Manual Therapy Forum

Case Study #1 – Elbow Pain


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…



Eric Hitchcock PT, MSPT


There’s always a third-degree black belt out there to let you know you don’t have it figured out!


– Eric Hitchcock


Today, we get to speak with Eric Hitchcock.  Eric is a friend and very well respected work colleague with us here in Chico, CA.  I’ve actually been wanting to record something with him for a long time.  However, as you will hear from Eric, he had hesitations for quite some time.  Thankfully, he succumbed to peer pressure!  Aside from speaking with a great person like Eric, this podcast is unique because it is more of a freestyle episode where we didn’t have a set list of questions.  Instead, we actually get to discuss some topics that weren’t brought up in previous episodes.  So, I hope you enjoy this time spent with Eric.  He’s a special guy and I believe all who listen will learn a lot!


What are you doing, and why are you doing it?  Have purpose with everything that you do.


– Eric Hitchcock



I can’t believe how many times I have belly laughs every day.  That’s a wonderful thing in my life.


– Eric Hitchcock



Listen here:


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I think we are all brothers and sisters on this planet.  I think we are here to help each other.  And I think everyone in this room, individually, and as a group, we are all situated in this time and space to fulfill that part of our human destiny.  To help others.  So, get out there and keep on doing it.


– Bill Snyder (as quoted by Eric Hitchcock)



Advice For Young Professionals


Since the onset of this website, I’ve occasionally gotten questions from individuals about varoius topics.  Recently, a student had emailed me with a set of questions and instead of just responding to that email like I usually do, I decided to record a podcast out of it in hopes that many more people may benefit from these thoughts.  I really do hope this creates a dialogue though as I know many of you may have differing opinions.  Please share your thoughts in the comments below, or on any of our social media accounts.  And don’t forget iTunes!  We would seriously appreciate your feedback there in terms of leaving a review.  Thank you all for listening and I hope you enjoy!


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What is “manual therapy”?

Wow!  It’s certainly been a while since anything has happend here!  If you’ve visited the website recently, you may have noticed some changes.  The format looks different and I hope that it makes for easier navigation.  Now, instead of having to scroll all the way through previous blog posts, you can look through the different categories (i.e. videos, podcasts, written posts, etc.).  Also, I have changed the name as you may notice.  My overall goal for was to eventually be more than just a ‘blog’.  At the time I came up with this idea, that was the best name that came to mind.  I’d always wanted to have a website that wasn’t just a ‘blog’, but rather a place for ideas to be presented, discussed, and to further advance the field of manual therapy for current and future clinicians.  I’ve also wanted to include other things like ‘guest posts’ from other people, case presentations, etc.  So, now has become  I’ve been itching to do a specific post for a long time now about a fairly simple question.  What is ‘manual therapy’?  What does it mean to be a ‘manual therapist’? 

These are all my opinions, so take them for what they’re worth (which may not be too much).  To me, ‘manual therapy’ is truly an art form or craft.  There has been, and will continue to be, an ongoing debate about manual therapy and what is ‘evidence-based’ and what is not.  We can debate that for weeks/months/years on end, as many have.  However, I just want to speak to the fact that what we practice as ‘manual therapy’ ACTUALLY TAKES SOME SKILL!  I have personally seen myself and others grow from a clinician with rocks for hands to demonstrating the ability to artfully perform a manual therapy technique with the utmost skill that the patient is butter in your hands and has no apprehension whatsoever.

Acquisition of a high level of skill in manual therapy cannot be learned in a weekend setting, nor an online module, nor occasionally trying out something you were taught a year ago.  No, it takes time, effort, and dedication.  Seriously though, what in life doesn’t take those things if you want to be great at it?  Consistent practice in and out of the clinic will provide you the opportunity to acquire a level of skill.  However, the ability to recognize (or have someone else point things out to you) skills that need improving about yourself over time will help you direct your focus toward specific things.  Mindlessly practicing manual therapy skills that you are good at on a consistent basis only allows you to get better at those skills.  What we need to do is continually self-analyze our skills in the clinic.  Are the manual interventions I’m performing on a daily and weekly basis effective?  Are they efficient?  Am I performing them with the least amount of force being imparted into the patient?  Is there anything else I could learn that would help my patients further?  So, having the dedication to practice your craft and obtain the level of skill you are seeking is just as dependent on a certain level of introspection, as it is how much you practice your skills. 

