Clinical reasoning & treatment for lateral epicondylitis

Tendons are the tissue that attaches the muscles to the bones. Overuse in the upper extremities can result in the diagnosis of the tendonitis or the tendonitis of the wrist, elbow or shoulder. The most common wrist or forearm problems include tendinopathy of the muscles that extend the wrist, otherwise known as tennis elbow.

The major muscles that move the wrist have their origin at the elbow. If the wrist is improperly used, pain may arise in the forearm and/or outside of the elbow. Tennis players and athletes who use backhand and does repetitive motions that extend and fled the wrist is, particularly at risk. Lateral elbow pain may not affect only such players or athletes but also affect who use a screwdriver or hammer on the daily bases or those who great amount of time in gardening taking, painting. The patient who works with a pronated forearm and flexed wrist like computer workers also feel lateral elbow pain and burning sensation which is called as (supinator syndrome).

Clinical reasoning in determining the nature of elbow pain:

Tennis elbow is the common nomenclature for lateral elbow pain.

It is caused due to one or more following consequence,

maligned bones in the elbow and/or carpals, tendonopathy, capsular pain, radial nerve pain, neck and thorax dysfunction.


Clinical reasoning of tennis elbow, proactive physiotherapy 


Treatment strategies :

Frequently tennis elbow is treated with local ultrasound, stretching and wrist strengthening, however, there are several reasons need to be addressed and treatment should be planned accordingly.

Depending on the examination findings, treatment could include

  • joint mobilizations 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 scapulothoracic-cervical mobility & stability (rhythm)
  • exercises for thoracic (vertebrae & ribs) mobility and cervical mobility & stability
  • mobilization with movement (MWM’s – Mulligan’s technique) for upper ribs, wrist, and elbow
  • Mulligan’s and/or McConnell’s taping
  • Kinesiotaping
  • prescription of elbow or wrist brace
  • strengthening exercises for the shoulder, elbow and wrist muscles.
Shoulder joint

Shoulder impingement syndrome : Contribution of scapula



The shoulder is a ball and socket synovial joint . The shoulder is such a fascinating joint with 180 degrees of freedom, which relies on excellent dynamic movement.

How should we use it in the diagnosis of shoulder pain?

In early 1980, Neer et all describes Shoulder impingement and researched for many years and some of the original work . As our understanding of impingement has expanded we have come to realise that there are types of shoulder impingement i.e internal and external, and primary and secondary (Ludewig & Braman, 2011).

What is Internal versus external impingement?

It depends on the site of the impingement. If it is located in the subacromial space it is known as external impingement. If it is located within the glenohumeral joint it is known as internal impingement (Cools, Cambier & Witvrouw, 2008).


External impingement : According to Neer et all, when there is compression between the rotator cuff tendons or long head of bicep tendons, between the humeral head and the undersurface of the acromion, coracoacromial ligament .

Internal impingement : compression of the supraspinatus tendon and/or infraspinatus tendon between the humeral head and posterosuperior glenoid rim. This usually occurs at 90 degrees abduction and external rotation.

Remember , when you simply saying “shoulder impingement” as a diagnosis. This label does not indicate you:
• Which structures are involved.
• Where is the exact site of impingement


What is Primary and secondary impingement?

When there is injury to shoulder joint, it gradually leads to structural narrowing of the subacromial space due to acromioclavicular athropathy, or pathology within the tissues in the subacromial space .

According to Lewis (2011) et all, many people directly jump to the assumption that if structures are impinged, surgery is required to ‘make more room’, but it’s not the case. The pathology lies within tendon itself.

Secondary impingement :

• Glenohumeral joint instability, which can lead to excessive humeral head translation and/or poor position of the humerus in relation to the scapula. In addition to that subscapularis inefficiency to maintaining huneral head in central position.

• Scapula dyskinesis

• GIRD (glenohumeral internal rotation deficit) There is a loss of glenohumeral internal rotation and increase in external rotation, often the posterior cuff & capsule become tight and there is excessive anterior translation of the humeral head resulting in secondary impingement also we can say it’s shoulder medial rotation uncontrol movement. ( Lewis2011 et all)

Many authors said that secondary impingement can affect the rotator cuff tendons or long head of biceps, and it can be both internal and external (Burkhart, Morgan & Kibler 2003; Cools, Cambier & Witvrouw, 2008; Ludewig & Braman, 2011).


The knee movement occurs in sagittal plane only which we consider 1) flexion and 2) extension. Shoulder is complex joint and it has many range of motion which are even more complex.

When we see shoulder patient walk into our clinic , First question comes in our mind where to start assesment. The key to improving your assessment of shoulders is to have a routine checklist in your assessment technique. For instance you should always assess the injured then the non-injured side. According to chief complaint make order of your test because if you prove ke pain initially then all test will be false positive . You should always assess movements in the same order.

