I recently began treating a patient who was seeing another physical therapist for "lateral epicondylitis." The original physical therapist treated the patient with wrist and elbow ROM, eccentric extensor strengthening, and the appropriate stretching. The patient was not getting better. He saw this physical therapist for two visits and stopped attending therapy for two months because the patient felt that the treatment was not addressing the cause of his pain.
Following two months of increased pain, the patient returned to therapy. During my initial re-evaluation, the patient had complaints of lateral elbow pain as well as pain along the dorsolateral forearm. Pain increased with wrist extension, elbow flexion, and shoulder D2 flexion. The patient had a positive Cozen's Test, positive Mill's Test, tenderness to palpation at the common extensor tendon mass, and pain with resisted elbow extension. Of note, the patient also had a positive radial nerve tension test. Remember, positive neural tension testing reproduces the patient's primary complaint of pain. Assessing proximally, the patient had hypomobility in the CT junction, thoracic spine, and lower cervical spine.
During the re-eval, I was able to decrease the patient's pain from 8/10 to 4/10 by performing a thoracic manipulation, CT junction manipulation in prone, lower cervical sideglides with active radial nerve glides, and IASTM along the radial nerve (EDGE Tool). Additionally, I focused on strengthening the scapulothoracic muscles per his impairments. At his second follow-up the patient returned with 5/10 pain. Following a similar treatment progression, the patient left physical therapy pain free. The patient's third visit was last Friday. He presented to the clinic with pain only during overhead movements and end-range radial nerve stress testing. After addressing postural deficits (see his resting shoulder position in the picture above) and GH joint rotational deficits, he again left treatment pain free.
I have only seen this patient for 3 visits thus far, but he has made significant improvements. These improvements were made because of proper differential diagnosis. As for prognosis, I am expecting 2-3 more visits to maximize strength, normalize GH joint and thoracic ROM, improve posture, and education.
Always assess the radial nerve in patients with lateral elbow pain.
The Student Physical Therapist
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