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Case 23: Jin
Case Description
46 year old male with 4 month history of right lateral elbow weakness and pain. He is right handed and owns a home renovation company and is trained in carpentry work. It is not uncommon for him to get aches and pain in both arms and into his neck, depending on the job. He started a job 3 months ago with a very tight timeline and he was working 10-12hrs a day, 5-6 days a week. It started as a dull soreness in his right elbow , and then moved into his forearm and wrist. More recently he finds that he loses strength w hen he has to use a screw driver or perform any kind of repetitive twisting movement with his wris t, or with repetitive hammering. His general health is good and is on no medications. He plays re creational hockey once a week and in his late 30s he had shoulder injury on the right side. He was hit into the boards and he couldn’t raise his right arm higher than his shoulder. He saw a Physiotherapist who said he had separated his shoulder and helped him get his range and strength back. He went to physio for about 6 weeks and other than the bump on his shoulder, he doesn’t notice the shoulder. He is married and has a 12 year old daughter that he walks to and from school. He plays the guitar and likes to practice most days of the week. depending on his work schedule, for about an hour. He usually jams with some friends once a week for a couple hours. His daughter has started singing lessons and they like to practice together, which is increasing his playing time. After about 30mins of playing his forearm feels really tired and then after about another 30 minutes he gets a dull ache on the outside of the elbow. If he continues to play longer than 1 hour, his neck and both shoulder blades feel tired. Case Specific Questions: History:
- What is the impact of his previous shoulder injury? Jin has suffered a shoulder injury approximately 10 years ago (in his late 30s, now 46) and says he has a bump on his shoulder. This bump could represent an AC separation that had happened 10 years ago. The improper placement of the clavicle on the acromion can lead to altered scapulohumeral rhythm because scapular elevation needs to occur at the AC joint in upward rotation. Because of this, more control is required from scapular and rotator cuff muscles during scapular upward rotation. In addition, Jin’s job as a carpenter requires overhead proximal control which also recruits the scapular and RTC muscles. These muscles could therefore be overworked and could be leading to Jin using his forearm muscles for the lack of scapular control. Additionally, this also leads us to think that something proximal could be affecting the radial nerve distally where Jin has his symptoms.
Non surgical management of shoulder separation Analysis:
- What elements from the subjective and objective assessment helped you to develop your diagnosis? What elements were confusing or lead you towards another diagnosis? Our primary diagnosis of extensor tendinopathy was formed based on the subjective complaints of the patient. The patient reported aggravating factors of repetitive twisting or hammering resulting in right lateral elbow weakness and pain. These initial complaints are typical and consistent with subjective findings that precede a diagnosis of extensor tendinopathy as the pain is local to the compromised site and the functional movements affected are primarily performed through use of the forearm extensors. Additional reports of high work demand, repetitive nature of work, and previous short-term bouts of aches and pain with work-related tasks cluster with these reports of pain to further strengthen the hypothesis of extensor tendinopathy. The patient reports no neurological signs, such as tingling/ loss of sensation, and the pattern of pain and progression of disorder follows the typical pattern in extensor tendinopathy cases, thus pointing us to a primary diagnosis of extensor tendinopathy. However, there were some elements to the patient’s case that led us to other diagnoses. One of the difficult factors to piece together was the patient’s history of a shoulder separation, as well as reports of fatigue neck and bilateral shoulder blades during prolonged guitar playing. This presentation of painless weakness is less consistent with typical extensor tendinopathy and may suggest the presence of a nerve/ myotome involvement, especially if the weakness follows a nerve root distribution pattern. Additionally, although the patient reports weakness subjectively, it is difficult to conclude if weakness is due to nerve compromise, such as in radial tunnel syndrome, or a function of a disrupted tendon, resulting in decreased strength and endurance in this muscle group. These diagnoses are also likely to co-exist, so teasing apart specific aspects of the patient’s story to point us towards a specific diagnosis became more difficult without more objective testing Management planning:
- How would you treatment differ if you focused on 1 diagnosis vs the other? What clinical signs will you be looking for during the management phase to confirm your original diagnosis?
