Seminar Clinical Impression

PT 606: Week 2 Seminar Case


Referring Diagnosis: Right elbow pain


History of onset: Patient is a R handed 19 year old softball pitcher that presents to PT today
with a chief concern of R medial elbow pain that began during her preseason practices 4-5 weeks ago. She reports increasing her pitching and throwing volume and frequency at that time. She now has immediate onset of pain with throwing and pitching. She also has pain with blow drying her hair, holding onto handles overhead to stay balanced while standing during her commute riding on the subway, and doing push-ups. Pt denies any clicking, shifting, or feelings of instability. Pt has also completely stopped playing softball at this time due to immediate onset of pain with any level of throwing at this time.


Medications: None.


Imaging: X-ray negative for pathology.


PMH: Ehler’s Danlos Syndrome (EDS). Intermittent R anterior shoulder pain over the last 2-3
years, but is not currently bothering her during this season.


Social History: Currently living at home with parents and siblings with good social support.


Pain/Symptoms: Immediate onset of right medial elbow pain with pitching and throwing. The pain becomes more severe with increased repetition and increasing power behind pitching or throwing. The pain usually stops immediately upon cessation of the aggravating activity with returning to rest, but can occasionally remain for 10-15 minutes if she really pushes her intensity in practice.
At rest: 0/10. At worst: 7/10.
Denies numbness/tingling. No pain at night or during sleep.
Aggravating factors:

  • Pitching or throwing, blow drying hair, holding overhead handles on the train, push ups or planks.

  • Pain comes on immediately with pitching/throwing (7/10). For blow drying hair, holding train handles, and push ups/planks pt reports pain is intermittent and can take several minutes for onset of much less severe symptoms compared to throwing (2-3/10).

    Easing factors: Rest.
    Patient Goals:
    1. To be able to return to practicing and eventually games without restriction.
    2. Perform all of her normal daily activities without pain.

Subjective:

  • 19 years old

  • female

  • right-handed

  • softball pitcher

Chief complaint:

  • right medial elbow pain with immediate onset during throwing/pitching

History of present illness:

  • onset: 4-5 weeks ago during preseason practices

  • trigger: increased pitching and throwing volume/frequency

Pain behavior:

  • intensity: 7/10 at worst, 0/10 at rest

  • resolves immediately upon stopping activities occasionally lasting 10-15 minutes

Activities that aggravate pain:

  • throwing/pitching (7/10)

  • daily tasks including

Objective:

  • assess posture, arm position, and elbow/shoulder alignment

  • look for signs of swelling, redness, or deformity around medial elbow

ROM:

  • active and passive ROM: flexion, extension, pronation, and supination of the elbow

  • scapular and glenohumeral motion

MMT

  • elbow flexors/extensors

  • grip strength for deficits

Special Tests

  • valgus stress test: assess for medial ulnar collateral ligament involvement

  • milking maneuver: evaluate UCL instability

  • moving valgus stress test: check UCL instability under dynamic valgus stress

  • golfer’s elbow test: tests for medial epicondylitis

Palpate:

  • medial ulnar collateral ligament

  • flexor pronator

  • ulnar nerve in the cubital tunnel

Hypothesis:

  • presentation is consistent with an overuse injury of the medial elbow, likely involving the medial ulnar collateral ligament

  • Medial ulnar collateral ligament sprain: increased pitching volume places repetitive valgus stress on the medial elbow

  • pain is localized to the medial elbow, worsened by throwing motions, no report of instability, suggesting sprain instead of rupture

  1. Joint Hypermobility from Ehler’s Danlos Syndrome (EDS)

    • Rationale:

      • EDS predisposes patients to joint laxity and repetitive strain injuries due to connective tissue fragility.

      • Underlying hypermobility may contribute to excessive valgus forces and increased stress on the MUCL and surrounding tissues.

      • connective tissue is not doing its job effectively, leading to an increased risk of injuries and potential long-term joint damage. This can result in chronic pain, instability, and a reduced quality of life for affected individuals.

Less Likely Differential Diagnoses

  1. Medial Epicondylitis (Golfer’s Elbow)

    • Rationale:

      • Similar symptoms to flexor-pronator tendinopathy but less likely here due to no history of gripping/aggravation with specific wrist motions being the primary driver.

  2. Ulnar Nerve Irritation

    • Rationale:

      • Pain location aligns, but absence of numbness/tingling or neurological symptoms makes this less likely.

Extra information

Clinical Impression

1st draft

Pt is a 19-year-old female presenting with R medial elbow pain. She reports that she is a right-handed softball pitcher and pain began 4-5 weeks ago during practices coinciding with increased pitching and throwing volume. Pt says activities that include repetitive or sustained upper extremity use such as blow drying hair, holding overhead train handles, and performing push-ups have exacerbated symptoms to a pain level of 2-3/10 that is alleviated with rest and is absent at night during sleep. Pt has a past medical history of Ehler’s Danlos Syndrome (EDS) which may be contributing to her joint hypermobility and altered stress on connective tissues, potentially predisposing her to repetitive strain injuries. Pt also stated she had intermittent right anterior shoulder pain over the past 2-3 years but is not currently symptomatic. Imaging reveals no pathology. Given the patient history and current symptoms, her presentation suggests an overuse injury to the right medial elbow, likely involving the medial ulnar collateral ligament, and possibly related to her increased pitching volume with valgus stress and underlying connective tissue laxity associated with Ehler’s Danlos Syndrome. No signs of mechanical instability, neurological involvement, or night pain suggestive of different pathology are present.

Key impairments and activity limitations include pain and inability to pitch or throw, limiting her sports participation, and difficulty with upper extremity tasks requiring sustained grip or repetitive use affecting the functional activities of the patient. Clinical goals include alleviating pain and restoring functional mobility and strength in the right upper extremity, addressing contributing biomechanical factors such as hypermobility from EDS, developing a graded workload for a safe return to softball, and educating the patient on activity management and injury prevention strategies. A treatment plan will aim to alleviate pain, address contributing impairments, and safely progress the patient toward her goals of unrestricted return to softball and pain-free participation in daily activities.

2nd draft

Pt is a 19-year-old right-handed softball pitcher presenting with right medial elbow pain that began 4-5 weeks ago during increased pitching and throwing volume. Activities involving repetitive or sustained upper extremity use, such as blow-drying hair, holding train handles, and push-ups, exacerbate symptoms to 2-3/10, relieved with rest and absent at night.

Her history of Elher’s Danlos Syndrome (EDS) may contribute to joint hypermobility and increased strain on connective tissues, predisposing her to overuse injuries. She also reports intermittent right anterior shoulder pain over the past 2-3 years, currently asymptomatic. Imaging shows no pathology.

The presentation suggests an overuse injury to the medial ulnar collateral ligament, likely due to valgus stress during pitching