Cools et al (2008) published a fantastic paper outlining an assessment algorithm to assist clinicians in their screening of shoulder patients with suspected impingement and clinical diagnosis. This algorithm is a great place to start when you’re developing skills in shoulder assessment.

The images below represent the Hawkin’s Kennedy, Neer, and Jobe test for shoulder impingement described in the algorithm above (Cleland, 2005).




after reading this algorithm the scapula assistance test & scapula retraction test will become your routine clinical test

(Cools, Cambier & Witvrouw 2008)


Scapula assistance test : assesses the impact of correcting scapula position on shoulder pain and impingement symptoms during active shoulder elevation. the clinician assists the scapula into upward rotation while the patient elevates their arm and observes if there is a change in pain.


Scapula retraction test assesses the impact of maintaining scapula position during loading and assessing the impact on pain. For the scapula resistance test the therapist resists the scapula into retraction while assessment pain in the resisted elevation in an abducted and internally rotated position.

Let’s gather all points :

When assessing a shoulder you should always try to focus on the following:

• Carefully observing the functional aggravating position.
• Reproducing shoulder symptoms and then trying to change them with scapula positioning, muscle activation exercises or manual therapy.

• If there is a reduction in pain it indicates a ‘green light’ to go ahead and treat with same rehabilitation.

• If there is Red light during your assessment – you will need to reconsider your diagnosis, consider a referral for medical imaging and/or referral to a specialist.




1. Braman, J. P., Zhao, K. D., Lawrence, R. L., Harrison, A. K., & Ludewig, P. M. (2014). Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgery and physical therapy. Medical & biological engineering & computing, 52(3), 211-219.

2) Cools, A. M., Cambier, D., & Witvrouw, E. E. (2008). Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British journal of sports medicine, 42(8), 628-635.

3)Cools, A. M., Declercq, G., Cagnie, B., Cambier, D., & Witvrouw, E. (2008). Internal impingement in the tennis player: rehabilitation guidelines. British journal of sports medicine, 42(3), 165-171.

4) Kibler, W. B., & McMullen, J. (2003). Scapular dyskinesis and its relation to shoulder pain. Journal of the American Academy of Orthopaedic Surgeons,11(2), 142-151.

5) Kibler, W. B., Ludewig, P. M., McClure, P. W., Michener, L. A., Bak, K., Sciascia, A. D., … & Cote, M. (2013). Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’. British journal of sports medicine, bjsports-2013.

6) Kibler, W. B., Sciascia, A. D., Bak, K., Ebaugh, D., Ludewig, P., Kuhn, J., … & Cote, M. (2013). Introduction to the second international conference on scapular dyskinesis in shoulder injury—the ‘Scapular summit’report of 2013.British journal of sports medicine, bjsports-2013.

7) Ludewig, P. M., & Braman, J. P. (2011). Shoulder impingement: biomechanical considerations in rehabilitation. Manual therapy, 16(1), 33-39.

Guideline for Rotator cuff rehabilitation

There are many school of thoughts for RC rehabilitation, here we try to make you easy understanding how to approach . While assessing the rotator cuff in person .

when patient come to us after rotator cuff repair surgery we need to fully understand his daily activities affecting their ability to their normal life. Here there are few keys that need to be consider…….

Key consideration factors in Rotator Cuff Rehab :

• age of the patient,
• activity level,
• injury to affected shoulder,
• response to previous treatment,
• imaging and what were the findings,
• past medical history,
• joint status (hypermobile or hypomobile),
• what they think is going on in their shoulder,
• most importantly is the ultimate goal of the client.


Plan for treatment……..

what do we do for people presenting some form of shoulder pain? There are many different answers but for the purpose of this, we will keep it simple that will help restore
pain free ROM, strength, and slowly return them back to their functional level.

Control on the shoulder pain :

We want to get the shoulder joint moving through self-ROM activities. We prefered patient to go for foam roll their thoracic spine and Latismus dorsi muscles to achieve overhead shoulder mobility. We will work on external rotation ROM at 45 degrees and 90 degrees of abduction.

Following this exercise we prefer to work on shoulder flexion AAROM in supine position, once gradually ROM restore we’d prefer kinetic chain activation exercise.

For strengthening,we like to begin with isometric activities to help with pain control.


When to start  higher level strengthening programme:

Once you achieve all criteria for advanced training we would like to start strengthening activities, we add isotonic strength training with  theraband  : full can, sidelying external rotation, prone horizontal abduction, prone extension and prone full can. There are Many studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities.

