2 years and 3 elbow injections, all for what?

I recently had this case:

Subjective History: 87 y/o female presents with right elbow pain.  It has going on 2 years or more.  She has had all of the injections should could have in the right elbow (at 3), and now she is told the elbow pain is from the neck.  She has also tried bracing and was treated by a physician for her wrist, which did not help (she was prescribed a wrist brace but it did nothing for her).  Sometimes the pain is so bad that she can’t stand it.  She said her hands can get numb too.  She is also trying to recover from shingles (had in February) that affected under the right arm and across chest.  She cannot elevate the right arm now due to pain from shingles.  She was seeing Dr. ***, who referred to Dr. ^^^.  The last injection that was given gave her relief for 2-3 months.

Relieves symptoms: hot shower.  She denies finding a comfortable position for arm when pain arises.

Location of Arm and Elbow Pain: Mostly in the right elbow but has pain all the way from shoulder to fingers on right side. Pain is aggravated with the following activities or positions: She does not know.  She said sometimes it just “hurts” and does complain of the fingers to get numb. Pain Quality: Dull and just hurts, almost to the point where she can’t stand it.

Pain rating: 5/10 currently, 0/10 at best, 10/10 at worse that can take 1-2 days to ease.

QuickDASH: 65%

Objective
Elbow: Full, pain-free elbow AROM and PROM

Cozen’s Test – Negative

Mill’s Test – Negative

3rd finger extension (ECRB) MMT: Negative (same with 2nd digit for ECRL)—negative for pain and weakness

Cervical Active ROM
Cervical Extension: 20 degrees, Cervical Flexion: 30 degrees with pulling at CTJ (no reproduction of concordant signs), Cervical L. Rotation: 40 degrees, Cervical R. Rotation ROM: 40 degrees

Technically you should put overpressure to ROM to rule-out the neck…but come on she was 87.

Shoulder Active ROM
Shoulder elevation Active Range of MotionL 70 degrees
**Patient says she has had trouble with shoulder elevation since shingles, which came on over a year after her current symptoms**

Considering lack of motion, I did not test functional rotation moments and only tested MMT in neutral by side (in 90/90 position):

Infraspinatus/teres minor: 4 /5
Weakness noted Bilaterally
Subscapularis: 4+ /5

Grip Strength:
R: 30#, L: 25#. No pain.

Note: marked TTP at lateral epicondyle but biggest finding==>Reproduction of concordant symptoms in elbow with ischaemic compression over the infraspinatus and teres minor.

Treatment:

Simple: Ischaemic compression with wiggle using middle phalanx for 20-30 seconds over infraspinatus and teres minor MTrP.  It reproduced symptoms initially but abolished them upon completion.  As taught by the Dry Needling Institute, the main MTrP for infraspinatus muscle is frequently 1/3 of the distance from the middle of the spine of the scapula along a line to the inferior angle of the scapula—so no need to push all around the shoulder—the Institute teaches you specifically where the highest percentage of pain generators are located. This could have been addressed with dry needling too, but unable to perform without MD order in VA. Exercise prescribed: S/L scapula retraction and S/L shoulder ER with towel roll.

Follow-up at 2nd visit:

Right UE symptoms STILL 0/10 but 2/10 at worse in last several days.

SOAP note Impression: Patient’s symptoms have been complex and very irritable for the last 2 years at least, with only short term relief from medical management.  From further assessment today, it appears patient’s symptoms are arising from shoulder girdle complex (see objective above) > cervical spine, but I do not see marked dysfunction of the right elbow (all negative lateral epicondylitis tests) other than tender to palpation at lateral epicondyle.  Considering she did not have symptoms today other than reproduction at MtRPs in the shoulder, we will continue to re-assess our treatment approach.  She is a good candidate for PT intervention.

Blog Impression: Basically no active or passive movement reproduced concordant symptoms (again did not put overpressure at joints but don’t typically for this age).  I was not satisfied with the medical diagnosis of lateral epicondylgia based on 1. Negative 3rd digit (ECRB) weakness and pain & 2. Negative pain and weakness with grip testing.  Only diagnostic sign was tenderness over the lateral epicondyle, which is not unusual for mostly anyone and did not give me any more clinical utility.  She has marked limitation in shoulder girdle function, which was interestingly limited after the onset of symptoms started 2 yrs ago.  I felt her symptoms (wooo nocioception coming from the shoulder) that referred into the upper extremity.  Now one thing I do not know is if she had positive lateral epicondylalgia tests that led to steroid injection initially.

Bottom line: Send to a physical therapist EARLIER in the care for a full musculoskeletal assessment.   A PT could have picked up symptom arising more proximal and actual lead to treatments to abolish symptoms, then a program to address the underlying dysfunction.  This patient could have avoided 3 cortizone injections and not lived with right upper extremity pain for 2 yrs with only relief in short duration by a hot shower.

My question to you’ll:

1. Why do you think the cortizone injection worked? What would be some of the mechanisms?  

2. What led me to the infraspinatus and teres minor muscles specifically?

3. Would you have treated more her cervical spine vs shoulder? Why or why not?

4. What other manual and/or exercise treatment would you have given for day 1?