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Case Study: Patient with Elbow Pain Self-Misdiagnoses

Our Patient


Our patient is a 57 year-old barber and recreational bodybuilder complaining of “tennis elbow” that would not go away. The pain worsened while lifting weights at the gym, and he reported pain and stiffness after waking up in the morning.  He had previously had physical therapy, and an orthopedist had blindly injected a steroid into the elbow extensor attachment, but the pain persisted.   

The Challenge


Special orthopedic tests that provoke tennis elbow symptoms did not reproduce the patient’s elbow pain. He was tender over the Frohse arcade of the radiocapitellar joint, where the supinator muscle thickens.The radial nerve travels above the radiocapitellar joint and divides into two branches near the Frohse arcade. We were able to palpate multiple fascia densifications in the forearm.

Our Diagnostic Process


We visualized the structures of the elbow and forearm using high-resolution diagnostic ultrasound. 

Our examination revealed:

  • Moderate thickening of the extensor carpi radialis brevis (ECRB) tendon
  • Effusion (fluid accumulation) in the radiocapitellar joint
  • Normal appearance of the radial nerve and its posterior interosseous branch
  • Small osteophytes (bone spurs) on the capitulum of the humerus
  • Normal appearance of other tissues and structures

 

Our Diagnosis 


We concluded that the patient did not have lateral epicondylitis (tennis elbow), but rather was in the early stages of arthritis of the radiocapitellar joint, along with distortion of the surrounding fascia.

Our Treatment Plan:

We performed manual Stecco fascia manipulation therapy, combined with radial shockwave therapy on the affected tissues. We also performed eight sessions of extracorporeal magnetic transduction therapy (EMTT) to reduce inflammation of the synovial capsule. After the patient’s pain had subsided by 70%, we followed up with ultrasound guided dry needling to release myofascial trigger points, and manual mobilization to restore elbow mobility.

 Conclusion


Not all pain near the lateral epicondyle of the elbow indicates tennis elbow. 

Multiple other conditions can mimic tennis elbow, such as:

  • Elbow osteoarthritis
  • Entrapment and compression of the radial nerve and its branches
  • Proximal radio-ulnar impingement
  • Bicipito-radial bursitis
  • Lateral collateral ligament sprain
  • Synovial PLICA entrapment

 

Differential diagnosis is key to successful treatment. Every pathology requires a unique treatment approach, and many patients present with multiple pathologies. In most cases, findings from the clinical examination should be confirmed with diagnostic imaging. 

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

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Complete tear of rectus femoris
with large hematoma (blood)

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Separation of muscle ends due to tear elicited
on dynamic sonography examination

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