Tennis Elbow – Case Study

This is a case history of a 49 year old lady with a classical tennis elbow. This is a typical presentation at the practice and shows how it is important not to just look at the painful spot. There are often a number of additional problems that have to be dealt with to get a good result.

Subjective Pain on the outside of the right elbow with referral to top of shoulder and into the forearm. It aches most of the time and then becomes sharp with use. Pins and needles into thumb and first finger when it is at its worst. No numbness. No heat/cold/mottling of skin. No neck/thoracic pain.
Aggravating factors – Gripping, (handbag), elbow flexion or wrist extension. It does not like static positions for long, e.g. 30 min plus
Easing factors – Rest, but not for too long or it stiffens. Heat.
24hrs – Very stiff for 1 hour in the morning. Ache in evening. Depends on activity.
History – Gradual onset over two years, worse in the last three months since playing golf in summer. No particular reason for starting, no obvious trauma.
Social History – Housewife, uses the gym, some machines can affect it. E.g. cross trainer.
Past Medical History – No previous problems in arm. Previous treatment for foot problem in 2000.
General health good. No diabetes, epilepsy, high blood pressure, haemophilia, fits. No Rheumatoid Arthritis in family, No allergies. No Pacemaker. Not pregnant. No circulatory issues. Drug history – no medication at present.
Objective Observation – Poor posture, slouched flexed thoracic (mid spine), extended cervical spine (neck). Right forearm/elbow looks wasted in comparison to left (Right Handed). No swelling/colour.
Neck. Good range bar stiff to right rotation. No pain or referral even on sustained hold.
Bilateral shoulder joints. Full ranges all directions, no pain, no stiffness. Good shoulder stability/control but the outside neck muscles were tight. No joint impingement on testing. 1st and 2nd ribs were found to be stiff and tight.
Right elbow Assessement.
Active movements. (Patient performed) Moving the elbow itself was just a little stiff. Wrist extension (pull back) caused pain at the end of the range. Flexion (wrist down) produced a pull in the forearm muscles. Grip was weak and painful.
Passive movements. (Physiotherapist performed) Elbow movements were full and normal. Bending the wrist with the elbow straight pulled in the spot.
Muscles. Elbow flexion/extension no pain in all ranges. Wrist grip, hand and thumb/finger extension all immediately painful in the outside forearm muscles and tendon and into the lateral epicondyle (bony lump on outside of elbow).
Additional Tests Nerve tension test produce restriction and pain in the forearm.
Other tests Cervical spine palp. Stiff and painful C4/5/6 on the right only (mid neck). 1st and 2nd ribs tender. Lateral neck muscles tight and tender.
Palpation Painful, thick lump in the tendon just below lateral epicondyle.
Problem list

  1. Cervical spine dysfunction C4/5/6 with associated posture problems
  2. 1st and 2nd ribs stiff with associated outside neck muscle tightness.
  3. Nerve tension signs associated with neck and rib problems
  4. Old tear in tendon on outside of elbow with extensive scarred/degenerative/inflamed tissue

Treatment Plan

  1. Mobilise neck and ribs and address muscular imbalances in shoulder girdle – manual and exercise based techniques
  2. Nerve tension signs – will ease with treatment of above but some mobilising of the nerve tissue is also indicated
  3. Deep tissue mobilisation of the scarred musculo-tendinous junction
  4. Graded exercise regime for the restoration of normal tissue structures
  5. Assistance with the local inflammation

Overview of treatment techniques used

  1. Neck manipulation and mobilisation – trigger points released with pressure techniques.
  2. Mobilisation of nerve tissue with arm in nerve tension positions.
  3. Local deep mobilisation of painful area in extensor tendon with extensors on stretch.
  4. Exercises for loading of muscle and tendon, nerve mobilisation and neck muscle stretching and self neck mobilisations.
  5. Acupuncture and electrotherapy. Possible use of braces to off-load the area in the short term to allow healing.

The above assessment, treatment and home exercise prescription would take place on the first visit. For this condition with a two year history I would expect to have to see the patient about 6 to 8 times over a couple of months to clear all the problems. Subsequent treatments will vary according to how the condition is progressing.
We feel it is essential to involve the patient in their treatment at all times. Ensuring they understand what is happening to them and what they can do to help themselves.
The aim will be to clear all of the symptoms and to return the patient to full activity – including tennis.


Sue Hayes