CLINICAL PATTERNS CASE REFLECTION TOOL
The clinical patterns reflection tool has been designed to enable your group to document your reasoning regarding your assessment and management approach for your clinical pattern. This tool will use the MSK Clinical Translation Framework to structure your exploration of your case. This document will be used by your classmates to prepare for your clinical patterns presentation, for study and clinical practice purposes. Please be clear in your responses and provide references as appropriate. INDIVIDUAL’S PERSPECTIVES a) Provide your response to the key questions listed for each of the 3 categories in this section.
- Individual problems - right lateral elbow weakness and pain
- Develops weakness with repetitive twisting or repetitive hammering
- Fatigue in forearm after 30 mins of playing guitar, dull ache on outside of elbow after 1 hour, and neck and R>L shoulder blades start to feel tired b) What else would you like to know about this individual’s concerns or history?
- Has he ever experienced this elbow pain/weakness in the past?
- Is this similar to the ache/pain he usually gets with work, or is this new/different?
- Did he get any forearm fatigue/neck and shoulder blade fatigue in the past while playing guitar?
- What hand does he use to play the guitar?
- How does he feel this pain/fatigue is impacting him or his ability to work? (level of concern)
- Does he find his symptoms to be distressing/upsetting/stressful?
- How quickly does the pain come on and how long does it take to go away?
- What is the pain’s pattern like in the morning and at night?
- How would he describe the pain, what would he rate the pain out of 10?
- Does he have any pain at rest?
- Does he have any numbness, tingling, or paraesthesia?
- Does he have any swelling or loss of range/movement?
- What are his primary concerns and what are his goals?
- Is he experiencing any pain at night? DIAGNOSIS a) Are there red flags present? If yes explain and what is the appropriate next step/referral?
- No red flags present:
- Mechanical pattern/mechanism of injury, doesn’t follow a visceral referral pattern, no cord signs/symptoms, no recent trauma b) Before using the flow chart for this section, based on the information in your case, what are the 3 most likely diagnoses? Depending on your case, these could be 3 competing diagnoses (not co-existing) or your case may have 1 diagnosis and 2 potential co-existing diagnoses.
- Extensor tendinopathy
- Radial tunnel syndrome (could be co-existing)
- Cervical radiculopathy Primary diagnosis:
- Extensor tendinopathy Differential diagnosis or co-existing diagnosis:
- Radial tunnel syndrome
- May be co-existing with primary diagnosis _Differential diagnosis or co-existing diagnosis:
- C6 Cervical radiculopathy c) Use the table below to summarize these 3 conditions to compare and contrast based on_ prevalence/incidence, typical population, pathophysiology, subjective complaints/severity of pain & disability and 5 key objective tests. The goal with identifying 5 key tests is to help you develop assessment clusters for common conditions. You are to review the literature and other reliable sources, to determine if a valid and reliable cluster exists for the condition and if not, what key pieces of information from the patient history and your assessment help you to identify this condition. In some cases patient history will provide more ‘key tests’ than your assessment ie: osteoporosis fragility fracture is a key piece of information vs ROM testing does not help you to rule in the condition. Please cite
Primary Diagnosis: Lateral epicondylitis/ extensor tendinopathy Differential or co-existing diagnosis #1: radial tunnel syndrome Differential or co-existing diagnosis #2: C6 Cervical radiculopathy Prevalence/Incidence ● Prevalence = 1-3% in general population annually (Donaldson,
