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Case Studies & Featured Topics

Tennis Elbow, Golfer's Elbow, Epicondylitis

By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.


Case Presentation

A 44-year-old double glazing worker presented with bilateral elbow pain of 13 months’ duration.

The patient attributed symptom onset to repetitive occupational activities, particularly movements involving wrist extension and forearm supination. Symptoms were aggravated by work-related tasks and relieved with rest and elbow extension.

Previous medical management included two corticosteroid injections (December 2008 and June 2009), which failed to provide sustained relief.

Clinical Examination

The patient demonstrated classical features of lateral epicondylitis:

  • Lateral elbow pain, described as a dull ache that intensified with activity
  • Focal tenderness over the lateral epicondyle
  • Pain reproduced with resisted wrist extension (Cozen’s test)

Range of motion:

  • Moderate restriction in elbow extension (−8°)
  • All other movements were within normal limits

Neurological examination:

  • Upper limb motor function and strength were intact
  • No neurological deficits were identified

Clinical Impression

Findings were consistent with chronic lateral epicondylitis (tennis elbow), likely involving:

  • Degenerative changes at the common extensor tendon origin
  • Repetitive mechanical overload
  • Chronic soft tissue adhesion and dysfunction

Treatment

A multimodal conservative treatment programme was implemented:

Deep Transverse Friction (DTF)
Applied to the common extensor tendon to:

  • Reduce adhesions and scar tissue
  • Improve local circulation
  • Facilitate tissue remodelling

Manual Therapy / Manipulation

  • Mills’ manipulation
  • Lateral glide technique (Mulligan concept)
  • Marble’s mobilisation

These techniques aimed to:

  • Improve joint mobility
  • Reduce pain
  • Restore functional movement

Cryotherapy
Ice massage (5 minutes) was used to reduce inflammation and provide analgesia.

Acupuncture
Acupuncture was applied to local and channel points to reduce pain and muscle tension.

Elbow Support (Epicondylitis Clasp)
Used during the initial 3-week phase to reduce mechanical load through relative immobilisation.

Rehabilitation
A home exercise programme was prescribed, focusing on:

  • Stretching of wrist extensors
  • Gradual return to functional loading

Treatment Schedule

  • Twice weekly for 3 weeks
  • Followed by once weekly for 2 weeks
  • Reassessment at 3 weeks

Clinical Outcome

After 5 treatment sessions:

  • Significant reduction in pain
  • Only mild discomfort during work-related activities
  • No symptoms at rest

At 3-week review:

  • Pain largely resolved
  • Residual tenderness on palpation
  • Mild discomfort with orthopaedic testing

At follow-up:

  • Only minimal tenderness in wrist extensors
  • Functional recovery achieved

Discussion

Lateral epicondylitis affects approximately 1–2% of the general population and is a common cause of work-related upper limb pain (J A Verhaar, 1994).

Although a wide range of treatment options exists, evidence remains variable. Common approaches include:

  • Rest and activity modification
  • NSAIDs
  • Corticosteroid injections
  • Bracing
  • Physiotherapy and manual therapy
  • Surgery (in refractory cases)

Corticosteroid injections may provide short-term relief (2–6 weeks), but evidence suggests limited long-term benefit (W J Assendelft et al., 1996; N Smidt et al., 2002).

Manual therapy approaches, including mobilisation with movement (Mulligan concept), have demonstrated beneficial effects on pain reduction and function (Bill Vicenzino & A Wright, 1995).

Deep transverse friction (Cyriax technique) is traditionally used to address tendon adhesions and promote tissue healing (James Cyriax concept).

Acupuncture has also been investigated as an adjunctive treatment, with studies suggesting potential analgesic effects in lateral epicondylitis (Brattberg, 1983; Fink et al., 2002; Haker & Lundeberg, 1990; Molsberger & Hille, 1994).

Chronic cases may require prolonged recovery periods, often exceeding 3 months even with appropriate management (G T Gabel, 1999).

Conclusion

This case demonstrates that a structured, multimodal conservative approach — including manual therapy, soft tissue techniques, acupuncture, bracing, and rehabilitation — can be effective in managing chronic lateral epicondylitis, even in cases unresponsive to previous medical interventions.

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