Physical Therapy in Sport 4 (2003) 192–198

www.elsevier.com/locate/yptsp

Case Study

A case study of lateral epicondyle pain in a cricketer: a clinical

reasoning approach to management
Huw Griffithsa,*, Nicola Phillipsb
a
Brecon War Memorial Hospital, Cerrigcochion Road, Brecon Powys, LD3 7NB, UK
b
Department of Physiotherapy Education, University of Wales College of Medicine, Cardiff, UK

Abstract
The differential diagnosis of musculoskeletal disorders in general, and sports injuries in particular, is complex, as they often present
interdependent pathological and aetiological processes. Clinical reasoning is a powerful tool that can allow effective differential diagnoses to
be made and consequently successful outcomes achieved. It is a hypothetic-deductive reasoning process that encompasses pattern
recognition and pathognomonic signs (Jones, 1995). This case study explores its use in the diagnosis and management of a sports injury. It
demonstrates the application of the clinical reasoning process by outlining the reasoning underpinning the generation and testing of
hypothesis and the re-evaluation that is performed following intervention. During this it considers the contributions and interactions of the
physical, neurogenic, psychological and physiological systems, and additionally highlights the importance of active involvement of all
parties in achieving a successful outcome.
q 2003 Elsevier Ltd. All rights reserved.
Keywords: Sports injuries; Clinical reasoning; Lateral epicondilitis

