Medial Epicondylitis Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 45y/o male with gradually worsening right elbow pain over several months. 3-7/10 medial elbow pain. Worse with activity. No noted history of repetitive activities or throwing or golf. 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:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: just distal to medial epicondyle
Resisted wrist flexion and forearm pronation exacerbates pain
No pain on resisted suppination (PIN irritation).
ROM (R/L): 0-135 / 0-135
Suppination (R/L): 90 / 90
Pronation (R/L): 90 / 90
Negative Tinel's at the Cubital tunnel
No numbness with elbow maximally flexed and wrist extended
no generalized ligamentous laxity
subjective normal M/U/R distal sensation
2+ Radial pulse
Xray: no osseous deformity, no ulnar traction spurs, no medial collateral ligemant calcifications
MRI: none
ASSESSMENT: Medial Epicondylitis (726.31)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
activity modifications
ICE
Physical therapy
Counterforce brace
NSAIDS
Information sheet given
Follow-up 6-8 weeks