● Prevalence = 2.97/100,000 cases of radial neuropathy in men, 1.42/100, cases in women (Kaswan, 2014) ● Incidence = 0.003% annually (Kaswan,
● The C6/C7 nerve roots are most commonly involved (Rainville et al., 2017) ● Incidence: Cervical radiculopathy affects about 4% of the population annually (Rainville et al., 2017) Typical Population ● Prevalence is equally in men and women (Faro & Wolf, 2007) ● Most prevalent in ages 35-50 (Karanasios et al., 2021) ● Occurs more commonly in working population (Shiri et al.,
● 50% of tennis players over the age of 30 are likely to present with this diagnosis at any stage of their playing career (Nirschl, 1973) ● Manual labourers, smokers, and those who repetitively bend/straighten their elbow (Winston & Wolf, 2015) ● More prevalent in women aged 30- years old (Moradi & Jupiter, 2015) ● Seen more frequently in individuals who repetitively pronate and supinate the forearm (Lutz, 1991) ● See increased incidence with specific work activities such as handling tools with the elbow at full extension, and regular use of a force of at least 1kg >10 times per hour (Lutz, 1991) ● Highest incidence of cervical radiculopathy in the 6th decade of life (Rainville et al.,
● See greater risk of cervical radiculopathy in individuals of white race, cigarette smokers, and individuals with past lumbar radiculopathy (Iyer & Kim, 2016) Pathophysiology ● More appropriately viewed as a tendinopathy due to lack of inflammatory cells in affected ● Entrapment and intermittent compression of the posterior interosseous nerve ● C6 nerve root irritation resulting in arm pain as well as sensory and motor
tissue (Waseem et al., 2012) ● 4 stages of progression (Waseem et al., 2012) ● Stage 1: Peritendinous inflammation/ tendinitis ● Stage 2-4 describe the presence of angiofibroblastic degeneration/ degeneration of the tendon (Waseem et al., 2012) ○ In later stages, tendon rupture and calcification of the tendon may occur (Waseem et al.,
● High eccentric and concentric forces at common extensor origin leading to microtears (Faro & Wolf, 2007) may contribute to the progression of these stages ● May be caused initially and progressed due to repetitive forces on a region with decreased healing potential due to hypovascularity and vascular dysfunction. (Faro & Wolf, 2007) ● Most common tendon involved is the extensor carpi radialis brevis (ECRB) (Waseem et al., 2012) (PIN) in the radial tunnel (Lutz, 1991) ● The nerve is compressed between the radial head and the supinator (Lutz,
● Pressure on the small myelinated and unmyelinated afferent fibers of the PIN that are associated with nociception and pain and temperature sensation (Naam & Nemani, 2012) ● Results in pain along the dorsolateral forearm, and wrist extensor muscle weakness (Lutz, 1991) symptoms (Rainville et al., 2017) ● Mechanical compression of the nerve root may occur due to herniation of the intervertebral disc, the formation of bony osteophytes that impinge on the nerve root as it exits the intervertebral foramen, and/or degenerative changes in the cervical spine with age (Iyer & Kim,
● Mechanical compression of the nerve root leads to local ischemia and nerve damage (Iyer & Kim, 2016)
Objective testing 5 Key tests: List 5 key objective tests that will help you rule in your primary diagnosis (ROM, Stability testing, Muscle strength/length testing, Special Tests, Functional Testing etc). For some patterns, key ‘test’ may actually be key pieces of information from the individual’s history, past or current medical history. Be specific with what & how you are testing and what response/ outcome/deficit you are looking for to help you rule in your condition.
