Fatima University Medical Center

Physical Medicine and Rehabilitation Department

IE
(March 10, 2021)

GENERAL INFORMATION
Pt.’s Name: R.M
Age: 30 y/o
Sex: M
Address: Phase 1 Greenland Subdivision Cainta, Rizal
Civil Status: Married
Handedness: Right
Height: 5’8”
Weight: 65kg
Occupation: Tennis Player - Athlete
Religion: Roman Catholic
Nationality: Filipino
Referring Unit: Cainta Valley Hospital
Referring MD: Dr. M.C
Rehab Unit: Marikina Rehab Center
Rehab MD: Dr. A.D
Date of consultation: March 1, 2021
Date of Referral: March 1, 2021
Date of IE: March 10, 2021
Dx: Lateral epicondylitis on ® elbow
Informant/Reliability: Patient/Good

S:
C/C: “Habang naglalaro ako bigla nalang akong nakaramdam ng sakit sa aking siko hindi ko na pati
naituloy yung paglalaro ko. Para siyang masakit na mainit sa pakiramdam. Pagkatapos ko maramdaman
yun, araw-araw na yung atake nung sakit. Napapansin ko din sa tuwing naglalaro ako bigla ko nalang
nabibitawan yung raketa tapos bigla ulit sasakit yung siko ko”

PT Translation: Pt. c/o of constant localized dull aching pain (PS 8/10) and LOM towards elbow
flexion, pain is aggravated (PS: 9/10) while performing ADLs such as eating, UE dressing and bathing
and relieved by rest.

PT Goal: “Gusto kong mawala yung sakit na nararamdaman ko lalo na kapag naglalaro pati na rin yung
lakas ko para makakilos na ako ng maayos at makabalik sa normal na paglalaro. ”

PT Translation: Pt. wants to ↓ pain and LOM on his ® shoulder and ↑ grip strength to be able to
perform his ADL’s such as eating, UE dressing, and bathing. Pt. also wants to attain full recovery to
perform tennis for the upcoming tournament.

HPI:

~ 2 weeks. ago prior to PTIE, the pt. felt pain (PS: 8/10) on her (R) elbow while playing his
favorite sports, tennis. The pt. took mefenamic acid (see present medication) to relieve the pain. While
driving home the pt. felt pain again (PS 8/10) Then the pt. went directly to his room and asked his son for
some medicine to ease the pain. His son gave him mefenamic acid.
2 days prior to PTIE, the pt. experienced a severe dull aching pain (PS: 10/10) on his (R) elbow
upon playing tennis and immediately his coach took him to Cainta Valley Hospital. Dr. M.C the attending
physician checked the pt. 's condition in the emergency room and ordered him to be given ibuprofen (see
present medication) as a pain reliever and do some tests (see laboratory procedures). Dr. M.C. then
referred him to the Marikina Rehab Center.

1 day prior to PTIE, the pt. went to Marikina Rehab Center. Rehab doctor Dr. A.D. ordered
laboratory tests (see Ancillary procedure). Upon reading the results Dr. A.D. diagnosed the pt. with (R)
Lateral Epicondylitis and then prescribed him with PT exercise and referred her to the PT depart. for
further intervention.

Ancillary Procedures
Procedure Date Result

MRI (+) Mild focal increase in the tendon signal on fat

March 01, 2021
suppressed T2 images not equal to that of fluid
Xray (Oblique
(+) Calcifications at extensor tendon origin
View of Lateral March 01, 2021
indicative of Lateral epicondylitis
Epicondyle)

Present Medication
Drug/ Frequency Indication
Dosage
Medication
Mefenamic acid 500 mg prn Pain-reliever
Ibuprofen 500 mg prn NSAIDS

PMHx:

FMHx:
Maternal Paternal
HTN (+) (-)
DM (-) (+)
CVA (-) (-)
TBI (-) (-)
Pulmonary Dse (-) (-)

P/SHx:
Personality: Type A
Lifestyle: Active
 Cigarette Smoking Hx: Non-Cigarette Smoker
Alcohol Consumption: Occasional (Beer 2-4 bottles, twice a month)
Diet: Well-balanced diet
Hobbies/Leisure: Playing computer games
Financial Stability: Pt. is stable c health care insurance

Home & Work/School Situation:

