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A-33 Clinical Case Slide - Upper Extremity I

Medicine & Science in Sports & Exercise: May 2013 - Volume 45 - Issue 5S - p 19–20
doi: 10.1249/01.mss.0000433608.28556.a7

May 29, 2013, 9:30 AM - 10:50 AM

Room: 117

142 Chair: John P. DiFiori, FACSM. UCLA Division of Sports Medicine, Los Angeles, CA.

(No relationships reported)

143 Discussant: Holly J. Benjamin, FACSM. University of Chicago, Chicago, IL.

(No relationships reported)

144 Discussant: Bobby Huggins. Kaiser Permanente, Fontana, Fontana, CA.

(No relationships reported)

145 May 29, 9:30 AM - 9:50 AM

Elbow Pain-badminton

Paripati Sharat Kumar1, Rupa Paripati2. 1Apollo Health City, Hyderabad, India. 2Health First, Hyderabad, India.

(No relationships reported)

HISTORY: The patient is a 45 year old otherwise healthy, right hand dominant male, who presents with a year history of progressive right-sided elbow pain. Pain is centered over lateral epicondyle radiating to right shoulder and forearm region. Pain was aggravated on lifting weights. There is no associated neck pain or paraesthesia. He gives no history of weight loss or fever. He also gives history of three local steroid injections without any long lasting relief. Despite physical therapy and injections pain worsened stopping him from playing badminton.

PHYSICAL EXAMINATION: On gross inspection, he had mild swelling over lateral aspect of elbow with minimal wasting. He has tenderness over lateral epicondyle. Resisted dorsiflexion of wrist caused severe pain. His neurological examination was normal


1.Lateral Epicondylitis

2.Paneer Disease


4.Cervical Disc Disease

5 Loose Body


Right Elbow X Rays- AP and Lateral - normal

Cervical Spine X Rays- AP and Lateral - normal

Blood work

CBC, ESR normal

MRI suggestive of loose body in the lateral aspect of elbow joint and tennis elbow


Loose Body Right Elbow


1.Removal of large loose body

2.Tennis elbow release

3.Physical therapy focused on stretching and strengthening exercises

4.Post therapy, patient without ROM limitations or motor strength deficits

5.Patient returned to play Badminton successfully in 3 months

146 May 29, 9:50 AM - 10:10 AM

Uncommon Acromion Fracture - Cyclist

Hans J. Swart1, Dina C. Janse van Rensburg2. 1Private Practice, Pretoria, South Africa. 2University of Pretoria, Pretoria, South Africa.

(No relationships reported)

HISTORY: A 51-year old recreational male mountain bike cyclist was injured during training when he fell and hit the ground with his right shoulder. Immediately following the accident he presented to a general practitioner. He was treated for pain and discomfort with analgesics, anti-inflammatories and a shoulder sling. He presented 12 days later at our rooms with complaints of pain in the right scapular region and severe discomfort with shoulder movements.

PHYSICAL EXAMINATION: There was swelling and tenderness over the right scapular region. He was neurovascularly intact. Due to severe pain, active and passive movements were difficult to perform.


1. Rotator cuff injury.

2. Humeral fracture.



- Fracture of the base of the acromion extending through the spine of the scapula. (This is quite an uncommon finding.)


Displaced, unstable fracture of the base of the acromion.


1. Treated by orthopedic surgeon.

2. Open reduction and internal fixation (ORIF) was performed entailing a screw and plate fixation.

3. Immobilized in a sling for 6 weeks.

4. Careful passive mobilization started after 2 weeks.

5. Final follow-up after 12 weeks showed good union of the fracture and normal functioning of the shoulder.

147 May 29, 10:10 AM - 10:30 AM

An Novel Approach to Shoulder Pain in an Active Septuagenarian

Eugene Hong, Smitha Ballyamanda. Drexel University College of Medicine, Philadelphia, PA.

(No relationships reported)

HISTORY: 72 year old male, TR, 1 year history of right shoulder pain Pain at rest, with overhead reaching and driving Tried physical therapy, 2 cortisone injections, glenohumeral injections with hyaluronic acid Pain wakes from sleep Denies parasthesia or distal weakness Retired Merchant Marine, worked shipyard for 35 years Runs 4 days a week and weight trains weekly Has seen two shoulder surgeons who both recommended shoulder replacement.