1. Introduction 2. Subjective information

A 22-year-old semi-professional cricketer presented for
treatment with a provisional diagnosis of ‘tennis elbow’
provided by his general practitioner. Musculoskeletal
dysfunctions in general, and tennis elbow in particular, are
often complex, multi-factorial problems. Tissue pathology,
mechanical or physiological processes, neurogenic sources,
primary inflammatory disease and psychological influences
may be involved (Abbott et al., 2001; Jones, 1995;
Vicenzino and Wright, 1995). Tennis elbow has been
defined as: Pain on palpation of the lateral epicondylar
region of the elbow with concurrent pain and weakness
during gripping activities (Haker, 1993). It is common and
can interfere with work and leisure activities. It may also
have financial implications for the individual and society as
a whole (Labelle et al., 1992). However, there is no clear
evidence to support any particular intervention and its
prognostic indicators have not been ascertained (Labelle
et al., 1992; Vicenzino and Wright, 1995).
* Corresponding author. Address: Department of Physiotherapy
Education, University of Wales College of Medicine, Ty Dewi Sant,
Heath Park, Cardiff CF14 4XN, UK. Tel.: þ 44-29-2074-2267.
E-mail address: h.griffiths@iname.com (H. Griffiths).
1466-853X/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2003.08.002
The patient was a 22-year-old semi-professional cricketer
complaining of lateral elbow pain radiating down the dorsal
aspect of his right forearm which prevented him from training
and impaired match performance. He was currently employed
on a part-time basis as the club professional for the season,
having previously lived in Australia, competing as an amateur.
He was a right-handed batsman but also bowled and fielded in
the covers or outfield. His current club was successful and its
previous professionals had made significant contributions to
this success. He played in matches 2 days every weekend with
mid-week training once or twice a week.
A three-week history of symptoms were noted following
practising boundary returns, requiring repeated, maximum
velocity, low trajectory throws. Symptoms persisted for the
rest of that day, and then returned whilst batting during a
match 3 days later, although he continued with moderate
discomfort, which increased the following day. This
prevented him from fielding in the outfield and impaired
his ability to bat, but his bowling was unaffected. He
consulted with his physician the following week, who
prescribed rest, oral non-steroidal anti-inflammatory medi-
cation (NSAID) and referred him for physiotherapy. His
symptoms remain unchanged.
 H. Griffiths, N. Phillips / Physical Therapy in Sport 4 (2003) 192–198
Fig. 1. Pain distribution around the lateral epicondyle, radiating to the
dorsal aspect of the right forearm.
Main symptoms were reported as severe, sharp, pain over
his right lateral epicondyle with a dull continual ache,
radiating diffusely down the dorsal aspect of his forearm
(Fig. 1). This impaired his performance and prevented him
training. He reported this as a maximum of 10 on a 10 cm
visual analogue scale (VAS), which is considered to be a
sensitive, reliable and valid method of measurement of
musculoskeletal pain intensity (Jensen et al., 1986). The
player reported that power grip activities reproduced the
sharp pain and repetition increased the intensity of
the continual ache and the severity of the transient pain.
The intensity of the ache could increase to severe and the
raised intensity of both could last for the rest of the day
following sustained provocation. Batting (particularly when
mis-timing shots) and throwing were the main aggravating,
functional activities. Rest eased them and NSAID slightly
reduced the intensity of the ache.
He reported that he was using the same equipment as
previous seasons, although, the seam of the ball used in the
UK was lower and that wicket conditions differed from what
he was used to; with a lower, more variable bounce. Match
durations and frequency were also similar. As he had been
travelling for three months before taking up his new post, he
had not performed his usual pre-season cardiovascular and
strength conditioning programmes. He reported no previous
occurrence of this condition and claimed his general health
was good. The only injuries he described were fractures of
both his right index and left middle fingers from which he
made a complete recovery, and a mild whiplash injury
sustained four months previously. He described two weeks
