Bilateral Forearm And Elbow Pain - Tennis

Abstract

HISTORY: A 75 year-old female tennis player was referred for bilateral elbow pain with suspected lateral epicondylitis. She noted 3 months of pain in her left more than right ventral forearms with radiation into her lateral elbows as well as posterior bilateral shoulder pains. The forearm pain was constant and worsened by single backhand with tennis, lifting weights. She reported reduced grip strength and her racquet falling out of her hands. PHYSICAL EXAMINATION: Cervical range of motion was within functional limits. Elbow examination showed full active and passive range of motion, minimal tenderness along lateral epicondyle and just distal at tendinous origin, and no pain with resisted wrist extension and middle finger extension. She had finger extension weakness without pain bilaterally 3/5 and otherwise motor testing was 5/5 C5-T1 myotomes. Sensation was intact in C5-T1 dermatomes bilaterally. Reflexes were 2+ and symmetric of biceps and brachioradialis and 3+ at the triceps bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Bilateral lateral epicondylitis 2. Cervical spine stenosis with myelopathy 3. Posterior interosseous neuropathy TEST AND RESULTS: Cervical Spine anterior-posterior and lateral radiographs: - Grade 2 anterolisthesis of C7 on T1 is seen with bilateral pars fracture of C7. Moderate multilevel degenerative disc disease. MRI of the Cervical Spine without Contrast: - Advanced facet arthropathy at C7-T1. Anterolisthesis of C7 on T1 causing moderate/severe spinal stenosis with mild cord deformity. Severe bilateral foraminal stenosis at this level. FINAL/WORKING DIAGNOSIS: Cervical central spine stenosis with myelopathy TREATMENT AND OUTCOMES: 1. Neurosurgery referral recommended urgent C7-T1 anterior cervical discectomy and fusion followed by C5-T2 posterior spinal fusion 2. She was placed in hard cervical collar at all times and surgery was performed 1 week after neurosurgery evaluation 3. At 1 week postoperative, patient felt 80% improvement in pain in forearms and elbows along with subjectively improved grip strength 4. She continued the hard cervical collar until repeat radiographs at 6 weeks post surgery. 5. Patient was instructed to avoid playing tennis. She was also informed to avoid bending, twisting of her neck or lifting greater than 5 pounds until further evaluation in 6 week visit.