Four Case Histories
Case History #2
Cathy is a 42-year-old employee on the housekeeping staff at a local hospital. Cathy presented with pain at the lateral epicondyle of the right elbow. This was the result of a sprain/strain of the right forearm and elbow, which occurred while lifting an unexpectedly heavy trash bag filled with books and periodicals, instead of the usual crumpled pieces of paper.
Whenever Cathy used her right arm to lift an object of any appreciable weight, such as a 6-oz tumbler of iced tea or heavier, she experienced pain from the lateral epicondyle down into the right hand and simultaneously up to the right shoulder.
Since the pain pattern for scaleni muscles fit Cathy’s pain almost to a “T”, I did ROM testing for active myofascial trigger points in the scaleni muscles. Of all the tests I did, the scaleni cramp test was the only one that proved negative. All the rotator cuff muscles, coracobrachialis and anterior deltoid were positive for active myofascial trigger points as demonstrated in the Backrub and Hand to Shoulder Blade tests.
Both tests were also painful at the extensors of the right forearm when supinating the hand and forearm. The Handgrip test was positive for trigger point activity in the brachioradialis and extensors of the right hand and fingers. Testing of pronation and supination against resistance was positive for active myofascial trigger points in the supinator and pronator teres, respectively.
This evaluation indicated to me that the right epicondyle pain was the result of continuous subclinical trauma to most of the musculature from the shoulder girdle to the hand. Lifting the unexpected weight of books and periodicals in a trash bag was simply “the straw that broke the camel's back.”
When Cathy first came in for treatment, she stated that her pain was as much as an 8/10. By the sixth treatment, the pain never rose above a 4/10. During those six treatments, continued release of active myofascial trigger points in the entire right arm, coupled with a home exercise program, was successful in decreasing the intensity of Cathy’s pain.
Although the six treatments reduced the right epicondyle pain by 50%, it seemed there was a piece of the puzzle I had not yet discovered. After much discussion and inquiry, I learned that Cathy not only slept face down, but also with her right arm overhead, under the pillow and with her elbow flexed to approximately 90°. This position keeps the brachioradialis, biceps brachii, pronator teres and extensors shortened, thereby perpetuating the pain.
After discussing various methods to change her sleep position, it was agreed that Cathy would sleep with her right arm inside a T-shirt instead of through the normal arm opening. This would prevent her from sleeping with her arm in the usual position that was perpetuating the pain. A week later, Cathy returned with very little pain during normal daily activities, including lifting. There was still pain upon palpation at the right lateral epicondyle, but pain no longer traveled up to the shoulder and down to the hand.
Although I was not able to relieve all of Cathy’s pain using Myofascial Trigger Point Therapy, I was able to greatly decrease her pain and return her to nearly normal function. Since the muscles were shortened and contracted due to myofascial trigger points, a long time before the actual injury, the chance of inflammation at the attachment of the tendon to the periosteum of the lateral epicondyle was considered. I sent Cathy back to the referring physician to be evaluated for the possibility of injection of an anti-inflammatory to resolve the remaining pain.