1. A Case of Lateral Epicondylalgia After Elbow Trauma
Christina Zmolek
PT 788
4/13/16

2. Introduction
Lateral epicondylalgia is a common condition affecting an estimated 1 to 3% of the population. It
typically presents with pain over the lateral epicondyle of the humerus and pain with resisted
wrist extension.3
Epidemiological studies have shown that it is a self-limiting disease with 83%
to 90% of patients showing improvement within a year with a wait-and-see approach8,9
, and
there is mixed evidence for physical therapy interventions when looking at systematic reviews.3,4
There are many randomized controlled trials that show improved function with interventions
such as instrument-assisted soft tissue mobilization6
, elbow mobilization with movement2
, and
eccentric exercises5
compared with standard care, so this case study will look at how those
interventions affect a patient with lateral epicondylalgia.
Subject description
The patient is a male in his early 50’s presenting on 2/23/16 with chief complaint of right lateral
elbow pain. He sustained a fall directly onto his right elbow on 11/23/15. He reported that he
had been moving a big sheet of plywood that wasn’t counterweighted, the ground was slippery,
and he lost his balance and fell. Imaging performed afterwards showed no sign of fracture. At
initial evaluation, the patient stated that his biggest problem was being awoken at night due to
pain when he would roll over onto his right side. He stated that his pain would reach a 2/10 on
the NRPS, and described it as a throbbing pain. Pain would ease with repositioning of his arm.
The patient denied red flags, including dizziness, drop attacks, blurred vision, nausea,
nystagmus, changes in bowel or bladder function, recent unexplained weight loss or gain,
unexplained balance difficulty and unexplained muscle weakness. Cardiovascular and
pulmonary systems were found to be normal and the integument was fully intact. The patient
was fully cognitively aware and able to communicate.

3. Examination Procedures
The cervical spine and shoulders were cleared of involvement with active movements and
overpressures, none of which reproduced the patient’s symptoms. Elbow range of motion was
assessed. The patient had normal range on the left side (0-160 degrees) but had some mild
limitations on the right side, lacking 4 degrees of extension with pain at end-range and only
reaching 140 degrees of flexion. Gross upper extremity strength was assessed with manual
muscle testing and all resisted movements were within normal limits, although resisted elbow
extension did reproduce his elbow pain. Further resisted testing revealed pain with resisted 3rd
digit extension.10
Pain-free grip strength was assessed using a dynamometer, which showed an
8% decrease in grip strength on the right side, which has been shown to be indicative of elbow
pathology.1
Upper limb tension tests were performed to assess radial nerve involvement in
particular, but there was no symptom reproduction with any of the test positions. Palpation
around the elbow revealed tenderness around the lateral epicondyle and radial head and painful
symptomatic trigger points were found in the wrist extensor musculature.
Evaluation
Based on the impairments found, it appears that the patient is presenting with lateral
epicondylalgia secondary to elbow trauma from sustaining a fall. The fact that he has pain
around the lateral epicondyle, decreased pain-free grip strength, and symptom reproduction
with resisted 3rd
digit extension is indicative of wrist extensor tendon pathology. This falls under
APTA Practice Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and
Range of Motion Associated With Connective Tissue Dysfunction.
The patient has an excellent prognosis, due to the mild severity of his symptoms, lack of central
sensitization, lack of concomitant neck or shoulder pain, lack of widespread upper extremity
weakness, and a job with a variety of duties that doesn’t require the patient to be lifting heavy

4. loads every day or performing the same repetitive tasks every day.3
The plan of care will include
manual therapy, specifically elbow mobilization with movement7
and instrument-assisted soft
tissue mobilization, trigger point dry needling as appropriate2
, neuromuscular re-education,
therapeutic activities and therapeutic exercise, focusing on eccentric wrist extensor
strengthening5
. The patient will be seen three times a week for four weeks, which has been
shown to be more effective in functional improvement than two times a week.10
The patient’s
goals for therapy are as follows: The patient will improve by 5 points on the QuickDASH in the
next 2 weeks, the patient will improve by 13.75 points on the QuickDASH in the next 4 weeks,
the patient will be able to sleep on his right side all night without being awoken by pain in the
next 4 weeks.
Interventions
After the initial evaluation, treatment was initiated and humero-ulnar posterior glides and
distraction were performed with the intent of improving elbow extension. The patient had no pain
at end range of extension afterwards. He was given a self-distraction mobilization for his home
exercise program.
Visit 2, elbow mobilization with movement was initiated. Pain-free grip strength was assessed
beforehand and was the same as it was at the initial evaluation. After the mobilization, he was
able to grip with maximal strength without pain. Radial head mobilization was performed
afterwards and he was able to reach full elbow extension without pain afterwards. He still had
tenderness around the lateral epicondyle and trigger points were noted in the surrounding
musculature so dry needling was performed. A twitch response was observed and this was
followed up with soft tissue mobilization. Gripping activities with putty and clips were initiated
and he was able to do them without pain, but fatigued quickly. He also did eccentric wrist flexion