of cervical stiffness and mild paraesthesia of the dorsal
aspect of his right hand. These symptoms resolved gradually
and spontaneously and had not reoccurred. He denied night
symptoms, morning stiffness or taking medication other
than the prescribed NSAID.
3. Interpretation of subjective assessment
The hypotheses generated from this information were a
chronic primary soft tissue injury (CPSTI), neurogenic
symptoms with influence of psychological effects and
193
alteration of general physiological parameters. There was
little evidence to imply a primary inflammatory disorder at
that stage.
3.1. Hypothesis 1
A CPSTI could have been responsible for the symptoms
which began during maximal intensity, high velocity
repetitive activity, suggestive of soft tissue injury. The
internal forces generated during such activities are thought
to be large and potentially injurious to musculoskeletal soft
tissues (Garett, 1990, 1996) with repetitive activity increas-
ing the likelihood of injury (Taunton et al., 1988). The
patient’s failure to rest may explain why the healing process
had not resolved the problem, resulting in a chronic
presentation (Hunter, 1994). As pain was localised to the
lateral epicondyle, and isometric contraction provoked pain,
support was added to the hypothesis of a common extensor
mechanism problem (Kendall et al., 1983).
Objective assessment would allow visual examination to
discern atrophy or other significant trophic changes,
palpation to identify tenderness, but would not differentiate
hyperalgesia produced by inflammation of locally damaged
tissue from neurogenically mediated hyperalgesia (Yaksh
and Malmberg, 1994). Evaluation of active and accessory
movements would confirm involvement of the mechanical
structures of the elbow and allow evaluation of biomecha-
nical dysfunctions, which may have contributed to the
original injury (Garrett, 1990, 1996). The presence of
significant dysfunctions would contribute to the hypothesis
of a CPSTI. Pain reproduction during isometric activity
primarily implicates contractile structures such as the
common extensor mechanism (Kesson and Atkins, 1998)
and would therefore be included. Isometric grip strength has
also been established as a reliable and valid outcome
measure for patients with tennis elbow (Abbott et al., 2001),
with maximum pain-free grip (PFG) demonstrating the
highest reliability coefficient (0.87) (Stratford et al., 1993).
3.2. Hypothesis 2
The pain experienced may have had a neurogenic origin.
Whiplash injury, with its associated paraesthesia is strongly
indicative of neuropathic injury (Lamb, 1994; Mimori et al.,
1999) and the peripheralisation of symptoms from a central
locus has been associated with secondary neurogenic
hyperalgesia (Yaksh and Malmberg, 1994) or sensitised
nerve trunk tissue (Cowell and Phillips, 2002). It is also
probable that maximal effort throwing would produce
traction forces in neural tissue causing injury if excessive
or the nerve tissue immobile.
Evaluation of the mechanical sensitivity of neural tissue
would test this hypothesis. Neuro-dynamic testing (NDT) is
considered a significant indicator of pathological sensitis-
ation of neural tissue (Balster and Jull, 1997; Cowell and
Phillips, 2002; Elvey and Hall, 1999), and is reliable with
194 H. Griffiths, N. Phillips / Physical Therapy in Sport 4 (2003) 192–198
a high retest correlation (Van der Heide et al., 2001). Direct
palpation of peripheral nerve trunks could highlight
sensitised trunks exhibiting a hyperalgesic response (Van
der Heide et al., 2001). All sources of potential mechanical
impingement with neural tissue would be evaluated as
Cohen et al. (1992) suggested that recurrent mechanical
irritation can produce peripheral nerve sensitisation. Neu-
ropraxic injury would also need to be excluded.
3.3. Hypothesis 3
Psychological effects may have pre-disposed the patient
to the original injury or may have affected prognosis and
rehabilitation. The subjective assessment highlighted sev-
eral potentially significant psychological factors. The
patient was clearly experiencing significant life events
during a period of reduced emotional and social support.
This was occurring at a time when he perceived the
expectations of him to be high. It has been suggested that
significant life events increase pre-disposition to injury and
can reduce prognostic expectations (Kelly, 1990), whilst
similar effects have been noted in the absence of strong
social and emotional support (Dawes and Roach, 1997). It is
also widely accepted that performance can drop if levels of
