Russ is 56 years of age and has right elbow pain. The pain started about four months ago after he finished a rowing practice. He thought he just "over did it" and that the pain would eventually go away but it didn't.
He tried various over the counter anti-inflammatory medications - Advil, Motrin - but it didn't help much. Now, his elbow hurts anytime he lifts anything or grips something like a coffee cup. Sometimes, he hurts during the night. The pain is sharp, stinging and easy to locate over the right lateral elbow.
He went to see his family doctor who prescribed anti-inflammatory medication and advised him to avoid aggravating his elbow. After a few weeks and not feeling any better, Russ asked his doctor if there was anything else he could do. He was then referred to us.
His doctor diagnosed Russ with "Right elbow strain; lateral epicondylitis". I'm not sure he actually had inflammation of the bone (epicondylitis). I think the tissue injury was an common extensor tendonopathy. He was tender to palpation over the common extensor tendon and his grip strength was 50lbs (limited by pain) compared to his left grip of 120 lbs. His right finger extension strength was 4lbs; the left was 9.5 lbs.
Occasionally, extensor tendonopathy will be accompanied by too much motion in the wrist. Or, sometimes the problem can be a lack of shoulder strength, as in the case of a tennis backhand, but, in Russ' case, the only findings he had on exam were the above items. He otherwise was remarkably normal.
Russ' self-reported pain level was high - around a 7 out of a maximum of 10 and he found it difficult to perform certain activities around the house and at work. But, he could do them. He didn't exercise regularly which is why he had started the rowing. What bothered him was that he couldn't get more involved with the rowing, that his pain didn't seem to be improving much, and that he didn't understand how to fix it.
Here's what I did to help him. First, I explained what tendonopathy was, how it healed, and why exercise was critical for him to regain the strength of his tendon. He naturally wondered why I didn't treat him for epicondylitis. Whenever there is a mismatch between what the referring source says and what I say, it always creates some tension. I explained the terminology, the anatomy, and that the term "epicondylitis" is often used as a label for tendon problems. That seemed to ease the tension.
I chose to classify him at Stage 4 (Stage 4: Mild to moderate pain before, during, and after exercise which alters the exercise or activity. ADLs are affected. Stage 4 is indicative of some level of tendon damage.). Some might argue to stage him at a higher level since he complained of some pain at night and his pain levels seemed high. But, I look at both what a person says and what he or she does. So, since pain is three dimensional (physical, emotional, mental), it's possible to report moderate to high levels of pain but still function at a moderate to high level. Functionally, he was closer to a Stage 4 and maybe even Stage 3 but I chose to be conservative and stick with Stage 4.
Stage 4 drills involve higher loads and speeds and fewer repetitions than Stage 5 or higher. And, to complicate matters, Russ really needed to have something that he could do completely on his own due to his work and home schedule. So, I decided to keep things very simple. And, at the risk of offending someone, he was an engineer. Engineers like to tinker with stuff. They think they can figure out a way to do it better and in so doing, usually screw things up. I know, I'm over generalizing, but I'm reporting from my experience.
I taught Russ how to perform eccentric movements of the wrist (lowering the wrist and then lifting it up with the other hand) in a sitting position with his forearm resting on his leg. He held a dumb bell in the right hand. His job was to perform three sets of this exercise consisting of 25, 20, and 15 repetitions but he had to use a weight that created a high level of fatigue in his elbow and, by the third set, caused some mild to moderate pain as well. He should rest one minute between sets. Once he had that weight, he had to write it down so he would know what he had done. He was to perform these three sets, every other day each week. When he noticed that his fatigue and pain level decreased, he was to increase the weight just enough to keep the fatigue and pain in the moderate zone.
This demonstration took about 30 minutes. At the end of it, Russ said, "So, that's it? That's all?"
I said,"For now. Do this for three weeks, come back, and I'll re-test you."
This routine is harder than it seems. Sure, it's three sets of one exercise but you have to generate fatigue and pain. A lot of people bail on the drill before reaching even the right level of fatigue much less pain.
Russ went home and did the routine. He noticed that after the first week, he had to increase his weight a couple of pounds and again the third week. He returned for testing after the three weeks. His grip test increased from 50 lbs. to 110 lbs. He had little pain. He didn't hurt at night. He generally felt good. He wanted to go back to rowing.
"I would like you to do this for one more round of three weeks. Let's get your grip strength all the way to 120 lbs. Then, I think rowing will work." He agreed.
Russ continued with the same exercises and followed the rules. He increased his weight but after the fifth week, he no longer could produce any pain. He kept his weight the same then and finished the final sixth week and returned.
His grip test was now 120 lbs. He was asymptomatic. I suggested he start rowing.
Why this worked
Russ had the right combination of pain, functional loss, and motivation. If Russ had been a Stage 5 or 6, my options for him at home would be very limited. A Stage 5 or 6 requires a lot less load and many more repetitions and without the tools to do this, the program usually fails. If he had other problems, such as shoulder weakness, hypermobility in the distal radioulnar joint, the program becomes too complex to execute independently.
If Russ had been a Stage 2 or 3, he may not have had sufficient motivation to do the drills. Unless you're competing for something or have a strong level of self-motivation, the pain levels have to be higher for an independent program to work.
Russ did the program. He didn't tinker with it or abandon it because it was too simple. In fact, he told me that what he liked was both how difficult the drills were and that he only had to do one exercise.
I was ok with a simple program. I used to think that in order for something to be valued, it had to be hard or complex. Not true. The solution just needs to match the problem. Just think about a band-aid and you'll get what I mean. Band-aids work great for a cut; not so hot for an arterial bleed.
Why this WON'T work for everyone
For all the reasons that it worked for Russ, it might not work for someone else. Getting the staging correct, understanding if there are other problems involved, the client having sufficient motivation and not tinkering with your program, you and the client being ok with something so simple, making sure you re-test to identify the degree of improvement are all things that have to be in place for this solution to work.
What else I could have done
The list is endless. I could have jiggled his proximal radioulnar joint to promote pain relief; used kinesiotaping for sensory input and pain relief; given him more exercises of countless variety; issued stretching drills; massaged his forearm and elbow; given him a forearm strap; used deep friction massage. None of those things are wrong really but why do more if you don't need to? If he had returned after the first three weeks and not improved or had been worse, then I would have had a much different scenario. I would be tempted to do more stuff mostly to alleviate my own stress. If I do something, anything, then at least I'm trying. But, I've learned to not do that. Instead, I would first collect the data and make sure his numbers hadn't changed or were, in fact, worse. Just because he says he's worse, doesn't mean that everything is worse. Then, if the numbers are worse, I would ask him to demonstrate the program. The whole thing. Usually, this is where the problem shows up. Wrong movement, not enough load, too much load, too fast, resting too much or too little, etc. If he executes the program correctly and his numbers are worse or not better, then I would look into ancillary activity: what else is he doing? If I find nothing here, then I would start looking at my diagnosis. I may have missed something or, maybe he really did have an inflamed bone after all :)
DK
