objective Examination
• Observations
_General_
 Body built-well build
 Posture- anterior, posterior and lateral no remarkable abnormalities
-scapular level-same
-elbow level- same (anterior, posterior views)
 Gait- normal
 Mood –Friendly and supportive
_ Local_
 Gait- arm swing phase decreased in right arm
 Muscle wasting-none
 Jerky movements –None
 Deformities-none
 Swelling –on medial side of elbow
 Scars-none
 Tropic Changes- mild redness on medial side of the elbow
 Carrying angle- normal

Palpation
• Temprature -normal
• Muscle tone-normal
• Tenderness- over the medial epicondyle and along the pronator teres, fkexor carpi radialis
muscles
• Trigger points- Flexor carpi radialis
• Muscle spasm- Flexor carpi radialis, Flexor carpi Ulnaris
• Odema-Non pitting oedema in medial side of elbow
_Examination _
• Odema Measurements
 Around Elbow
• Muscle power
Key muscle Right side Left side
Elbow flexion 4/5 5/5
Elbow extension 5/5 5/5
Wrist flexion 4/5 5/5
Wrist extension 4/5 5/5
Finger flexion 4/5 5/5
Finger extension 5/5 5/5
Right side(Inches) Left Side(Inches)
Around elbow 11’5 11

 Sensation-
• C5-T2 (light touch & pinprick)
 Range of Motion
Right side Left side
Normal Normal
Movement Right(AROM) Left(AROM) Normal Range Passive ROM
Right
Shoulder flexion 170 170 160-180
Shoulder
extension
50 50 50-60
Shoulder
abduction
180 180 0-180
Shoulder
external rotation
80 90 0-90
Shoulder internal
rotation
70 70 0-70
Elbow flexion 120 150 0-150 150
Elbow extension 0 0 0 0
Wrist Flexion 50 80 0-80 80
Wrist Extension 60 70 0-70 70

 Special Tests
• Golfers Elbow Test- Positive
• Cozens Test- Negative
• Valgus Stress Test-Negative
 Co-Ordination
• Finger to nose test- Bilateral normal
 Limb Girth Measurements
Critical Analysis
Following subjective assessment
• He is 32 years old patient with no chronic illness.
• Complaining of medial elbow pain worsen with movements, poor grip, weakness in wrist, and
difficulties in wrist movements.There was no trauma history. Patient was complaining during
weight lifting at gymnasium there was strenous force to the elbow. And it worsens with his
occupation. According to subjective assessment those hypothesis can be made.
• 1.Golfers elbow
• 2.Ulnar colateeral ligament sprain
Measurement Right upper
limb(Inches)
Left upper
limb(Inches)
Upper mid arm 13 13
Mid forearm 10 9’5

 Following Objective assessment
• On observation there were swelling on medial side of elbow and mild redness over the medal
side of the elbow.
• On palpation tenderness over the medial epicondyle and pronator teres, FCR muscles. There
was a trigger point in FCR muscle. And also muscle spasm in those muscles.
• On examination AROM of wrist joint was restricted due to pain and tenderness but
coordination, sensation was not impaired.
• Muscle strength of right elbow and wrist were level 4. According to special tests golfers
elbow test was positive and other tests were negative.As so as those symptoms are related to
medial epicondylitis. So I planned my treatments based on medial epicondylitis
Physiotherapy Diagnosis
• Functional limitations in activities of daily living, muscular weakness, tenderness, swelling
and restriction of movements due to pain caused by medial epicondylitis.
Physiotherapy Management
Aim- To make the patient functionally independent as much as possible to do his occupation and
exercises and gain maximal functional life back within a minimal time period.

Short term Goals
Goal Intervention
Educate and reassure the patient • Explain about the condition,current state and
prognosis
• Explain about the goals and the interventions,
clearly explain the procedures of home
exercises.
 To reduce pain from 6 to 2 within 2 weeks • Resting, apply ice 15mins 6 times per
day,elevation and immobilize the area when
possible
• Prevent painful activities( Stop vigrous upper
limb gym exercises for 2 weeks)
• TENS(100-150Hz,15mA)
 Reduce swelling over the medial epicondyle
within 1 week
• Ultrasoundtherapy6-8 mins (0.8Wcm2) every
other day
• Compressive bandage
 Reduce muscle spasm, tenderness, and release
trigger points effectively within 2 weeks.
• Myofasical release
• Soft tissue mobilization( kneeding,pickung
up)
• Deep frictional massage with 48 intervals.
 Improve,maintain AROM in wrist and elbow
upto FROM within 3 weeks.
• Static stretching for wrist and forearm
flexors30 secs hold*3 sets, 3 times per day
• Active and active assisted movements for
elbow, wrist,fingers flexion and extension

Treatment plan
Improve and maintain muscle strength in
affected side upto grade 5 within 3 weeks.
• Do some isometric strengthening for
forearm muscles and wrist flexors in
affected side (10 reps* 3 sets per day)
• Strength affected side upper limb by
using 1RM and 10 RM.
• Grip strengthening –rolling, squeezing of
a ball
LONG TERM GOALS
Make the patient functionally independent as
much as possible within 4 weeks.
• Small weight lifting activities
• Posture management during worktime and
exercises
• Hand grip training modification.

References
O Jayanthi N, Esser S. Racket sports. Curr Sports Med Rep. 2013 Sep-Oct. 12(5):329-
36. [QxMD MEDLINE Link].
O Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and
management. J Am Acad Orthop Surg. 2015 Jun. 23 (6):348-55. [QxMD MEDLINE Link].
O Kiel J, Kaiser K. Golfers Elbow. StatPearls [Internet]. 2018 Jan. [QxMD MEDLINE
Link]. [Full Text].
O Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med. 1996 Jan.
15(1):65-83. [QxMD MEDLINE Link].
O Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin
Sports Med. 1988 Apr. 7(2):289-308. [QxMD MEDLINE Link].

Clinical presentation in musculoskeletal physiotherapy

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