cognitive anxiety, dependent on the level of perceived
demand, become too large for an individual (Bird and Horn,
1990). The patient also had to adapt his technique to a new
playing environment, which may have increased the injury
risk, as it would have required technique adjustments,
potentially increasing the error in his motor control
feedback processes. It has also been suggested that the
increased cognitive demands required when making tech-
nique adjustments reduce the individual’s ability to process
other information required for successful skill performance
(Bird and Horn, 1990). This in itself may increase the risk of
injury and can also affect the rehabilitation process, as
technique adaptations can occur in response to pain or
fatigue (Lees, 2002).
There are also physiological factors that should be
considered in this case. The patient lived a sedentary
lifestyle for three months prior to the start of the season and
had failed to undertake his typical pre-season strengthening
and cardiovascular routines. His physical conditioning
would therefore have been lower than usual. This has
been associated with an increased incidence of injury due to
potentially lowered strength, increased fatigue rates and
consequently altered biomechanical performance (Komi,
1994; Lees, 2002). Unfortunately, benchmarks for com-
parison of current physiological status were not available.
At some stage of the rehabilitation process these would need
to be performed to allow objective measurement of change.
The subjective assessment also suggested that the
patient’s symptoms were exhibiting moderate severity and
irritability with significant build (Edwards, 1992). In view
of the irritability and time restraints, the order of the
objective examination was prioritised. Initially a local
examination, PFG, active range of movement of the upper
quadrant and cervical spine, neurological testing and an
initial postural evaluation would be performed. Neurody-
namic testing, spinal palpation and a comprehensive muscle
imbalance assessment would be performed at the sub-
sequent appointment.
4. Initial objective assessment
The patient exhibited comparable hyperalgesia on
palpation of the CEO. This was pronounced at the teno-
osseous junction, marked at the teno-muscular junction and
less pronounced in the muscles. There was also non-
comparable hyperalgesia on palpation of radial nerve at the
elbow. All other elbow and forearm structures were non-
tender. The right forearm bulk was greater than the left but
with no evidence of heat, swelling or trophic changes. The
patient’s postural type was classic swayback (Kendall et al.,
1983) with no significant left/right asymmetry other than a
slightly elevated and protracted right shoulder girdle.
Objective markers of the right side can be viewed in
Table 1. Maximum isometric grip with the left hand was
42 kg. Active and passive elbow movements were full and
symptom free as were individual wrist and digit movements.
However, wrist flexion and composite finger flexion
reproduced comparable discomfort that significantly
increased when they were performed together and further
increased with ulnar deviation, pronation and elbow
extension. Isometric wrist and finger extension also
reproduced comparable pain. All other upper quadrant
isometric tests were asymptomatic. Accessory movements
of the elbow and wrist were unremarkable, as were all
ligament integrity tests. There was no sensory impairment
or reflex alterations and the patient demonstrated full,
asymptomatic shoulder movements. Active and combined
cervical movements were also asymptomatic, although
reduced low cervical mobility was noted, particularly to
extension. By this stage the patient complained of increased
symptoms and PFG had reduced to 3 kg. The assessment
was therefore terminated and the patient was advised to
avoid provocative activities. There was no training or
competition planned until after the next assessment two
days later.
4.1. Analysis
The palpatory and isometric findings supported the
hypothesis of a primary chronic soft tissue injury. The
enhanced comparability of the combined wrist and elbow
movements were suggestive of neuropathic dysfunction as
they are the primary components of the radial upper limb
tension test (ULTT2b) (Butler, 1991), somewhat weakly
supported by the non-comparable hyperalgesia on palpation
of the radial nerve. Clearly differential diagnosis was not
possible until the assessment was complete.
 H. Griffiths, N. Phillips / Physical Therapy in Sport 4 (2003) 192–198 195

