Physical therapist screening and differential diagnosis for traumatic-onset elbow pain: A case report

• Published in: Physiotherapy theory and practice Vol. 32; no. 7; pp. 556 - 565
• Main Authors: VanWye, William R, Hoover, Donald L, Willgruber, Sean
• Format: Journal Article
• Language: English
• Published: England 01-10-2016
• Subjects: Accidental Falls; Arthralgia - diagnosis; Arthralgia - etiology; Diagnosis, Differential; Elbow; Female; Humans; Physical Examination; Physical Therapy Specialty - methods; Radius Fractures - complications; Radius Fractures - diagnosis; Young Adult; pay-for-performance; Accidental falls; imaging; fracture
• ISSN: 0959-3985; 1532-5040
• DOI: 10.1080/09593985.2016.1219798

Elbow pain can originate from many sources yet have similar signs and symptoms, thereby presenting differential diagnostic challenges. The elbow is commonly injured, thus requiring all clinicians to possess excellent diagnostic skills.
A 24-year-old woman slipped and fell on her outstretched left hand, experiencing immediate elbow pain. The same day radiographs were deemed negative by her orthopedist, who referred her to physical therapy with the diagnoses of elbow sprain and contusion. Immediately after examining the patient, the physical therapist consulted with the referring orthopedist. The decision to consult was based on: the mechanism of injury, pain severity out of proportion to the referred diagnoses, significantly limited ROM, abnormal joint end feels, exquisite pain with tactile and tuning fork bony palpation, and positive elbow extension test.
The treating physical therapist shared the above-noted findings with the orthopedist, who overruled and recommended continuing the original prescription of non-steroidal anti-inflammatory medication and physical therapist treatment for four weeks. The physical therapist's updated plan of care at four weeks noted the patient's continued reports of pain, functional limitations, and disability. A magnetic resonance image (MRI) was then ordered, revealing a radial head fracture.
A thorough history and examination by the physical therapist led to clustering of signs and symptoms, allowing for the development of a differential diagnosis list which included occult radial head fracture. All clinicians should be prepared to screen for complex conditions. Timely diagnosis and improved outcomes for clinically complex patients are increasingly necessary in contemporary healthcare reimbursement models.