Home:
Pt. lives in a Bungalow house c his wife and son.
Having the front door as the reference the following measurements were obtained:
● Type of doorknobs: keyed entry door knob
● Door width: ~90 cm
● Pt.’s bedroom is located near the living room.
● Bed ht.: ~45 cm
● Type of mattress: Memory foam
● Pt.’s house is along an inclined road with a small gate and 2 steps before the front door.
The following measurements are obtained:
○ Gate ↔ Front door ~ 10 steps
○ Front door ↔ Living room ~ 9 steps
○ Front door ↔ Kitchen ~ 13 steps
○ Front door ↔ Restroom ~ 13 steps
○ Front door ↔ Pt’s Bedroom ~ 10 steps
○ Front door ↔ Bathroom ~ 17 steps
○ Inside flooring: Vinyl tiles
○ Outside flooring: Concrete cement
● Restroom flooring: marble tiles
● Toilet ht. : 48 cm

Work:
Pt. previously works as a sports athlete
Pt. usually plays tennis every day for 6 hours
Pt’s racquet size is 27 inches in length

O:
V.S.
VS Before During After
BP
120/80 mmHg 110/70 mmHg 120/80 mmHg

PR
72 bpm 83 bpm 70 bpm

RR
15 cpm 16 cpm 14 cpm
Temp Afebrile to touch

Finding: VS was WNL

Significance: Values are used for baseline purposes and treatment purposes

OI:

● Pt. amb. independently

● Pt. is alert, coherent & cooperative
● Pt. is oriented 3x (time, place, person)
● Pt. is endomorph
● (-) Postural deviations
● (-) Gait deviation
● (-) Pressure sores
● (-) Atrophy on (B) UE & LE
● (-) Deformities on (B) UE & LE
● (-) Edema on (B) UE & LE
● (-) Attachments
● (-) Swelling
● (-) Ecchymosis
● (-) Wounds

PALPATION:
● Normothermic on all exposed body parts
● Normotonic on (B) UE & LE
● (+) Grade 2 Tenderness over (R) lateral epicondyle
● (+) Muscle guarding on (R) elbow
● (-) Tightness
● (-) Contracture
● (-) Edema

REFLEX TESTING:
Legend:
0 Absent, no response
1+ Slight reflex, present but
depressed, low normal
2+ Normal, typical reflex
3+ Brisk reflex, possibly but not
necessarily abnormal
4+ Very brisk reflex, abnormal,
clonus
 Findings: (++) Normoreflexia on (B) UE & LE
Significance: Findings will not affect any ADLs and indicates (-) UMNL

RANGE OF MOTION
All major jts. of (B) UE & LE were actively and passively taken, noted to be pain-free, WNL & c (N)
end-feels, except:
Normal (R) (R) Difference
Motions Values Active Passive Active Passive End-Feel
Elbow Flexion 0-150 0-120 0-130 30 20 Soft (Painful)
Elbow Extension 150-0 150-30 150-20 30 20 Hard (Painful)
Elbow Pronation 0-80 0-50 0-60 30 20 Hard (Painful)
Wrist Flexion 0-80 0-60 0-70 20 10 Firm (Painful)
Wrist Extension 0-70 0-60 0-70 10 0 Firm (Painful)
Wrist Ulnar
Deviation 0-30 0-15 0-20 15 10 Firm (Painful)
Findings: There is LOM on UE towards elbow flexion, extension & pronation, wrist flexion, extension
and ulnar deviation. Weakness is also apparent during assessment.
Significance: Findings may affect ADLs such as eating, dressing, bathing, and self-care activities.

BREAK TEST
All major muscles of (B) UE and LE were assessed using standard MMT & graded 5/5, the following
muscles were assessed using break test:
Muscle group (L) UE Muscle Grade
Elbow Flexor 3-/5 @ 0-120
Elbow Extensor 3-/5 @ 150-30
Elbow Pronator 3-/5 @ 0-50
Wrist Flexor 3/5 @ 0-60
Wrist Extensor 3/5 @ 0-60
Wrist Ulnar Deviator 3/5 @ 0-15
Findings: (R) elbow flexor, extensor and pronator were graded 3-/5 (fair minus) while (R) wrist flexor,
extensor and ulnar deviator were graded 3/5(fair).
Significance: Findings may affect ADLs such as eating, dressing, bathing, and self-care activities.