5. with a Flex-Bar, due to evidence showing functional improvement with the addition of eccentric
exercises.
Visit 3, the patient reported that he had soreness after the last visit but it resolved after a day
and since then he had no elbow pain and was not woken up at night. Radial head mobilizations
were performed again, followed up by soft tissue mobilization. He still noted tenderness around
the lateral epicondyle to the touch. He continued with gripping exercises and eccentric wrist
flexion.
Visit 4, the patient continued to report no pain, so wrist and forearm strengthening activities
were progressed, with the addition of resisted supination/pronation and resisted wrist extension.
Visit 5, the patient presented with achiness in his elbow that he attributed to the weather (it had
gotten colder and rained over the weekend) but he still had been sleeping without any problems.
Strengthening activities were progressed with the addition of more resistance. Soft tissue
mobilization was performed again due to tenderness to palpation in the musculature around the
lateral epicondyle.
Visit 6, the patient had no pain and strengthening activities were progressed further. We added
supination curls, BOSU push-ups, body blade, and supination rows with the TRX straps. The
patient reported mild soreness afterwards but not his familiar pain.
Visit 7, the patient reported 5/10 pain and noted that he was very sore after last visit and had
difficulty sleeping. Due to his increased pain, we backed off strengthening activities and focused
on soft tissue mobilization and stretching. He responded well to pin and stretch of wrist
extensors and brachioradialis as well as instrument-assisted soft tissue mobilization.

6. Visit 8, the patient reported no pain and had no difficulty sleeping since the last visit. Some
strengthening activities were included today (gripping with putty and clips, resisted wrist
extension, pronation/supination, supination rows) and he was able to do everything without any
pain or soreness. Radial head mobilizations were performed followed by pin and stretch of
lateral epicondyle musculature.
Visit 9, the patient reported no pain after last visit and had no difficulty sleeping. Strengthening
activities were progressed with the addition of the body blade and roll up bar to increase
pronation/supination strength and supination curls. We continued pin and stretch and radial
head mobilization.
Visit 10, the patient reported no pain and no difficulty sleeping. He stated that he still felt like he
had forearm weakness but was almost at full function. A progress note was needed so the
patient’s strength and function was re-assessed. His pain-free grip strength was about the same
on both sides. He didn’t have pain with any resistive testing and had full range of motion. He still
had tenderness around the lateral epicondyle but noted that it was markedly decreased since
his initial evaluation. Due to the rigorous demands of his job, we decided to continue therapy for
a few more visits for improved strength.
Visit 11, the patient reported no pain and noted that he had been doing push-ups at home with
no pain. Weighted ball toss with the rebounder was initiated and he was able to throw a 7 lb
ball with no problem. No manual therapy was performed due to lack of tenderness around the
lateral epicondyle.

7. Visit 12, the patient continued to report no pain, so we added BOSU push-ups and increased
the resistance on several of his exercises. He was able to do everything without an increase in
pain.
Visit 13, the patient reported no soreness after last visit, so resistance was increased on all his
exercises and he did more repetitions of the BOSUpush-ups with no pain.
Visit 14, the patient reported no pain or difficulty with sleeping and had no soreness after the
previous visit, so his plan of care was concluded and he was discharged from therapy.
Outcomes
The patient was given a QuickDASH questionnaire and scored 13.75 points at the initial visit.
When he filled it out at discharge, he scored 0 points, indicating no functional deficits. We also
took measurements of his pain-free grip strength, reported as the average of 3 trials, which was
found to be 99 lbs at initial visit, improving to 128 lbs at discharge. Since the patient’s chief
complaint was being woken up at night due to pain, we would ask him to report on his progress
with that at the beginning of every visit and by the 8th
visit, he was able to sleep through the
night without being awoken by elbow pain.
Discussion
The patient did achieve all of his goals for therapy and had no functional deficits by the time he
was discharged. The main thing that could have been improved was a more gentle progression
of strength training activities. Since he had been reporting no pain for a few visits, we added a
lot of new resistance activities at once, which really increased his pain and it set us back a few
visits. If we had been more gradual in progressing those activities, we may have been able to
complete his plan of care sooner.

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