1) ROM
● PROM: decreased PROM and/or pain with elbow extension, wrist flexion, ulnar deviation and pronation help rule in extensor tendinopathy ● AROM: Painful and possibly decreased (due to pain) AROM of wrist extension, supination, and wrist radial deviation help rule in extensor tendinopathy
- Muscle assessments: ● Cozen’s Test: Positive test is indicated by pain in the lateral epicondyle with resisted wrist extension (Karanasios et al.,
○ A positive test will elicit a sharp pain on the lateral epicondyle - rules in extensor tendinopathy ● Mill’s test: length-tension assessment of the wrist extensors (Waseem et al.,
- A positive finding would be indicated with pain at the lateral epicondyle
1) ROM
● PROM: pain with wrist flexion, pronation, and ulnar deviation due to traction placed on the nerve ● AROM: wrist extension, supination, and radial deviation would reproduce pain and symptoms
- Muscle assessments ● Mills and Cozens test: positive, reproduce radial tunnel symptoms
- Grip strength ● See grip strength weakness
- Palpation ● See pain/symptom reproduction with palpation at radial tunnel with main tenderness 3-5 cm distal to lateral epicondyle (Lutz,
- location of pain helps rule in radial tunnel syndrome vs. extensor tendinopathy
- Nerve conduction/ Neurodynamics ● No nerve conduction findings with dermatome, myotome, or reflex testing ● Pain/symptom reproduction with
1) ROM
● No changes in symptoms with elbow/wrist AROM/PROM ● Symptoms aggravated with C-spine AROM/PROM; predominantly extension and ipsilateral side flexion toward the painful side
- Muscle assessments ● Mills test: negative ● Cozen’s test: negative
- Grip strength ● slightly weak
- Palpation ● May see pain in palpation of lateral C-spine around C5/C level ● No pain with palpation of lateral elbow
- Nerve conduction/ Neurodynamics ● Positive ULTT (at least 3/4) ● Positive Wainner’s cluster ● Changes in sensation seen along the ipsilateral C dermatome ● Fatigable weakness in ipsilateral elbow flexors and wrist extensors
during the test - helps rule in extensor tendinopathy
- Suspicion for the condition would increase if clustered with pain on palpation (Tuomo Pienimäki et al.
- Grip strength assessment
- A positive finding would be indicated with a 5-10% decrease in grip strength in an elbow extended position compared to an elbow flexed position (Karanasios et al., 2021)
- Palpation
- Pain/tenderness over lateral epicondyle/ 1-2 cm from lateral epicondyle rules in extensor tendinopathy (Lutz,
- Palpate ECRB for tight bands or areas of tenderness - helps rule in extensor tendinopathy (Donaldson et al.,
- Neuroconduction/ Neurodynamics
- Findings WNL ULTT with radial nerve bias
Rationale for our primary diagnosis: Our primary diagnosis for this case is extensor tendinopathy. This condition has the highest prevalence in individuals aged 35-50 (Karanasios et al., 2021) and in individuals working in manual labour who perform a lot of repetitive elbow flexion and extension (Shiri et al., 2016). Jin is a 46 year old male who works in carpentry, which requires a lot of heavy lifting, raising arms overhead, hammering (flexion and extension), and repetitive actions contributing to repetitive loading of the extensor tendons. His history of overuse and repetitive movements through his work and leisure activities provide good support for the theory that his extensor tendons may have gone through repeated cycles of microtearing and improper healing leading to tendinopathy (Faro & Wolf, 2007). Jin’s pain pattern also supports a diagnosis of extensor tendinopathy as he is experiencing pain in the lateral elbow that can sometimes radiate into the wrist, with some referred pain into the C-spine and upper T-spine. This is typical of the pain location experienced with extensor tendinopathy (Faro & Wolf, 2007). Pain with extensor tendinopathy also comes on gradually (Waseem et al., 2012), which matches with the insidious onset of pain described in Jin’s case. This can also help us rule out a more traumatic injury such as a fracture or a ligamentous injury, as there was no specific mechanism of injury or trauma immediately preceding the onset of pain. Jin also reported weakened grip strength, which is a common subjective subjective complaint with extensor tendinopathy. Extensor tendinopathy often develops due to a recent change in load (Donaldson et al., 2017), and Jin described having recently been working very long hours due to an intense work project, as well as recent increases in his time spent playing guitar as his daughter has taken up singing lessons. Jin is not experiencing any paraesthesia or describing neuropathic pain characteristics, so we decided it was unlikely that his case involved radiculopathy. However, Jin’s pattern of pain and extensor muscle weakness does align with that seen in radial tunnel syndrome, which is why this was included as a potential coexisting diagnosis. b) Elaborate on the information in the differential diagnosis chart by addressing each