Legends
Grade Scale Criteria
Normal 5 Full ROM against gravity, strong manual resist
Good (+) 4+ Full ROM against gravity, nearly strong manual resist
Good 4 Full ROM against gravity, mod. manual resist
Good (-) 4- Full ROM against gravity, mod. manual resist
 Fair (+) 3+ Full ROM against gravity, slight manual resist
Fair 3 Full ROM against gravity, no resist
Fair (-) 3- At least 50%, ROM against gravity, no resist
Poor (+) 2+ Full ROM, min. gravity, slight manual resist
Poor 2 Full ROM, min. gravity, no resist
Poor (-) 2- At least 50% ROM, min. gravity, no resist
Trace (+) 1+ Min. observable motion, <50% ROM, min. gravity, no
resist
Trace 1 No observable motion, palpable mm contraction, no
resist
Zero 0 No observable or palpable mm contraction

SPECIAL TEST
Name of Test Procedure Findings & Significance

Cozen's Test The patient’s elbow is stabilized by the (+) Severe pain in the
examiner’s thumb, which rests on the area of lat. epicondyle
patient’s lateral epicondyle. The patient is
then asked to actively make a fist, pronate Significance: R/I Lateral
the forearm, and radially deviate and Epicondylitis
extend the wrist while the examiner resists
the motion.

Mill’s Test While palpating the lateral epicondyle, the (+) Pain over the lateral
examiner passively pronates the patient’s epicondyle
forearm, flexes the wrist fully, and extends
the elbow Significance: R/I Lateral
Epicondylitis

Maudsley’s Test
The examiner resists extension of the third (+) Pain over the lateral
digit of the hand distal to the proximal epicondyle
interphalangeal joint, stressing the extensor
digitorum muscle and tendon. Significance: R/I Lateral
Epicondylitis

Posterolateral Rotary
Apprehension Test
The patient lies supine with the arm to be (-) Elbow
tested overhead. The elbow is supinated at dislocation/subluxation
the wrist, and a valgus stress is applied to
the elbow while the examiner flexes the Significance: R/O
elbow. Posterolateral Rotatory
Instability
FUNCTIONAL ASSESSMENT:

I. FUNCTIONAL TESTING OF THE ELBOW

Starting Position Action Functional Test Result

Sitting Bring hand to mouth Lift 2.3 kg to 2.7 kg: Pt. was able to lift 0.5
lifting weight Functional kg
(elbow flexion) Lift 1.4 kg to 1.8 kg:
Functionally fair
Lift 0.5 kg to 0.9 kg:
Functionally poor
Lift 0 kg: Nonfunctional

Standing 90 cm from wall, Push arms straight 3 to 4 Repetitions: Pt. was able to perform
leaning (elbow extension) Functionally fair the action 2 times
against wall 1 to 2 Repetitions:
Functionally poor
0 Repetitions:
Nonfunctional

Standing, facing closed Open door starting 5 to 6 Repetitions: Pt. was able to perform
door with palm down Functional the action 5 times
(supination of arm) 3 to 4 Repetitions:
Functionally fair
1 to 2 Repetitions:
Functionally poor
0 Repetitions:
Nonfunctional

Standing, facing closed Open door starting 5 to 6 Repetitions: Pt. was able to perform
door with palm up Functional the action only 2 times
(pronation of arm) 3 to 4 Repetitions:
Functionally fair
1 to 2 Repetitions:
Functionally poor
0 Repetitions:
Nonfunctional
Findings: Pt. has functionally fair grading when it comes to (R) elbow flexion, extension and pronation.
Significance: Findings may affect ADLs such as eating, dressing, bathing, and self-care activities.

II. FUNCTIONAL TESTING OF WRIST AND HAND

Starting Position Action Functional Test Result

Forearm supinated, Wrist flexion Lift 0 lbs: Nonfunctional Pt. was able to lift 2 lbs.
resting on Lift 1 to 2 lbs:
table Functionally poor
Lift 3 to 4 lbs:
Functionally fair
 Lift 5+ lbs: Functional

Forearm pronated, Wrist extension lifting 0 Repetitions: Pt. was able to perform
resting on table 1 to 2 lbs Nonfunctional the action for only 2
1 to 2 Repetitions: times
Functionally poor
3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm between Radial deviation lifting 0 Repetitions: Pt. was able to perform 4
supination and 1 to 2 lbs Nonfunctional repetitions
pronation, resting on 1 to 2 Repetitions:
table Functionally poor
3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm between Thumb flexion with 0 Repetitions: Pt. was able to perform 5
supination and resistance from Nonfunctional repetitions
pronation, resting on rubber band* around 1 to 2 Repetitions:
table thumb Functionally poor
3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm resting on Thumb extension 0 Repetitions: Pt. was able to perform 5

table, rubber against resistance of Nonfunctional repetitions
band around thumb and rubber band* 1 to 2 Repetitions:
index Functionally poor
finger 3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm resting on Thumb abduction 0 Repetitions: Pt. was able to perform 5

table, rubber against resistance of Nonfunctional repetitions
band around thumb and rubber band* 1 to 2 Repetitions:
index Functionally poor
finger 3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm resting on Thumb adduction, Hold 0 s: Nonfunctional Pt. was able to hold for 6
table lateral pinch of Hold 1 to 2 s: seconds
piece of paper Functionally poor
Hold 3 to 4 s:
 Functionally fair
Hold 5+ s: Functional