Table 1
Objective markers used at initial assessment and subsequent treatments

Isometric pain free grip (PFG) VAS ULTT1 and 2 ULTTb

Start session 6 Kg Not tested Not tested

Initial assessment 10
End session 6 Kg Not tested Not tested
Start session 6 Kg Moderate resistance Moderate resistance
Visit 2 Protective guarding from 3/4 range Protective guarding from 3/4 range
End session 20 Kg
Start session 14 Kg 50% improvement 50% improvement
Visit 3 6 Significant restriction Significant restriction
End session 22 Kg
Start session 16 Kg
Visit 4 6 No change No change
End session 18 Kg
Visit 5 No change No change No change No change
Start session 16 Kg No change No change
Visit 6 6
End session 36 Kg End range restriction End range restriction
Start session 37 Kg Slight end range restriction Slight end range restriction
Visit 7 2
End session 37 Kg Full range Full range

Results are given for pre- and post-treatment for each marker where appropriate. VAS scores were only taken once on each visit.

5. Visit 2 5.1. Analysis

The patient complained of moderate symptom exacer-
bation for 24 h, less marked than that produced by a
match. Table 1 shows the objective marker tests. A
muscle balance evaluation was undertaken at this stage.
The main dysfunctions were, short, overactive anterior
and medial scaleni, levator scapulae, pectoralis minor,
hamstrings and tenso-fascia lata, and long, underactive
deep cervical flexors, lower fibres of trapezius and
gluteals. Cervical and thoracic movements were asymp-
tomatic although he demonstrated poor low cervical, mid
and upper thoracic mobility, with increased segmental
mobility at his lumbo-sacral junction. Passive physio-
logical intervertebral movements (PPIVMs) demonstrated
reduced mobility between C5/6/7/T1 and T4/5/6. Palpa-
tion of the cervical and thoracic spine did not reproduce
comparable symptoms in neutral or combined positions
(Edwards, 1992) although moderate stiffness was con-
firmed at C6/7/T1 and T4/5/6. Palpation of the first rib
and clavicular joints was unremarkable although slight
hyperalgesia was discerned on palpation of the lower
cervical roots. The slump test did not reproduce pain but
the patient reported ‘tension’ at his cervical/thoracic
junction with cervical flexion. Continued slump increased
this with the patient reporting thoracic ‘tension’.
Introduction of bilateral straight leg significantly
increased the thoracic discomfort and was restricted.
There was no further support for the hypothesis of a
CPSTI but strong evidence to support the hypothesis of a
neurogenic disorder. The NDT tests and palpation implied
that neural tissue was sensitised to mechanical deformation
giving an indication of neurogenic pathology. There was
also moderate support from the identification of sights of
potentially abnormal neuro/mechanical interface (i.e. the
upper quadrant muscle imbalances and the impaired low
cervical and mid thoracic mobility). It was also possible that
a primary soft tissue injury at the elbow may have caused or
contributed to neuropathic sensitisation. The objective
assessment did not provide evidence to change the
judgement of severity or irritability made from the
subjective data.
5.2. Ordering the evidence
There was strong evidence to support the hypothesis of a
neuropathic dysfunction and moderate evidence to support a
primary chronic soft tissue injury. It was possible that both
dysfunctions were concurrent. It is known that nociceptive
stimulation produced by injury can produce neuropathic
sensitisation and that sensitised peripheral nerve tissue is able
to release inflammatory mediators in peripheral tissues
(Cowell and Phillips, 2002; Yaksh and Malmberg, 1994).
The strongest evidence pointed to a primary neuropathic
196 H. Griffiths, N. Phillips / Physical Therapy in Sport 4 (2003) 192–198
dysfunction. The neural/mechanical interactions that were
likely to be involved in this dysfunction were the spinal
immobility and the muscle imbalances. There is also strong
evidence to suggest that physiological and psychological
effects may have a significant influence on the patient,
although quantification of the magnitude of these is difficult.
There was little evidence to suggest a primary inflammatory
lesion.
5.3. Initial treatment plan
The cervical spine was the most likely neural interface
with its clear anatomical relationship with the sensitised
neural tissue and reduced mobility. It would therefore be the
first structure treated followed by the other interfaces, once
function had been restored and the outcome evaluated.
Local soft tissue management such as local soft tissue
techniques, biomechanical adjustment and modification of
training would also be included as required. It would also be
important to address the patient’s physical conditioning and
attempt to manage some of the psychological factors. This
could be done concurrently with the physical management
but would need to be done by developing trust and
understanding and with the patient’s agreement, involving
the coach.
5.4. Treatment performed
Sustained Natural Apophyseal Glides (SNAG) were
performed on C6/7/T1 (Mulligan, 1999). Low cervical
mobility exercises were taught and the patient was advised
to liase with his coach to institute a conditioning
programme. He was advised to avoid activities that may
cause further injury or delay the rehabilitation process. He
was specifically advised to avoid outfield-fielding practice
drills and was instructed to field in the slips during games.
He was also advised to avoid all activities that involved
forced or repetitive isometric gripping, bench press or
overhead pressing to allow his muscle imbalances to be
addressed without interference. He was suggested to meet