differential or co-existing diagnosis. State why or why not you believe each differential or co-existing diagnosis is relevant to the case. Refer back to the 5 key tests and state how these tests will help to rule in co-existing diagnoses or rule out a differential diagnoses and when appropriate, what other tests would be helpful. Be clear about how likely (very likely, somewhat likely, less likely or not likely) your patient is to have one of the other conditions. Radial tunnel syndrome: Radial tunnel syndrome is a likely potential coexisting diagnosis for this case. Previous research has found that these two conditions may present together, due to their similar location and the common mechanism leading to these injuries (Kaswan et al., 2014). In cases where treatment for extensor tendinopathy has not been successful at resolving a patient’s symptoms, radial tunnel syndrome is often a comorbid contributor to their presentation (Kwaswan et al., 2014). Radial tunnel syndrome is also commonly seen in the manual labor population in individuals who use tools with the elbow at full extension and frequently pronate and supinate the forearm (Lutz, 1991). This condition also typically presents with pain in the dorsolateral forearm that may radiate proximally or distally, extensor muscle weakness without any sensory symptoms, and loss of grip strength (Lutz, 1991). All
of the key muscle tests used to rule in extensor tendinopathy will also show up positive for radial tunnel syndrome (Donaldson et al., 2017). Grip strength would also be affected with radial tunnel syndrome, as the radial nerve innervates the wrist extensors. One differentiating factor between these two conditions is the location of pain, as with extensor tendinopathy pain on palpation is typically localized to 1-2 cm away from the lateral epicondyle, whereas with radial tunnel syndrome this pain is usually 3-4 cm distal to the lateral epicondyle (Lutz, 1991). However, this is not a strong enough indicator to rule in or out either of these conditions. Finally, all nerve conduction tests including dermatomes, myotomes, and reflexes would be normal, however, neurodynamic ULTT with a radial nerve bias would be likely to reproduce radial tunnel symptoms, and greater changes in these symptoms with movement of distal segments (wrist flexion/extension) vs. proximal segments (neck side flexion) would help rule in radial tunnel syndrome compared to a C6 radiculopathy. An additional test that is useful for ruling in radial tunnel syndrome is the Rule of Nine Test. This is a test used to assess patients with non-specific elbow and proximal forearm pain that is helpful for diagnosing radial tunnel syndrome (Moradi et al., 2016). The proximal forearm is divided into 9 zones and pressure is applied to each area to differentiate between median nerve and radial nerve irritation. Finally, administering a local anesthetic and observing changes in symptoms can help differentiate between extensor tendinopathy and radial tunnel syndrome, as this will relieve pain from radial tunnel syndrome whereas pain from extensor tendinopathy would not be affected (Kaswan et al., 2014). Cervical radiculopathy: C6 nerve root A differential diagnosis of cervical radiculopathy is unlikely given this patient’s presentation. Cervical radiculopathy is a relevant differential diagnosis for this case due to the patient’s history of neck pain and the presentation of localized pain and weakness in the wrist extensors following the C dermatomal and myotomal pattern. However, this diagnosis is much less likely as Jin does not report any paraesthesia or neuropathic pain descriptors. The muscle assessments (Cozen’s test and Mills test) should all be negative with a diagnosis of C6 cervical radiculopathy, which would help strongly rule this in as these tests are all positive for the other two differential diagnoses. Grip strength may be affected with cervical radiculopathy, if held for long enough that fatigable weakness would begin to set in. Aggravation of symptoms with C-spine AROM/PROM would help rule in C6 cervical radiculopathy, with the most aggravation in cervical extension and ipsilateral flexion toward that painful side as this would cause the greatest compression on the C6 nerve root. No change in pain/symptoms with palpation of the dorsolateral elbow may also help rule in cervical radiculopathy as this may indicate that local tissues are not involved, and these symptoms may be more proximal in origin. Finally positive findings along the C6 dermatome and myotome and a diminished biceps tendon reflex with nerve conduction testing would help rule in C6 cervical radiculopathy, as well as a greater change in symptoms with proximal movement compared to distal movement during ULTT neurodynamics testing. An additional assessment that can be used to rule in cervical radiculopathy is Wainner’s cluster, where we would expect 3/4 of the following tests to be positive: Spurlings, ULTT, distraction test, and cervical rotation test.