Forearm resting on Thumb opposition, Hold 0 s: Nonfunctional Pt. was able to hold for 5
table pulp-to-pulp pinch Hold 1 to 2 s: seconds
of piece of paper Functionally poor
Hold 3 to 4 s:
Functionally fair
Hold 5+ s: Functional

Forearm resting on Finger flexion, patient 0 Repetitions: Pt. was able to repeat the
table grasps mug or Nonfunctional actions for 5 times
glass using cylindrical 1 to 2 Repetitions:
grasp and lifts Functionally poor
off table 3 to 4 Repetitions:
Functionally fair
5+ Repetitions: Functional

Forearm resting on Patient attempts to put 21+ s: Nonfunctional Pt. was able to put on
table on rubber glove 10 to 20 s: Functionally rubber gloves within 5
keeping fingers straight poor seconds
4 to 8 s: Functionally poor
2 to 4 s: Functional

Forearm resting on Patient attempts to pull Hold 0 s: Nonfunctional Pt. was able to hold for 6
table fingers apart Hold 1 to 2 s: seconds
(finger abduction) Functionally poor
against resistance Hold 3 to 4 s:
of rubber band* and Functionally fair
holds Hold 5+ s: Functional

Forearm resting on Patient holds piece of Hold 0 s: Nonfunctional Pt. was able to hold for 5
table paper between Hold 1 to 2 s: seconds
fingers while examiner Functionally poor
pulls on paper Hold 3 to 4 s:
Functionally fair
Hold 5+ s: Functional
Findings: Pt. has functionally poor grading when it comes to (R) wrist flexion and extension.
Significance: Findings may affect ADLs such as eating, dressing, bathing, and self-care activities.

GRIP STRENGTH TEST

Grip strength on (B) hands were assessed c elbow flexed at 90° using a grip dynamometer
TRIAL DOMINANT HAND NON-DOMINANT COMBINED SCORES
(R) HAND (L)

1 41 kg 55 kg 96 kg

2 45 kg 60 kg 105 kg
 3 43 kg 58 kg 101 kg

AVERAGE 43 kg 57 kg COMBINED AVERAGE:

100 kg (Below Average)
Findings: Pt. has decreased grip strength on the dominant (R) hand, pt. also has a below average grade in
combined (R) and (L) hand grip strength.
Significance: Findings may affect ADLs such as eating, dressing, bathing, and self-care activities.

Normal Values for Combined Right and Left Hand Grip Strength (Magee)
Grade Normal Values for Ages 30-39 Male (in kg)

Excellent ≥123

Above Average 113-122

Average 105-112

Below Average 97-104

Poor ≤96

POSTURAL ANALYSIS
All landmarks of (B) UE & LE, trunk and neck are found to be WNL and were assessed in sitting and
standing pos’n.

ADL ANALYSIS:
Pt. is maximally independent in all ADLs but experiences mod. difficulty in performing activities
such as eating, dressing, bathing, and self-care.

A:
MEDICAL DIAGNOSIS: Lateral Epicondylitis on ® Elbow

PT DIAGNOSIS:
Musculoskeletal Pattern C: Impaired Muscle Performance
Musculoskeletal Pattern E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range
of Motion Associated with Localized Inflammation

PT IMPRESSION:
Pt. was medically diagnosed with Lateral Epicondylitis on ® elbow manifested by constant localized dull
aching pain (PS 8/10) on ® elbow, aggravated by motions towards flexion, LOM of ® UE towards elbow
flexion, extension & pronation, wrist flexion, extension and ulnar deviation, tightness and weakness of
® elbow flexors, extensors, pronators, wrist flexors, extensors and ulnar deviators, (+) grade 2
tenderness on ® elbow, (+) mm guarding on ® elbow, (+) Cozen’s Test, (+) Mill’s test, (+)
Maudsley’s Test, functionally fair on ® elbow flexion, extension and pronation, functionally poor on
(R) wrist flexion and extension, ↓ grip strength on ® hand c below average grade, resulting in
having mod. difficulty in performing ADLs such as eating, UE dressing and bathing.