his coach to discuss the limitation imposed on him by his
current injury and his role within the team. A third visit was
booked for three days later.
6. Visit 3
The player reported reduced pain following the previous
treatment despite playing on consecutive days, batting for
approximately one hour on each occasion. His pain was less
intense whilst batting and settled in each case within a few
hours. He bowled without incident and fielded in the slips.
He undertook no specific training but discussed adapting his
training with his coach, who was amenable and much more
supportive than the patient had anticipated. Table 1 shows
the objective marker tests. He appeared to have improved
lower cervical mobility and hyperalgesia of the CEO was
less marked. These findings were interpreted as significant
improvement with carryover. Treatment was therefore
progressed and further muscle imbalance management
was introduced.
SNAGS were performed as on the previous visit, and
reverse, natural, apophyseal glides (NAGS) were applied to
the same cervical joints (Mulligan, 1999). The patient was
also taught transverse abdominis recruitment in crook lying
and gluteal/hamstring ordering in sitting. The fourth visit
was planned for three days later.
7. Visit 4
The coach had now agreed to allow the patient to
undertake individual cardiovascular conditioning in training
and avoid game practice drills. Table 1 shows the objective
marker tests. Cervical mobility had continued to improve
and all exercise techniques were acceptable. Palpation of the
CEO was unchanged.
The lack of continued improvement suggests either that
the treatment technique was ineffective, another neuro-
pathic interface was involved, or the chronic soft tissue
hypothesis was the primary dysfunction. As cervical
mobility had been restored it was probable that the
treatment techniques had been effective. There was equal
evidence to support further neurodynamic intervention and
CPSTI treatment. It was therefore decided to introduce
local management to clarify this. The extensor mechanism
was treated with soft tissue mobilisation and electro-
therapy. The patient was also taught to recruit the lower
fibres of his trapezius and his other exercises were
checked and progressed. The patient was not available for
one week.
8. Visit 5
The patient’s symptoms were unchanged. As there had
been a one-week gap in treatment the previous intervention
was repeated. No immediate change was observed. The next
appointment was booked for 48 h.
9. Visit 6
The patient’s symptoms remained unchanged and the
thoracic immobility remained. Table 1 shows the objective
marker tests. The lack of further improvement despite the
introduction of local soft tissue treatment implies that a CPSTI
was not the primary dysfunction. Other neurodynamic
mechanisms were therefore considered. Butler (1991)
suggested that poor thoracic mechanics can affect dural
mobility and could be considered as a potential source of the
altered neurodynamics.
 H. Griffiths, N. Phillips / Physical Therapy in Sport 4 (2003) 192–198
The risks and potential benefits of manipulation were
discussed with the patient. Consent was obtained and
vertebral basilar artery and stability tests were completed
(Edwards, 1992; Grant, 1994). Manipulation of T4/5/6 was
performed. SNAGS were then applied to the low cervical
spine, further improving the objective markers. This
outcome implied that the primary neuropathic interface
was the thoracic dysfunction, with some cervical involve-
ment. The patient was taught thoracic mobility exercises
and all other exercises were checked. The next appointment
was booked for three days later.
10. Visit 7
Table 1 shows the objective marker tests. The patient
reported a marked improvement in symptoms. He played
in two matches on consecutive days and reported mild,
occasional discomfort. Manipulation was repeated and all
exercises were checked and progressed. The patient was
advised to recommence net practice but to continue to
avoid fielding drills involving forced throwing for the
rest of the season. He was also advised to start modified
strength training. The next appointment was booked for
10 days.
11. Visit 8
The patient claimed continued improvement, reporting
occasional, transient discomfort. He was competing
successfully and had made significant contributions to
his team’s performance. Isometric grip was symptom free
and all NDT were unremarkable. Compliance with the
muscle imbalance programme had reduced. His exercise
programme was reviewed and its importance emphasised.
The patient was put on self-referred review for one
month. There was no further contact from the patient.
12. Conclusion
Musculoskeletal disorders often present as complex,
interdependent pathological and aetiological processes.
Resolution depends on a clear differential diagnosis and
clinical reasoning is a powerful tool that enables us to
achieve this. It demands hypothesis generation, testing and
re-evaluation after intervention. This case study demon-
strates how clinical reasoning can provide an effective
resolution in a complex case. It is also an example of how
physical, neurogenic, psychological and physiological
processes interact and require individual attention, and it
highlights the importance of the active involvement of all
parties to achieve a successful outcome.
197
Acknowledgements
The Physiotherapy Department, Brecon War Memorial
Hospital, Brecon, Powys, United Kingdom is acknowl-
edged. This case study was completed as part of the MSc
Sports Physiotherapy course, Department of Physiotherapy
Education, University of Wales College of Medicine,
Cardiff, United Kingdom.
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