Author: Ricardo Colberg, MD
Co Author #1: Kenneth Mautner

Patient Presentation:
A 59 year old right-handed male presented to our clinic with right lateral elbow pain of two years duration. The pain was described as severe, stabbing, and gradually worsening. Pain was intermittent, exacerbated with playing tennis and performing functional activities of daily living, and radiated down the dorsoradial side of his forearm, causing weakness of his grip strength and insomnia. The patient attributed his symptoms to overuse from playing tennis.

History:
He originally addressed the injury by: using a tennis elbow brace, modifying his tennis racquet by increasing his grip size, changing to soft multifilament strings at a medium range tension, and taking tennis lessons. His primary physician later prescribed a course of ibuprofen 800mg three times a day for 10 days and recommended stretching exercises.
Six months later, his pain had worsened. He sought care with a local physiatrist who gave him a corticosteroid injection at the point of maximal tenderness and prescribed diclofenac (Flector) patches plus physical therapy, including ice, ultrasound, stretching and strengthening exercises twice a week for 6 weeks. He had symptom relief for about three months, but symptoms soon resumed. He was then prescribed diclofenac cream and eccentric exercises and was instructed to stop playing tennis.
Unfortunately, he developed an allergic skin reaction to the diclofenac cream and did not experience significant pain relief. A musculoskeletal ultrasound was performed and reported heterogeneity and decreased echogenicity in the common extensor tendon at the lateral epicondyle consistent with tendinosis as well as a small calcification within the common extensor tendon. A methylprednisolone (Medrol)taper was prescribed for the allergic reaction. He began a second session of physical therapy, which included: warm compresses, electrical stimulation, and eccentric exercises twice a week for 6 weeks. The patient was educated about the role of eccentric exercises in healing this condition and encouraged to work as hard as possible with these exercises.
After six weeks of physiotherapy, the improvement was minimal. The treating physician ordered a rheumatologic work-up with blood tests, referred the patient to a rheumatologist for further evaluation, and prescribed a vitamin D supplement. The rheumatologic evaluation was negative, so the rheumatologist diagnosed the patient with a "chronic lateral epicondylitis" and injected him a second time with a corticosteroid medication at the point of maximal tenderness. Once again, the injection provided significant improvement, but it only lasted about three months.
As the pain recurred, he was referred to another physiatrist for dextrose-based prolotherapy injections. He received two injections at the point of maximal tenderness 6 weeks apart, each one followed by physical therapy, including eccentric exercises. Three months after the second prolotherapy injection, the patient had achieved meaningful improvement in his baseline symptoms. However, he continued to experience severe stabbing pain with functional activities of daily living and especially while playing tennis, which would severely aggravate his arm for a few days.

At this stage, the patient indicated that he was extremely frustrated with his outcome and was even considering learning to play tennis with his non-dominant hand. A family member suggested that he try a platelet-rich plasma (PRP) injection. He arranged an appointment at our clinic for evaluation for this treatment.

Past Medical and Surgical History: unremarkable

Family History: Father with Diabetes Mellitus II, Mother with Rheumatoid Arthritis

Medications: Multivitamin daily, Aspirin 81mg daily
Allergies: Diclofenac

Social History: Married, denied tobacco and illicit-drug use, drinks wine 1-2 times per week, holds a management position that requires mostly desk-work.

Review of Systems: Twelve systems were reviewed and were remarkable only for the musculoskeletal symptoms reported in the HPI. There were no symptoms suggestive of a neuropathy or cervical radiculopathy.

Physical Exam:
Height: 5ft 6 in. Weight: 175 pounds. BMI: 28.2
General: Well developed male, no acute distress
Skin: Normal turgor, warm and dry, no rashes noted on both arms
Neurologic: Sensation was intact in both arms, deep tendon reflexes were 2/4 and symmetric throughout, and Tinel's sign was negative at the radial tunnel.
Musculoskeletal: Muscle strength was 5/5 throughout except for right wrist extension and supination which were 4+/5 due to pain. There was tenderness to palpation at the right elbow over the insertion of the common extensor tendon at the lateral epicondyle as well as over the muscle belly of the extensor carpi radialis brevis (ECRB). Pain occurred with resisted wrist extension, forearm supination, and 3rd finger extension. Elbow range of motion was full in all planes. No instability was noted.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.