may suggest a neuropathic involvement due to the radiating pattern of pain/ dysfunction, it also is a symptom of our primary diagnosis (extensor tendinopathy), which is likely to cause a reduction in grip strength and/or endurance, which are tasks that the patient is involved in frequently due to his job. The patient also does not report any neuropathic signs i.e. pins/ needles, tingling, change in sensation; thus reducing the suspicion of neuropathic pain involvement. Based on the patient’s subjective complaints, it is evident that the pain is elicited with movements, such as twisting, gripping, hammering, and playing the guitar. As the pain is typically associated with a direct aggravator, the issue is most likely mechanical in nature. Finally, the issue appears to be moderately sensitized, as the patient still is able to complete their work tasks and duties and can participate in hobbies. However, they report that the pain has progressed and has spread down their forearm and wrist, and that the pain has been limiting his ability to fully participate in his tasks. c) Psychosocial considerations (yellow): Using the information provided in the case, identify the cognitive, affective and social factors (helpful and unhelpful) that will influence the outcome of the case. Rate each from low to high and provide your justifications. Cognitive factors: Getting aches and pain is common for him, thus he might push through the pain. However, he doesn't seem to have any negative thoughts or beliefs about pain and has had an injury in the past and has had physiotherapy for it. (Rating: Low) Affective factors: He doesn't seem to outwardly have any fear, anger, anxiety, etc related to his injury or pain however, his ability to do his job and play the guitar might cause him to have stress or frustration which is not helpful. (Rating: Medium) Social factors: His hobbies include playing the guitar which he isn't able to do with his injury and it's one way that he spends time with his daughter as well; thus, impacting his ability to heal. However, he does seem to have a supportive family which is helpful. (Rating: Medium)
d) Work considerations (blue and black flags): Using the information provide in the case, identify the workplace factors (helpful and unhelpful) that will influence the outcome of the case. Rate the overall influence for this section from low to high and provide your justification. Work functional activities/ duties are the primary aggravators that elicit the patient’s pain (i.e. repetitive twisting of screwdriver, hammering). The patient has a high work demand of 10-12 hour days, 5-6 days a week. Overall, his work considerations have a high influence on the outcome of his injury. Continuing to do the same jobs (hammering, screw driver) will continue to aggravate his injury, which is likely to negatively impact his recovery and could lead to a vicious cycle of reaggravating his injury. e) Lifestyle considerations: Using the information provide in the case, identify the lifestyle factors (helpful and unhelpful) that will influence the outcome of the case. Rate the overall influence for this section from low to high and provide your justification. The patient has an active job as a carpenter, and plays hockey once a week. He is not reported to have any co-morbidities or medications, and is in good general health. Overall, this will have a low influence on the individual’s overall outcome. He has experience of being active and has no lifestyle factors that limit us from therapeutic exercise. f) Whole person considerations: Using the information provide in the case, identify the general health and co-morbidities that will influence the outcome of the case. Rate the overall influence for this section from low to high and provide your justification. The patient is in overall good general health. They work in an occupation that is very active, play hockey once a week, and walks their daughter to and from school everyday. The
● influence of their personal, social, occupational, recreational contextual factor ● where will you get the most ‘evidence’ to rule in/rule out diagnoses from ie: patient history vs objective assessment or both ● Will you take every assessment test to end of range? ● Will you apply over pressure? Into pain? ● Will you be trying to reproduce pain with some or all of your tests? ● Are you testing each individual muscle or a group or direction or functional? RIM vs MMT vs functional with observation optimal vs suboptimal loading patterns (FMS) ● Are there functional movements that are important for this individual and/or condition that you also want to assess? Assessment rationale: Jin is a 46 year old male presenting with a 4 month history of chronic wrist extensor tendinopathy resulting in nociceptive pain and extensor muscle weakness, caused by overuse and increased load on the common extensor tendon with carpentry work. During the initial assessment, since this is a chronic condition and his symptoms are mild-moderately irritable, objective testing will be taken to the point of purposeful symptom provocation. We