Tennis Elbow…Or is it?
A 36 year old woman sees her doctor about a persistent aching pain in her elbow. She does not recall a particular injury; but, as a mother of two children, she often ignores her own aches and pain until she cannot take it anymore. After a brief examination of her elbow, the doctor determines that she has lateral epicondylitis—tennis elbow. After exhausting conservative treatment for tennis elbow, she undergoes a procedure. Most unfortunately for everyone involved, the procedure goes terribly awry and the patient goes into complete cardiac arrest. After resuscitative efforts, this 36 year old mother is left with an automatic defibrillator implant and the same old elbow pain. At this point, this patient is referred to me. My examination reveals no pain to resisted wrist extension. However, the most significant findings are the positive Upper Limb Neurotension signs. My diagnosis is not lateral epicondylits. Rather, my diagnosis is nervous system sensitization of the upper limb quarter causing referred elbow pain.
Whoa! Let’s back this up a bit. What are Upper Limb Neurotension signs? We are accustomed to a popular Lower Limb Neurotension sign—the straight leg raise test. This lower limb test can be done with the patient is lying on her back and raising the straight leg up towards the ceiling. This maneuver creates tension in the lower limb nerves like the Sciatic nerve. If the nerve is sensitive from a disc herniation or stenosis, the angle that the leg can raise to is significantly impeded by pain along the nerve pathway. This common physical exam technique tests for lower limb nerve sensitization. Well, a nervous system exam can also include a series of Upper Limb Neurotension signs for the median, ulnar, radial, and even musculocutaneous nerve. Those who wish to learn more are encouraged to read The Sensitive Nervous System and Explain Pain by David Butler. According to David Butler, nervous system generated pain can masquerade not only as tennis elbow, but also a hamstring strain, an ankle sprain, and plantar fasciitis. Sometimes these pains do not resolve because no one addresses the nervous system involvement.
After insurance delays and more delays, this 40 year old mother of two is finally getting some relief with manual therapy that is concentrating on thoracic spine tractioning and mobilization. She also has a home exercise program centered around David Butler’s concept of nervous system “sliders and gliders”. Additionally, the defibrillator, a tremendous source of psychological distress, was removed. Although, the traumatic memories are still fresh and boil just underneath the surface of this 40 year old mother of two.
This initial elbow pain might have begun as a simple sensitization of the spinal cord at the cervical/thoracic junction or directly at the C6 nerve root. The trauma of prolonged resuscitation and chest compression expanded the sensitization to the thoracic spine because her arm pain became bilateral and more widespread. Recent literature has shown the effectiveness of thoracic manipulation for the treatment of cervical radiculopathy/radiculitis symptoms. The integral relationship of the upper thoracic spine with the lower cervical nerve roots is not to be ignored and should be addressed in anyone showing signs of central sensitization of the upper limb quarter.
Despite this dramatic scenario for a seemingly innocuous problem of tennis elbow, no one is to blame. The current medical system does not foster thorough examinations and complications do happen. This case should serve as a reminder to imagine all the possibilities before jumping to conclusions especially if it is match point.
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