There are  evidance, we like to add program in our routine protocol but will change the weights, sets and reps depending on Patient tolerance during exercise.

We rarely have patients perform 3 sets of 10 repetitions so the goal of the exercise needs to be fully understood in order to prescribe it correctly.

Advanced strengthening :

Once an adequate base of strength is achieved , we will add another level of strengthening programme depending upon patient’s requirement. We also focus on proprioceptive exercise once adequate strength achieved.

For athlete , Plyometric strength training is incorporated to allow the athlete to produce a force and power in his sports activities. which will hopefully help them in their return to their sport. This may include chest press, overhead throws, and rotational throws etc…

Pull ups, push-ups, bench pressing and overhead pressing are also added to make sure the athlete is strong in multiple planes to performing his sports.

Finally,The key is knowing the ultimate goal of the athlete .there are many factors that need to be considered when returning a patient back to their highest functional level when they have a  cuff injury.

This post was my attempt at outlining a very general guideline for an athlete or non athletic poplution with a rotator cuff issue and what my thought process may be.

Remember, listen to their issues…they may just tell you what program is best for them!

Any question!!!!!!!


image courtesy:

Supraspinatus tendonitis : Guide to treatment

The supraspinatus is usually injured because of heavy repeated demands placed on it ,such as carrying a briefcase, laptop computer, purse, or baby carrier. It is often impinged under the acromiom due to tight pectoralis and tight subscapularis muscles.

The supraspinatus has a small superior shear component, but its main function is compression because
of the horizontal orientation of the muscle fi bers, thus, it opposes the upward superior shear action of the deltoid.

The impingement cycle is a continuum that can begin anywhere in the sequence and can cause a vicious succession.

supraspinatus from proximal to distal with forward elevation. The primary point of contact on the bursal side is at  the supraspinatus insertion throughout forward elevation. The subacromialbursa facilitates this motion and contact. It is a unique anatomic arrangement that exposes the soft tissues to wear and degeneration as the arm is elevated and rotated during range of motion of the shoulder. Furthermore, the impingement may be accelerated by any anatomic architectural changes in the acromion or acromioclavicular joint that reduce the volume of the subacromial space.  

The long head of the biceps and tendons of the rotator cuff pass through the subacromial space; these include the supraspinatus, infraspinatus, and teres minor muscles, which insert onto the greater tuberosity of the humerus. The subscapularis muscle inserts onto the lesser tuberosity. The rotator interval is created between the subscapularis and
supraspinatus tendons. All four rotator cuff tendons interlace with each other over the humeral head before inserting. This continuity allows a functional interaction of the rotator cuff.

What should you do ?

The patient will complain of posterosuperior shoulder pain. You do asses the shoulder in the first 20-30˚ of abduction. Movement beyond that is the action of

the middle deltoid, which will be painful to a resisted test above 30˚ of abduction. Also, the fibers of the supraspinatus tendon can be impinged where it runs under the acromiom process, which can cause chronic pain .



Start with the basic shoulder protocol. Concentrate on scapula muscle balance exercise. You do release the pectoralis major and minor, subclavius, upper trapezius, middle deltoid, and subscapularis. Muscular balance is essential in shoulder rehabilitation.

It is necessary to balance and release all of the muscles perticularly the pectoralis minor and subscapularis, to properly treat this condition. The enhancement between upper trapezius and lower trapezius will help to relieve pain. Most of the time while doing retraction ,patient does elevation with retraction. We should observe the movemtn pattern and break it. Concentrate on serratus activity because it is responsible for upward rotation movement.

Next follow the specific protocol for the supraspinatus including myofascial release, trigger point work, and Eccentric exercise for tendon load is also helpful.

Reassess and repeat the protocol until the client is pain-free.

To find out more on supraspinatus ……..


netter anatomy , pectoralis minor , physiotherapy


Pectoralis minor ,proactive physiotherapy, kinetic chain

Coutsey :

Human body is designed in such an intricate manner that upper limbs are for manipulative activities and lower limbs are for mobility. When each of the body segments is aligned properly it gives a pleasant appearance as well as a disorder free body. While poor posture and muscular imbalance often results into pain and loss of function.

Physiotherapy musculoskeletal assessment format consists of many points in observation, palpation and examination which are extremely important for proper diagnosis, treatment planning and knowing the prognosis. However, many a times while assessing shoulder and cervical region; one of the important muscle- Pectoralis Minor is often neglected. A shortened pectoralis minor muscle commonly contributes to muscular imbalance and pain in shoulder and cervical region.

