Elbow Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 45y/oRHD male with gradually worsening right elbow pain over several months. 3-7/10 lateral elbow pain. Worse with activity. Improved with rest. No noted history of repetitive activities or tennis. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Skin / Lymph: normal, no scars
Tenderness: lateral epicondyle reproduces pain
Resisted wrist and finger extension with the elbow in full extension exacerbates pain
No pain on resisted suppination (PIN irritation).
ROM (R/L): 0-135 / 0-135
Suppination (R/L): 80 / 80
Pronation (R/L): 80 / 80
Negative Tinel's at the Cubital tunnel
no generalized ligamentous laxity
No numbness with elbow maximally flexed and wrist extended
Subjective normal M/U/R distal sensation
2+ Radial pulse
Xray: no osseous deformity, no calcifications around lateral epicondyle
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
activity modifications
ICE
Counterforce brace
NSAIDS
Information sheet given
Follow-up 6-8 weeks