Clinical reasoning in defining 'tennis elbow'

Frequently, tennis elbow is treated with soft tissue massage, ultrasound and some stretches. However, there are several reasons which can lead to the onset of tennis. These reasons are usually highlighted in the subjective examination and generally are clarified by the findings in the physical examination. In such a manner an holistic approach is taken to treat a condition which could become severe and disabling if treated inadequately. Importantly, the aim of the physiotherapist is not to treat every single structure and hope for the best. Rather, the physiotherapist aids in the clarification of the structures which are contributing to the problem. Moreover, they define the order of priority/importance each structure has in the generation of lateral elbow pain. 

Mind map used for clarifying the multiple possibilties

Process for refining the treatment management strategies

Depending on the examination findings, treatment could include

• joint mobilisations to the elbow, cervical and thoracic spines
  
• soft tissue massage of the scalenes, levator scapula, upper trapezius, latissimus dorsi, wrist flexors
  
• dry needling of supinator, pronator teres, common extensors, posterior rotator cuff, upper trapezius, thoracic erector spinae
  
• exercises for scapulo-thoracic-cervical mobility & stability (rhythm)
  
• exercises for thoracic (vertebrae & ribs) mobility and cervical mobility & stability
  
• mobilisation with movement (MWM's - Mulligan's technique) for upper ribs, wrist and elbow
  
• Mulligan's and/or McConnell's taping
  
• prescription of elbow or wrist brace
  
• strengthening exercises for the shoulder, elbow and wrist
  
• gentle self massage with arnica of the elbow (5-10 minutes daily), ice or heat, and tennis elbow brace (temporary or during high loading) 
  
  

Both shoulder and scapula dysfunction needed to be addressed for effectively treating this "tennis elbow".

Thoracic mobility and wrist mobility needed to be addressed.

Lateral diaphragmatic breathing had to be taught for scapula dysfunction as well as maintaining normal sympathetic nervous system activity (metabolic acidosis/alkaloses, and sympathetic ganglia rythmical motion)

Deep neck flexor training and parascapula-post shoulder training was introduced to reduce upper trapezius tension, thereby reducing the compression loading on the cervical spine, as well as reducing adverse neural tension in the brachial plexus

Clearly, in this scenario, the "typical tennis elbow" with mid finger extension pain and ball sqeezing pain, had atypical medial elbow nerve pain, an anteriorly subluxating shoulder and some significant neck-scapula-thoracic spine dysfunction. The process of the physical examination clarified the significance of the limited information given during the subjective examination.