This topic contains 2 replies, has 2 voices, and was last updated by Carl Nottoli, DC June 8, 2018 at 5:42 pm.
June 6, 2018 at 4:54 pm #5353
63 year old female. pain directly over the medial epicondyle. Patient describes pain as a “bad bruise” but can get to a burning, searing pain. No pain at rest but gets up to a 10/10 with load (tennis). Provocative is direct pressure and first movement after rest, first few shots in tennis, and supination and pronation of the wrist. Rest and ice are palliative.
Patient plays a lot of tennis. Was bowling a lot but had to stop due to this pain a couple months ago.
Wrist extension with fingers flexed is full range with no symptom.
Wrist extension with finger extension was limited to almost no finger extension with a lot of tension felt in the hand but not reproducing the chief complaint.
Resistance testing the forearm flexors was painful 5-6/10.
My diagnosis was
1) tendinosis of the common flexor tendon.
2) adhesion of the fds and fdp
Patient has not played tennis or done any extra loading of the forearm in a month
I have done 7 treatments and have moderately improved the wrist and finger extension test but have had mild symptomatic improvement.
At visit 5 I ordered an MRI because of the slow symptomatic progress. I also added in eccentric exercise at this point.
I just got the MRI results back
1 “Edema and irregularity at the origin of the common flexor tendon” “this could represent a sprain/tear” “medial epicondylitis”
2 Mild joint effusion
3-edema around the distal biceps insertion “possible sprain”
the patient is bringing the films next visit so i can actually see them.
Are eccentric exercises a good idea if there is a suggested partial tear?
Should I be contacting the radiologist to determine if this is a tendinosis or a tendinitis? Does it even matter?
Any other suggestions with this case?June 8, 2018 at 5:17 pm #5354
Adam Holen D.C.
A 63-year-old female, up to 10/10 burning/searing pain at common flexor tendon insertion. Worse with load (forehand, resistance, direct pressure), better with rest/ice. Likely tears at the common flexor tendon and potentially distal bicep. If I have this right, it would still indicate tendinosis as the mechanism instead of inflammation/tendonitis (since rest and ice haven’t significantly helped). Not entirely sure when it would be best to add eccentric exercises with ‘potential’ tears/tendinosis, but my gut says 10/10 is at least grade 2 so I would aim to clear out any and all adhesion before trying to load up the tendons. Haven’t had many tendinosis cases, but they sure seem like a bitch and something that’s just going to take time to align the fibers and regenerate the tissue. My approach would be to hammer home communication on the importance of reducing all adhesion, explaining why symptoms are slow to improve (tendinosis), and that she has been working on this for probably 30-40+ years so it will take time to unload the tissue before proper exercises can be implemented and even then, the exercises are a slow process. Hope this helps, sounds like a difficult case.June 8, 2018 at 5:42 pm #5355
Carl Nottoli, DCParticipant
There’s definitely a tear and likely tendinosis of the distal bicep tendon. Your history screams tear. The radiologist is lazy but you have the clinical correlation with the patient. It would still be helpful to contact the radiologist and pin them down on the answers. Make the appropriate addendum.
Eccentric on a highly symptomatic tendon is a bad idea. Wait until symptoms are cut in half before adding those.
As Adam pointed out, communication is key here. This will take over a year to heal—assuming it will all the way. She’s old and had a lot of high load on a bad tendon. Keep chipping away and make sure she understands the expectations. There will not be a quicker and more complete option with the caveat of surgery to a high grade tear greater than 50%. Then she will still need all of this treatment anway
So this is where speaking with radiologist and making them use actual diagnostic terms will help instead of the nonsense he put in his report.
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