The Battle Of Wounded Elbow: A Case Study of Sorts
Taylor Weglicki, PT, DPT
I decided to take a bit of a different direction with this month’s article. I’ve had an interesting time lately working with some folks on elbow rehab, and beyond the typical “tendonitis” kind of stuff you hear about most frequently. One lifter in particular at NBS has had a hell of a time trying to get everything healed up, and it’s his path to healing that I’ve decided to make the focus of this article. Our outcome is not yet complete, as he’s not completely back to normal yet, but we’re heading that direction. Rehab is often an x+y=z path, but not everyone’s path is. As such, I think it is important to illustrate that when faced with a particularly difficult rehab, the most important thing is to keep trying to move forward. I want to provide a bit of history on the lifter (I have his permission, don’t worry), just to show how every case is not the same, and how important it is to start simple before you get to complex diagnoses (and attempt to major in the minors).
A History of Where He’s Been
The lifter in question competes in powerlifting. He’s competed in a few weight classes at this point, and in multiple meets to boot. He first approached me a few months ago with complaints of elbow pain when squatting. He wasn’t noticing it terribly when pressing, but squats were definitely a trigger for him. Luckily, he is body aware enough that he was able to determine that he was holding the bar more on his wrists than across his back, and subsequently increasing stress on his elbows. Doing a quick assessment, I noticed his external rotation was borderline nonexistent. In a range where you’d expect 90 degrees as “normal” he had maybe 30 degrees without substituting with thoracic extension to gain range. So, we started him on a generalized shoulder mobility program to address this. Should fix the problem right? Wrong.
Notice the difference in R and L arm positioning? Also how the bar almost is floating on his back?
At the second meet. Differential between R and L is more apparent here.
It’s harder to notice here, but his arms are better positioned, but he’s fighting to get elbows under that bar.
A Look at Where He’s Heading
So this is when things got interesting. We made huge gains in shoulder mobility, achieving closer to 60 degrees of external rotation cold, as well as improving overhead mobility. All things pointed to his pain should be improving. However, he continued to report pain with pressing. That seemed odd to me, so I began looking for soft tissue entrapment. Yvonna, our resident massage therapist, took up the challenge and began mashing all around shoulder and elbow to hit our typical compression points at the thoracic outlet of the brachial plexus, and also along the radial nerve through the tricep and proximal to the elbow. Upon palpation, our lifter had a band of tissue that seemed to be compressing the radial nerve along the proximal radial tunnel at the olecranon process. He continued with his shoulder mobility programming, and began reporting decreased pain when squatting, but it still remained when pressing. Interesting, right?
Thus, we began getting a little more aggressive. Our Lifter began getting dry needling done along parts of the tricep in an effort to release any of the tissues likely to be causing any source of compression. He began reporting relief of 2-3 days at this point, but then the symptoms and pain would come back. Not exactly the kind of result we were hoping for at this juncture. We tried a few more sessions but the result was the same. It was at this point that I began to sit down at the drawing board, so to speak, and take a look at the big picture at what really could be going on. What I concluded is less than exciting, but, once addressed, will hopefully give us a better look at what the depth of the injury actually is.
An Insight Into What Is To Come
From a neurologic standpoint, our Lifter has not experienced any loss of motor or sensory function in either arm. This would rule out any axonotmesis or neurotmesis type injuries. At this point, my thought is that when he squatted without the shoulder mobility he now has, that maintaining upwards of 500 lbs with regular frequency on both elbows, he experienced some traction injury to the radial nerve. This would make sense, as the flexed position you maintain when squatting is more of an open packed position for that joint (compared with lockout on the bench, for example). I’d classify the type of injury as likely a neuropraxia, which is the most mild form of nerve injury that luckily allows for full healing. It can take up to 6-9 week for full function to return from initial onset of injury, but therein lies our problem: our Lifter may have injured the radial nerve on both elbows MULTIPLE times before we discovered the issue. Thus, we currently can’t determine the exact healing time on the injury because of the lack of a definite initial onset.
As such, I’ve realized we might be beyond conservative measures that I as a PT can provide (along with my fellow therapists from different fields). Currently, I’m hoping to get this Lifter in to get a nerve conduction study to determine what the depth of the injury actually is. Thus, we could determine our time until we reach healing, and possibly get him back to functional levels faster than if we just continue on our current path. The key to success as a physical therapist is being able to understand differential diagnoses of a particular problem or injury, and know when to refer out for treatment. Hopefully we can get this Lifter to see a neurologist with a good understanding of sport related nerve injuries, and get him on the path to wellness.
That said, he will continue to maintain his mobility to prevent any further loss of function. That’s a given.
If you have questions, concerns, comments, or cries of outrage, let me know in the comments.
John Taylor Weglicki, PT, DPT