REHAB POTENTIAL:
Pt. has good prognosis d/t to the ff prognosticating factors:

Positive Prognosticating Factors Negative Prognosticating Factors

Pt. is financially stable and can attend weekly PT Pt. has (+) mm guarding
sessions

Pt. is cooperative and willing to be treated Pt.’s dominant hand is affected which greatly
affects performance of ADLs

PX REACTION TO TX:
Pt was seen and assessed today. All VS are WNL. Pt. did not show any adverse reactions and proceeded
with management.

PROBLEM LIST:
1. Constant, localized, dull aching pain (PS 8/10) on ® elbow
2. LOM of ® towards elbow flexion, extension & pronation, wrist flexion, extension and ulnar
deviation
3. ↓ mm strength and mm tightness of ® elbow flexors, extensors, pronators, wrist flexors,
extensors and ulnar deviators
4. ↓ grip strength on (R) hand
5. Difficulty in performing ADLs such as eating, UE dressing and bathing

LTG:
1. Preventive: Within 5 mos. of PT sessions, pt. will be able to prevent further progression of
conditions such as LOM and weakness of grip.
2. Rehabilitative: Within 5 mos of PT sessions, pt. will be able to improve functional capabilities
from mod. Assist, to independent in performing ADLS such as eating, UE dressing and bathing
3. Participative: Within 6 mos. of PT sessions, pt. will be able to return to his playing activities
again s restriction in the movements.

STG:
1. Within 3 wks of PT session, pt. will be able to ↓ constant, localized, dull aching pain from
(PS 8/10) on ® elbow to (PS 4/10) c prescribed PTMx
2. Within 4 wks of PT session, pt. will be able to ↑ ROM towards elbow flexion, extension &
pronation, wrist flexion, extension and ulnar deviation c 5-10 degrees increment c
prescribed PTMx
3. Within 4 wks of PT session, pt. will be able to ↑ mm strength on ® elbow flexors, extensors,
pronators, wrist flexors, extensors and ulnar deviators from fair grading to good grading c
prescribed PTMx
4. Within 4 wks of PT session, pt. will be able to ↑ grip strength on ® hand from below
average grade to average c prescribed PTMx
 5. Within 5 wks of PT session, pt. Will be able to perform ADLS such as eating, UE dressing and
bathing from mod. assist to min. assist.

/P/:
PTMx:
1. US on ® elbow x 1.5 w/cm² x 1 MHz x 5 mins, continuous
2. TENS on (R) UE (Shoulder, Carpal, Elbow) x 20mins/session
3. Manual Therapy on (R) UE (Mulligan Mobilization Technique) x 8 sec hold x 10 reps x 2sets x
10 rest p q
4. ESWT on (R) UE 0.10-0.13 mJ/mm x 200-300 impulses x 5mins
5. Stretching exercises on ® UE towards wrist flexion x 15 SH x 4 reps x 2 sets
6. Strengthening exercise on (R) UE x 10 reps x 2 sets c 10 sec res p q set
- FA supination c yellow theraband
- Wrist extension c twist bar
- Stress ball squeeze

PROGRESSION:
1. Strengthening exercise on (R) UE x 10 reps x 3 sets c 10 sec res p q set
- FA supination c red theraband
- Wrist extension c twist bar

SUGGESTED PTMx:
1. Strengthening Exercises on (B) UE x 10 reps x 2sets x 10 rest p q
- Fist Clench
- Supination c 3 lbs dumbbells
- Wrist (Flexion & Extension)
- Towel Twist
- Stress Ball Squeeze
- Finger Stretch
2. Theraband Exercise on (R) UE x 10reps x 2sets x 10set p q

HEP:
1. Ice massage x 10 mins
2. Self stretching on ® UE towards wrist flexion x 10 SH x 3 reps x 2 sets
3. Home AROMEs and strengthening exercises towards wrist extension and FA supination x 10
reps x 3 sets c 10 sec rest p q set
4. Pt. education on preventing excessive and abrupt motions on his ® UE.

PREPARED BY: NOTED BY:

ANDRES, MAYDEE Dennis B. Artangga, PTRP

OLFU-AC PT INTERN PT Staff-In-Charge
DELOS SANTOS, ALETHEYA
OLFU-AC PT INTERN

GONZALES, RALPH SEBASTIAN R.

OLFU-AC PT INTERN

JAVIER, ROCHELLE ANDREA

OLFU-AC PT INTERN

MARIANO, NICOLE
OLFU-AC PT INTERN

MENDOZA, ERICA MAE

OLFU-AC PT INTERN

MIRANDA, ERICA REIGN

OLFU-AC PT INTERN

TRINIDAD, JOHN DOMINIC

OLFU-AC PT INTERN