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Hyperventilation: an under-recognised condition

Elbow pain

In the last of our trauma clinics, Mr Fares Haddad details a case of tennis elbow

Case history

A 37-year-old right-handed healthy man presented with a three-month history of increasing lateral elbow discomfort. He had vague pain whenever he engaged in any physical activity. He worked as a printer and found lifting heavy items uncomfortable.

The background dull pain that he had was associated with occasional episodes of sharp pain whenever he was lifting in certain positions. He had no swelling or locking symptoms in his arm. There were no neurological symptoms. He had been in the same job for 10 years although some of the printing presses had recently been changed. His sporting activity involved going to the gym. He occasionally played softball with his children and work colleagues and had recently started playing in weekend competitions. He did not have diabetes and had no relevant medical disorders.

Analysis

On examination the patient looked well. There was no gross asymmetry in his arms and his muscle bulk was consistent with a slight increase on the right side, which was consistent with his right hand dominance.

There was symmetrical movement in his shoulders and no local tenderness. There was an excellent range of cervical movement and there were no obvious cervical tension signs. An examination of his elbows revealed there was a full range of pain-free flexion, extension, pronation and supination.

He had a subjective feeling of discomfort over the lateral humeral epicondyle and the common extensor origin. This was increased by palpation. There was no obvious palpable effusion in the elbow joint. But the dorsiflexion of his pronated wrist against resistance ­ the pronation dorsiflexion test ­ recreated some of his pain.

There was no abnormality of his wrist or hand and no neurovascular deficit. Plain X-rays of his elbow were unremarkable.

Diagnosis

An ultrasound scan confirmed synovitis of the common extensor origin. A diagnosis of lateral epicondylitis was reached.

Lateral epicondylitis, or tennis elbow, is the pain and discomfort associated with 'inflammation' at the extensor muscle group origin at the lateral humeral condyle insertion, principally in the extensor carpi radialis brevis tendon. Lateral epicondylitis is characterised by pain and local tenderness over the lateral epicondyle of the elbow. It is exacerbated by resisted wrist extension and tends to worsen when the elbow is extended. While the classic history is of a tennis-related injury, it can also be caused by unaccustomed activity, such as house painting or carpentry. There is usually no need for ultrasound or magnetic resonance imaging to confirm the diagnosis.

Differential diagnosis

Medial epicondylitis, or 'golfer's elbow', is less common but tends to be more difficult to treat. The affected area is at the interface between the pronator teres and flexor carpi radialis origin at the medial humeral condyle.

Medial epicondylitis is characterised by pain and tenderness at the flexor-pronator tendinous origin. Careful evaluation is important to differentiate medial epicondylitis from other causes of medial elbow pain such as ulnar collateral ligament instability or ulnar nerve pain/instability.

Treatment

The most popular methods to treat tennis elbow include rest, non-steroidal anti-inflammatory agents, a counterforce brace/strap, orthotic, and steroid injections. It is usually a good idea to engage in a prolonged course of non-operative treatment (nine to 12 months) because the majority of patients will get better. Modifications to their equipment, such as a more flexible racket, larger racket head or larger grip, may also prove to be beneficial.

The patient in this case study underwent six weeks of local physiotherapy treatment with a reassessment of his grip and technique when playing softball. He suffered no recurrence of the symptoms. One of his friends advised using a supportive band around his forearm and that also helped him. He was made aware that there was a still a potential risk of recurring symptoms, particularly with increased activity levels, and he was advised that he might potentially require injections, which could be administered directly or under ultrasound guidance if his symptoms recurred.

Steroid injections are one of the most popular methods used, with a high success rate. Patients who achieve pain control after only one cortisone injection successfully avoid surgery

88 per cent of the time, whereas those requiring multiple injections avoid surgery only 44 per cent of the time.

Some studies have suggested it may be the actual method of injecting itself rather than what is injected that helps relieve symptoms. They advocate a 'peppering' technique whereby after the needle is inserted into the tender area, multiple small injections are performed by withdrawing, redirecting and reinserting the needle without emerging from the skin.

Low-intensity laser irradiation was fashionable as a treatment for epicondylitis in the late 1990s. Lithotripsy shock wave therapy is currently in vogue as a treatment. It appears to be safe with no device-related, systemic or local complications.

Surgery is required in less than 10 per cent of cases. Surgical options for lateral epicondylitis include the release of the common extensor origin from the lateral epicondyle and/or debridement of the pathological granulation tissue. In medial epicondylitis, debridement of the medial epicondyle and reattachment of the flexor-pronator group can be undertaken in recalcitrant cases.

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