PHYSICAL EXAMINATION: C-spine non-tender, full active range of motion (ROM), negative Spurling’s Neurovascularly intact upper extremities Right shoulder:

Mild atrophy supraspinatus musculature Non-tender Active ROM: abduction 0-100 degrees, forward flexion 0-135, internal rotation T10 Passive ROM: external rotation 45 degrees Rotator cuff strength 4+/5 supraspinatus with pain Positive Neers, Hawkins.

DIFFERENTIAL DIAGNOSIS: Right shoulder rotator cuff tendonopathy (RCT)

Right shoulder glenohumeral degenerative joint disease (DJD)

TEST AND RESULTS: Shoulder ultrasound: echogenic changes consistent with RCT but no full thickness tear or calcifications Shoulder MRI: RCT and glenohumeral DJD.

FINAL/WORKING DIAGNOSIS: Right shoulder rotator cuff tendonopathy and degenerative joint disease.

TREATMENT AND OUTCOMES: Subacromial steroid injection with mild relief shoulder pain, no change in ROM Percutaneous needle tenotomy (PNT) and autologous plasma rich platelet (PRP) injection right shoulder rotator cuff tendon performed. Placed in sling 2 days. Advised avoid ice, NSAIDs, and upper extremity weight training. Tramadol for pain control At 2 wk follow up, no night pain and improvement in driving comfort . Denies symptoms with dressing, bathing. Denies new symptoms. Start ROM exercises and ok to start running At 4 wk, able to hold objects in his right hand without discomfort. Physical therapy for improving ROM and progressive strengthening At 8 wk, continued improvement with activities of daily living; continue physical therapy At 12 wk, TR notes overall improvement in comfort and function, though still reports some shoulder pain. Improved active ROM abduction 150 and forward flexion 150, PROM external rotation 60, strength testing. Further treatment possibilities include repeat PRP/PNT of rotator cuff and glenohumeral PRP intra-articular injection

148 May 29, 10:30 AM - 10:50 AM

Forearm Pain - Recreational Softball player

William R. VanWye1, Donald L. Hoover2. 1Active Physical Therapy, Hilliard, OH. 2Western Kentucky University, Bowling Green, KY. (Sponsor: Alan Mikesky, FACSM)

(No relationships reported)

HISTORY: 24-year-old female (pt) referred to a physical therapist (PT) by an orthopaedic physician (MD), diagnosis (DX) of left elbow sprain/strain with contusion. Pt reported lateral elbow & wrist pain after slipping on wet floor and falling on her outstretched upper extremity (UE). Pt’s UE was positioned posterior to her trunk, elbow & wrist extended. The pt had immediate diffuse pain, swelling, and compromised UE range of motion (ROM) which severely affected her activities of daily living (ADL), work and ability to participate in recreational softball.

PHYSICAL EXAMINATION: Worst pain labeled as sharp and rated 10/10, resting pain labeled as dull and rated 7/10. High ADL disability, complete work disability. Limited ROM of the elbow & wrist diffusely, severe impairment in wrist extension & supination. Manual muscle testing of the elbow & wrist was rated 3-/5 with poor left grip strength via hand dynamometer at 13 pounds, right at 41 pounds. Bony & soft-tissue palpation via tactile & tuning fork at length of the radius reproduced severe pain. Orthopedic testing revealed positive elbow extension test (see image):


1. Elbow sprain/strain, contusion

2. Occult elbow fracture


1. X-rays deemed negative, radiologist noted “extensive swelling.”

2. Abnormal pain pattern for sprain/strain or contusion

3. Significant ROM deficits with abnormal joint end feels

4. Reproduction of severe pain with boney palpation at the length of the radius

5. Positive elbow extension test

FINAL/WORKING DX: Suspicious for occult elbow fracture


1. MD plan of care (POC): Continue PT treatment, pain management via NSAIDS and, if no progress after 4 weeks, MRI indicated

2. PT POC: Pain management, limit pain-provoking activities, and address impairments & functional limitations

3. PT progress summary at 4 weeks: Continued ROM & strength impairments with high pain levels, high ADL disability, complete work disability, positive elbow extension test

4. MD updated POC at 4 weeks: MRI ordered and pt DX with radial head fracture

5. MD treatment: stabilization orthosis and continuation of home exercise plan

6. PT follow-up at 2 years pt reported: no follow-up care, ongoing popping & catching of the elbow joint, and mild disability with ADLs, work, and recreation

© 2013 American College of Sports Medicine