do not have to worry about reinjury or tissue damage as this condition is caused by repetitive overloading and is unlikely to be significantly flared from short, discrete objective tests. Our initial assessment will focus on ruling in and out our differential and potential co-existing diagnoses through active and passive mobility assessment, specific muscle tests, palpation, grip strength, and nerve conduction/neurodynamic assessment. We will also be exploring how changes in scapulothoracic positioning and function may impact the patient’s symptoms to evaluate whether his previous AC joint injury is impacting his presentation, and determine whether this is something that needs to be addressed in our management plan as well. The patient’s grip strength and patient-rated tennis elbow evaluation (PTEE) scores will be re-assessed over the course of treatment to assess for the effectiveness of our intervention and guide any further assessment of additional contributing factors (radial nerve involvement, scapulohumeral impacts). We would expect to see improvements in wrist extensor muscle strength, grip strength, and a reduction in dorsolateral elbow symptoms, and education will be provided regarding load management throughout the duration of treatment as well as to prevent re-occurrence. b) Management approach: Current literature suggests that recovery after tendinopathy will take at least 12 weeks and depends largely on loading intensity (>70%) (Bohm, 2015). Our patient’s intervention will be largely based on symptom monitoring. Progression will be based on pain, pain should either be the same or less to progress in exercises. Weeks 1- In the first 1-2 weeks of this patient’s management will focus on pain management. The patient’s pain largely came on because of his work activities and continues to be aggravated during them. Therefore, education first needs to be given to the patient about load
management and for him to consider performing less aggravating jobs at work and less aggravating everyday activities during this time (i.e. guitar playing for long periods). Realistically, the individual may not be able to reduce his workload i.e. from 5-6days/wk to 4 days/wk. Because of this, pain management is key in the first 1-2 weeks of the treatment. The pain should not increase, but may stay the same at this point. Low level laser therapy at 904nm wavelength has shown short term pain relief (Bjordal et al., 2008), therefore we will trial this modality with this patient in the first week to help with pain management. This modality will be used in the first 1-2 weeks only or when the patient has increased pain because it does not offer long term benefits. In addition, we will start with low load isometric exercises for the wrist extensors. It is assumed Jin will present with altered scapulohumeral rhythm, therefore rotator cuff exercises with shoulder below 90 degrees will be started during this phase (Alizadehkhaiyat et al., 2007). The current literature shows that pain may not decrease during this time, but it should not exceed 5/10 during exercise and/or the morning after (Silbernagel, 2007). Goals: education (avoiding over use, taking breaks, light movements, correct posture, etc), load management, ensure pain does not increase, isometric strengthening, mobilizations and increase ROM, shoulder RC stability (below 90deg) Weeks 3- In weeks 3-5 we will focus on concentric strengthening of wrist extension. It is expected that pain will stay the same at this point. In addition, we will also add grip strength in the clinic with the patient. Once Jin has given feedback on symptoms after grip strength exercise, then we will assign grip strength as a home exercise. Manual therapy will include MWM lateral glides and the patient strengthening in this position which should be pain free. If the MWM lateral glides are pain free then we will consider taping the patient’s radius into a lateral glide. At this point, we will also address the neuro symptoms the patient is having by giving them a radial nerve floss at home and passively in clinic by the therapist (Drechsler et al., 1997). At this phase we are also progressing the patient’s shoulder exercises to shoulder stability at 90 deg. The counterforce stap will be used less by the patient during this phase (every 2nd day → once/wk). By week 5 it is expected that the patient’s muscle tone, range, and symptoms are better controlled therefore we would move to physiotherapy 1x/week. Regress to physio 1x week by 5th week Goals: ensure pain does not increase, progress strengthening to isotonic focus on restoring concentric strength, introduce grip strengthening exercise, addressing neurodynamic symptoms, start weaning off counterforce strap, progress shoulder RC stability (at 90deg), continue mobilization and stretching Weeks 6- In this phase, we want to continue strengthening the extensor muscles, using progressive loading. With progression, we want to make sure the patient does not experience pain while doing the exercises. Overall, pain should be decreasing at this moment. ROM should also be
