For our first case study, we present a patient referred to physical therapy because of elbow pain.  See the details to follow and add your thoughts in the comments!

Patient demographics:  51 year old female

Referral diagnosis:  Lateral epicondylitis

Past Medical and Surgical History:  Nothing reported per patient

Subjective History:  Patient reports that she recently began having right elbow pain that began about four weeks ago.  She does not recall any particular incident or injury that has lead to the onset of her symptoms.  Also, she reports no significant change in her everyday activities that could have brought on her pain.  When asked, she reports that her pain is along the posterior elbow about 1.5 inches below her radial head.  She also feels radiating pain down toward her hand, but cannot recall exactly where this is located.  This patient has also noticed a deep aching pain within her right shoulder, as well as right sided neck pain that radiates down toward her right posterior scapula.  She reports that she has not had any significant history of neck/shoulder/elbow/wrist/hand pain, nor injuries/traumas/accidents to any of these areas.

Observation:  The patient demonstrated a mild forward head posture.  However, the most significant finding from observation was the her right scapula was elevated and downwardly rotated.  There were no other significant differences between either upper extremity in terms of posture, nor head head/neck position (other than the above).

Objective Examination:

• Left shoulder range of motion – full and painless
  • Flexion = 180 degrees
  • Abduction = 180 degrees
  • Extension = 70 degrees
  • External rotation = 90 degrees
  • Internal rotation = 80 degrees

• Right shoulder range of motion – painless
  • Flexion = 160 degrees
  • Abduction = 160 degrees
  • Extension = 70 degrees
  • External rotation = 90 degrees
  • Internal rotation = 80 degrees

• Left elbow range of motion – full and painless
• Right elbow range of motion – full and painless

• Scapula range of motion (protraction, retraction, depression, elevation) – full and painless

• Cervical range of motion – painless
  • Flexion = 80 degrees
  • Extension = 80 degrees
  • Right rotation = 70%
  • Left rotation = 70%
  • Right side-bending = ~15 degrees
  • Left side-bending = ~15 degrees

• Palpation – reproduction of patient’s symptoms with pressure applied to the biceps tendinous insertion to the radial tuberosity, as well as the anterior portion of the distal biceps tendon.

• Manual resistance tests – reproduction of symptoms most significantly with resisted elbow flexion and supination from a lengthened range, less significantly with resistance to supination from elbow flexion at 90 degrees.

• Neurodynamic assessments – not limited, nor symptomatic

• Specific joint assessments
  • Normal mobility throughout the right gleno-humeral joint, elbow joint, wrist and hand
  • Significant hypomobility noted of the right AC joint
  • Significant hypomobility of the C2/3 and C5/6 segments
    • C2/3 FRS left – loss of posteroinferior glide on the right side
    • C5/6 ERS right – loss of anterosuperior glide on the right side

Overall initial impression:  At this point, it is pretty obvious that this patient has a distal biceps tendinopathy.  However, there is no evidence at this time from the patient that there is a clear reason for this pathology.  Without any significant history to indicate an event that acutely overloaded these tissues, nor any change in her daily activities that would chronically overload the same tissues, we are left with the combination of mechanical and neuromuscular dysfunctions that have eventually eroded the ability for these tissues to handle every day stresses that were placed on them.

The combination of mechanical dysfunctions of the AC joint and cervical segments led to an over-recruitment and hypertonicity of the right levator scapula and subsequent inhibition of the upward rotators of the scapula.  This would account for the neck pain, posterior scapula pain, and deep aching in the shoulder.  However, the distal biceps tendinopathy is the result of chronic alteration of neural “flow” due to the dysfunctions within the cervical spine… essentially, the elbow pain was “driven” from the neck (well, and the rest of the upper quadrant).

Initial treatment:  Interventions at the initial evaluation were limited due to time constraints.  However, we were able to perform the following… upper cervical ligamentous laxity screen (-), ROM/mobility screen for cervical arteries (-), manipulation of the C2/3 segment from below to restore lost joint motion (consent was given), neuromuscular re-education to the C2/3 segment for the restored motion, manipulation of the C5/6 segment from the contralateral side to restore lost joint motion (consent given), neuromuscular re-education to the C5/6 segment for the restored motion, and lastly resisted axial elongation to the C2/3 segment (was found to be most inhibited) to reduce global inhibition throughout the cervical spine and restore proper resting tone to the key muscles innervated by those segments.  The patient was educated to perform a home exercise program of self-resisted axial elongation specific to the C2/3 segment (again, this was the most inhibited segment on assessment) once every hour for 1-2 minutes at a time.  Also, she was instructed to limit (to the best of her ability) positioning her head/neck into either forward head position (i.e. computer work) or looking down (i.e. reading a book).

Initial outcome:  The patient reported a significant reduction in elbow pain (at least 50%) and decreased pain in the neck and shoulder girdle.

Follow up visits will be performed on a weekly basis and are planned to include further mechanical treatment to the AC joint, extensive neuromuscular re-education to the right shoulder girdle to maintain appropriate scapula positioning at rest and when using the right shoulder/arm.  Local modalities will also be utilized to aid in the healing of the biceps tendinopathy.  Therapeutic exercises will be used to effectively stress the injured tissues for an appropriate healing response until the patient can perform all of her daily activities without any symptoms or limitations.

Well, that’s it so far for this case study.  What are your thoughts?  Would you have chosen to do anything differently?  We’d love to hear what you have to say in the comments below…