The case study was published in the the below Journal
The full PDF of the article is below for reference
Fullscreen ModeThis case study presents a 38-year-old, female rock climber with posterior elbow pain who was evaluated and treated using Telehealth. The use of telehealth for a clinical exam requires a larger emphasis be placed on posture observation and movement analysis since hands on assessment techniques cannot be used. During the patient exam, movement analyses identified scapulohumeral positional faults and dyskinesis, while self-palpation and self-midline resistance testing helped identify that the triceps tendon was the pathological tissue. A comprehensive rehabilitation program was developed based on concepts of regional interdependence to treat contributing factors in the scapular region and source tissues in the brachial region. After 10 weeks, the climber’s pain decreased from 4/10 to 0/10. She made a full recovery back to her previous grade of V8 bouldering and was able to complete a V10 longstanding boulder project pain-free. This is the first case study of its kind to identify unilateral scapular dyskinesia in a patient with suspected triceps tendinopathy and to demonstrate a positive treatment effect by combining scapular strength exercises with eccentric exercises addressing the affected tissue.
Since COVID-19 emerged in the first months of 2020, social distancing and stay-at-home orders moved telehealth from a convenient option to an essential tool (Lee, 2020). As a result of nation and local mandates, many medical providers had to adjust their practice models to include telehealth care. Telehealth is performed in the field of physical therapy mostly through utilizing two-way synchronous audio and video. It has several strengths when compared to the in-person setting. Telehealth has the benefit of improved access to care (Branford et al., 2016; Seto et al., 2019), reduced travel time (Seto et al., 2019), improved convenience (Powell et al., 2017), improved patient engagement (Guo and Albright, 2017), reduced costs (Powell et al., 2017; Jiang et al., 2019; Seto et al., 2019), and improved session attendance (Kairy et al., 2009; Morris et al., 2011). Telehealth objective exam measures have been shown to be valid and reliable (Russell et al., 2010; Somerville et al., 2017) and interventions have been shown to improve pain and physical function (Cottrell et al., 2016). Telehealth has comparable patient satisfaction levels when compared to in-person rehabilitation (Moffet et al., 2017).
Although Telehealth presents some advantages when compared to in-person sessions it also has drawbacks. These include technology barriers (Lin et al., 2018; Seto et al., 2019), increased difficulty with exam measures (Powell et al., 2017), patient/provider preferences (Kruse et al., 2016), security, privacy, and confidentiality challenges (Hall and Mcgraw, 2014; Powell et al., 2017). However, most notably, since manual assessments cannot be performed by the clinician, the objective exam has a greater emphasis on movement analysis (Malliaras et al., 2021). Although this can be a potential barrier, it can also be viewed a benefit. By not being able to manual assess a patient, the clinician needs to rely more heavily on analyzing a climber’s movement. This may allow them to look past the affected pain region and integrate concepts on regional interdependence (Wainner et al., 2007) into their diagnostic procedures. Regional interdependence is a concept that unrelated impairments in a remote anatomical region may contribute to or be associated with the patient’s primary complaint. By using this concept remotely, clinicians may be able to uncover impairments that may have been missed in an in-person clinical exam that was solely focused on the painful region. Additionally, since it has been shown that telehealth improves patient self-efficacy (Guo and Albright, 2017), it can be utilized for improved patient engagement by placing a greater emphasis on the self-performance of corrective exercises and optimizing movement patterns.
This article focuses on a rock climber who was evaluated and treated using telehealth with suspected triceps tendinopathy. There are three heads of the triceps muscle: the medial, lateral, and long head. The three heads share a central tendon that inserts into the olecranon process of the elbow. Triceps tendinopathy, like other tendinopathies, occurs when repetitive use of the tendon leads to activation and proliferation, matrix changes including disorganization of collagen and neovascularization. In a prospective single-institution study that evaluated the demographics of 911 independent climbing injuries (Shöffl et al., 2015), the most 149 common body regions injured were the finger (52%), shoulder (17.2%), hand (13.1%), and the forearm and elbow (9.1%). Most of the elbow injuries in the study (5.5%) were identified as epicondylitis. Triceps tendinopathy is not only a rare condition in climbers but also in the general population with some studies citing a 3.8% prevalence of elbow injuries when assessed with MRI (Koplas et al., 2011). However, although prevalence is low, the methods used in this case study to assess the injury in the remote setting can be generalized to all body regions.