Case of the Week 3-19-14: Chronic "Elbow" Pain | Modern Manual Therapy Blog

Case of the Week 3-19-14: Chronic "Elbow" Pain

Even though I am taking a break from my practice due to the arrival of my new little one, I am still seeing concierge patients as time and sleep quality allows. Here is a case I have been working on in the past two weeks.

Reminder: Terminology post here.

Subjective: The patient is male in his early 40s who works as a DEA agent, but in intelligence, with prolonged sitting. He is also an active girls softball coach for his daughter’s team. Sx started in right lateral epicondyle area started Oct 2013 after more throwing than usual at a practice. Since then his complaints have worsened in intensity. He also reports history of cervical pain and right scapular pain. Sx are intermittent and worsen with working out, grasping, throwing, general use of right arm and hand. His intensity improved after anti-inflammatory prescription from his MD who referred him to PT. His complaints are rated 7/10 on average


Cervical Patterns:

  • SB and rot/flex DP, mod loss on right
  • cervical extension DN, mod loss
Shoulder Patterns
  • LRF Left FN Right DN min loss
  • MRE Left FN Right DN sev loss (hand to lower lumbar spine)
    • pt was generally surprised at the functional IR loss
  • Left FN
  • Right FN
  • I did rotational breakouts anyway and lumbar locked upper and lower rotation were DN mod loss on right, and FN on left
Upper limb neurodynamic test FN in all except DP with mod loss on right radial bias

Grasping: painful, grasping in upright sitting posture with cervical retraction, significantly less painful, had patient slouch again and grasp, reproducing elbow pain. Repeated upright sitting posture this time with cervical retraction OP, almost abolished pain.

Assessment: Signs and Sx consistent with cervical rapid responder with accompanying neurodynamic dysfunction in radial bias


Day 1:
  • education on postural awareness and use of a lumbar roll in all sitting positions
  • break up prolonged sitting at work, which is 8-10 hours of sitting at a computer
  • light IASTM to cervical, upper trap, lateral upper arm, and posterior forearm (radial container) patterns
  • re-test of radial neurodynamics was now FP, with very minimal pain
  • instruction on cervical retractions with SB right and OP for HEP to be performed hourly or more
  • baseline pain 5/10 or less upon leaving
Day 2
  • reviewed HEP, was not performing cervical retraction and SB OP in retraction, would lose the retraction, thus not loading the right cervical spine (a common mistake)
  • baseline remained 5/10, was able to snowblow during a recent blizzard and did not aggravate it until trying to lift his 10 hp snowblower over the plowed hill at the end of his driveway
  • cervical SB, and flex/rotation still DP on the right, but improved ROM
  • shoulder MRE still sev loss (not surprising as was not addressed in HEP on eval)
  • upper limb neurodynamic test still FP, but a bit more painful than after last Tx
  • Tx, IASTM to the same patterns as above, added some functional forearm tissue release to improve tissue play with forearm pronation/supination to assist the tone reduction
  • added cervical thrust manipulation in downglide, and thoracic manipulation
  • neurodynamic post test was still FP, but very mild discomfort at passive end range OP
  • pt was able to grasp and shake my hand pain free
  • instructed on modified repeated shoulder extension against a corner for HEP
    • it's the second part of this video
  • finished with RockTape to right lateral epicondyle and common extensors
Verbal follow up via text
  • pt had a great weekend
  • Sx rated 3.5/10 at most, and only felt now after prolonged sitting, which is difficult not to do at work
  • I plan on instructing him either on self radial neurodynamic sliders or tensioners for HEP or repeated elbow extension
  • I will most likely regress to cervical retraction with OP or with extension depending on whether or not his cervical SB and flex/rot is FN
That's all for now, but just a great demonstration of how "chronic" pain can still be a rapid responder and easy patient education on cause and effect shows improvement in "elbow" pain with change in cervical position. Updates to follow! Also, can you guess what limitation I plan on addressing next to help with his MRE?

Keeping it Eclectic....


  1. For your question: is the mre a restriction or a control issue. If it is control I would go after the scap stabilizers. If it is a true restriction I might use a sleeper stretch and continue with the first mobilization that you gave him. I would also address his loss of tspine rotation to the R. Thanks.

  2. MRE in this case was mostly a true restriction. Especially limited by thoracic rotation to the same side.