Sorry, where was I?  Oh yeah, “what is manual therapy?”  Not only is manual therapy an art form or craft, it is also a ‘means to an end’.  As much as I love what we can do with our hands as manual therapists, I by know means believe that is all we need to do for our patients.  To the contrary, as I continue to practice over the years, my opinions have necessarily changed quite dramatically.  Going from trying to learn different paradigms and a large amount of manual therapy skills earlier in my career, to now realizing a bigger picture of what patients will need to help them advance their health and achieve their goals.  For myself as a physical therapist, our professional association (the APTA) really has done a great job with their public relations campaign about emphasizing “It’s all about movement”.  We as physical therapists are tasked as a profession with improving the function of individual lives by improving the way they move. 

One of my backgrounds is as a Certified Functional Manual Therapist (CFMT) with the Institute of Physical Art (IPA), as well as an instructor for three different courses.  Within their paradigm of Functional Manual Therapy, we describe limitations of an individual’s movement ability to be related to any combination of three possible dysfunctions.  Those are dysfunctions related to mechanical capacity, neuromuscular efficiency, and motor control.  Of course I’m biased in this opinion, but I really don’t believe any reasonable person would disagree with this line of thinking.  For example, say someone has difficulty extending their hip and is causing them a whole host of problems any where throughout the kinetic chain.  Well, do they have some sort of joint restriction or myofascial restriction limiting their ability to extend their hip?  If so, good luck using an exercise-based approach to improve that limited range.  That is where we can appropriately use manual therapy skills to benefit our patient.  After we restore movement and mobility where needed, then we can more effectively utilize any type of exercise needed to improve the individual’s use of that new range of movement.  That is where the neuromuscular efficiency side steps in.  Having the ability to demonstrate appropriate strength and endurance throughout that new range of movement will be necessary to avoid recidivism.  As this is trained in the individual, the need to utilize manual therapy techniques becomes less and less necessary.  Our focus as clinicians should be on strengthening the efficiency of neuromuscular or movement patterns for the individual.  As an aside, please don’t misinterpret that to mean we should only focus on “strengthening” muscles.  No, I mean “greasing a groove” so to speak where efficient movement patterns become so ingrained in our neuromuscular system that our patients can move with greater ease and effort than before.  That neuromuscular efficiency transitions easily onto the motor control side where an individual’s body should be able to appropriately control mobility and movement throughout any range, posture, or position.  We could utilize exercise for this aspect as well, although the design of those exercises would necessarily change as the goals are different.  This is also where a skilled clinician could utilize Proprioceptive Neuromuscular Facilitation (PNF), if they are so trained.  Using PNF allows the clinician to confirm via their own hands whether a patient truly has appropriate motor control through different ranges, postures, positions, movements, patterns, etc.  This may not be completely necessary to achieve various goals for a patient, but they are one very useful strategy.  So, here I hope I’m able to get the point across that being a manual therapist should NEVER be about only performing manual therapy techniques on our patients.  If that is all we do, we are grossly underserving them in their quest of optimizing movement and function.

So, all that said, manual therapy is again… a means to an end.  The end is to improve a patient’s ability to move appropriately and function as optimally as possible.  One of many means to that end is manual therapy.  Notice that during this soliloquy, I’ve made an effort to not imply a specific type of manual therapy approach is required to achieve this goal.  There are certainly many effective and efficient manual therapy approaches that can all improve a patient’s movement.  Whether you personally utilize joint mobilization/manipulation, muscle-energy techniques, muscular stretching, active release technique, cross-friction massage, dry needling, visceral manipulation, fascial manipulation, PNF, cranial osteopathy, soft tissue mobilization, etc. these can all help improve someone’s mobility or movement ability.  We will always have our own biases and personal beliefs as to what may be more effective and efficient, but all are likely to be useful and/or appropriate at some point in time during an individual’s plan of care. 

To summarize, I sincerely believe that what we practice as manual therapists is truly a craft that is passed down from teacher to student across generations and professions.  This craft is something that is to be honed and perfected (if possible) through years of dedication and purposeful, precise, practice.  Manual therapy as an intervention is something that is to be utilized at appropriate times to improve a patient’s ability to move.  There are many different types of manual therapy skills that a clinician could use to improve how a patient moves and depending on the timing and individual circumstances involved with a patient, most (if not all) of these types of manual therapy skills will be both effective and efficient.  Once we use manual therapy to improve how a patient moves, we must incorporate exercises in some form to further ingrain into our patients correct movement strategies or patterns.  As our patients become more efficient movers, we can further utilize exercise to help them achieve their specific individual goals.  I hope this commentary will be though-provoking in some way for any that read it.  Manual therapy is a passion of mine certainly, but it should never be all that I (or any of us) do with our patients.  What are your thoughts?  I’d love to hear them in the comments section below!