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Evidence In Practice |
Sara Maher, PT, MPT, OMPT is Physical Therapist, Michigan Rehabilitation Specialists, Hamburg, Mich, and, at the time this article was written, was a graduate student in the DScPT program, Oakland University, Program in Physical Therapy, Rochester, Mich
Submitted December 8, 2005;
Accepted May 9, 2006
| The purpose of "Evidence in Practice" is to illustrate how evidence is gathered and used to guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated.
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A 55-year-old woman, who was right-hand dominant, was referred to my physical therapy clinic with a 6-month history of pain in her left lateral elbow. The patient was an assembly-line worker in an automotive factory. She worked 40 to 50 hours per week in a rotating 9-job "loop" manufacturing diesel engines. Each day she would perform a different job in the loop for the duration of her shift, until she had performed all 9 job functions, at which point the "loop" would repeat.
The initial examination revealed normal active range of motion of the left elbow and wrist (using techniques described by Norkin and White1), with pain when moving into active wrist extension. The patient's grip strength was assessed using a Jamar hydraulic hand dynamometer.* Compared with her right upper extremity, the patient had decreased grip strength in her left upper extremity of approximately 40 lb. Passive range of motion was painful when moving into wrist flexion. Tenderness to palpation was noted in the lateral epicondyle and in the proximal one third of the extensor tendons. Joint play testing of the humeroradial and humeroulnar joints, using techniques described by Kaltenborn and Evjenth,2 was within normal limits. Varus and valgus stress tests, cervical screening, and neurological screens did not reproduce symptoms at the elbow.
The patient reported that her pain developed during one specific job in her loop-lifting oil pans out of a cardboard box and placing them on the line. She demonstrated how she lifted the oil pans from their packaging. The patient performed a 2-handed lift, using her wrist extensors to pull the oil pans up and toward herself. Each oil pan weighed between 4.1 kg and 7.2 kg (9 lb-16 lb), depending on the size of the engine being assembled. I immediately taught the patient proper lifting techniques using her biceps brachii muscles instead of her wrist extensors to lift and pull the oil pans, and she was advised to use this technique whenever lifting objects toward herself. The patient continued to work without restrictions at her job, and she was provided with a lateral counter-force brace to redistribute muscular forces away from her lateral epicondyle. The brace consisted of an inelastic cuff worn against the forearm extensors to diminish tension along the tendons proximal to the brace placement.
I had recently been contacted by a vendor about purchasing a low-level laser as a new intervention for musculoskeletal disorders. The vendor discussed common diagnoses, such as lateral epicondylitis, seen in the workers' compensation setting and provided literature in support of low-level laser therapy (LLLT) with these diagnoses. Lateral epicondylitis is a very common diagnosis at my clinic; at any time, as many as 25% to 40% of the patients are being treated for this condition. The repetitive nature of lifting engine parts, the use of power tools, and the force required to twist parts onto engines leads to the referral of numerous patients with this condition for physical therapy each month.
 | Footnotes |
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To view this content online, visit www.ptjournal.org
* Sammons Preston Rolyan, 270 Remington Blvd, Ste C, Bolingbrook, IL 60440-3593 
This article has been cited by other articles:
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  T. De Smedt, A. de Jong, W. Van Leemput, D. Lieven, and F. Van Glabbeek Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment Br. J. Sports Med., November 1, 2007; 41(11): 816 - 819. [Abstract] [Full Text] [PDF]
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 J. M Bjordal On "Is Low-Level Laser Therapy Effective..." Maher S. Phys Ther. 2006;86:1161-1167. Physical Therapy, February 1, 2007; 87(2): 224 - 225. [Full Text] [PDF]
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S. Maher Author Response Physical Therapy, February 1, 2007; 87(2): 225 - 226. [Full Text] [PDF]
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