Poor upper body posture is many a times referred to as a ‘forward head posture’, ‘slouched posture’, ‘poking chin posture’, or ’rounded shoulder posture’ and is considered to be a potential etiological factor in the pathogenesis and perpetuation of many clinical syndromes like Thoracic outlet syndrome, Scapular downward rotation syndrome, Scapular winging & tilting syndrome, shoulder impingement syndrome and also upper cross syndrome involving the neck and shoulder.1, 2

origin insertion of pectoralis minor , neurokinetic

The pectoralis minor attaches at the coracoid process of the scapula and at the third, fourth, and fifth ribs near their sternocostal junctions. A short pectoralis minor muscle increases the muscles passive tension with arm elevation resulting in restriction of normal scapular movements such as external rotation, upward rotation and posterior tipping and this in turn will affect glenohumeral and cervical motion.1, 3


Few Clinical tests have been recommended to test for shortening of this muscle.

AT Distance: 1, 4, 5

Pectoralis length test

The patient in supine lying, arms by side or resting on abdomen and instructed to relax. With the help of rigid standard plastic transparent right angle, measure the linear distance in millimeters between the posterior border of the acromion and the table. Take care not to exert any downward pressure into the table and place the base on the treatment table and the vertical side adjacent to the lateral aspect of the acromion. A distance greater than 2.54 cm (1 inch) suggests short pectoralis minor.

Pectoralis Minor Length Index (PMI): 1, 4, 5, 6

The PMI is calculated by dividing the resting muscle length measurement by the subject height and multiplying by 100.The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a measuring tape or sliding caliper. PMI is suggested to reflect a shortened pectoralis minor when 7.65 or lower.


Referances :

  1. Jain S, Shukla Y. “To find the intra-rater reliability & concurrent validity of two methods of measuring Pectoralis Minor tightness in Periarthritic Shoulder patients.” Indian Journal Of Physical Therapy 2013;1(2):34-38
  2. Lewis J.S., Valentine R.E. “The Pectoralis minor length test: a study of the intra-rater reliability & diagnostic accuracy in subjects with & without shoulder symptoms.” BMC Musculoskeletal Disorders. 2007; 8:64.
  3. Borstad J.D. “Resting position variables at the shoulder: Evidence to support a posture-impairment association.” Journal of the American Physical Therapy Association. 2006; 86(4):549-557.
  4. Borstad J.D. “Measurement of Pectoralis Minor Muscle Length: Validation and Clinical Application.” Journal of Orthopaedic and Sports Physical Therapy. 2008; 38(4):169-174.
  5. Struyf F., Nijs J., Mottram S., Roussel N., Ann M J Cools, Meeusen R. “Clinical assessment of the scapula: a review of the literature.” Br J Sports Med 2012;0:1–8.
  6. Muraki T, Aoki M., Izu.mi T, Fujii M., Hidaka E., Miyamoto H. “Lengthening of the pectoralis minor muscle during passive shoulder motions & stretching techniques: a cadaveric biomechanical study.” Phys Ther. 2009; 89(4).
  7. Pic : Netter`s Anatomy


Shoulder joint

Clinical assessment of scapula

Upper limb is designed in such a way that there is ample amount of mobility which is required for manipulative activities that are a part of daily functional activities. In recent days there is increased interest on the role of scapula, its related pathologies and how entire upper extremity function is dependent on the controlled movement of scapula.

For a full, efficient as well as atleast functional range of motion of entire upper limb, scapula plays many roles in facilitating optimal shoulder function by glenohumeral integration, motion on thoracic wall and as a part of scapula-humeral rhythm. With good proximal control there is good distal mobility. Any alterations in the activity of scapula hamper the control over all upper limb activities leading to pain, impingement and other clinical syndromes which gradually causes disability.


Observable alterations in the position of the scapula & the pattern of scapular motion in relation to thoracic cage are called scapular dyskinesis. It causes many clinical dysfunction of the shoulder leading to disabilities.


Causes of Scapular Dyskinesia:


  1. Bony injuries or abnormalities- Types of acromion process or postural alteration 
  2. .Alteration of muscle function- upper cross syndrome, inhibited muscle- serratus anterior, lower fibres of trapezius, rhomboids, deep neck flexors, force couples.


  1. Contracture & other flexibility problems- pectoralis minor & major, joint capsule, upper fibres of trapezius, levator scapula


  1. Nerve injury/ proprioceptive dysfunction- long thoracic nerve, spinal accessory nerve



Classification of Scapular Dyskinesia:



  • Type I – Abnormal rotation around transverse axis: commonly found secondary after rotator cuff dysfunction- inferior angle becomes prominent
  • Type II – Abnormal rotation around vertical axis: commonly seen in patients with glenohumeral joint instability- medial border becomes prominent
  • Type III – Abnormal superior translation of entire scapula: commonly seen in rotator cuff dysfunction and deltoid-rotator cuff force imbalances- superior border becomes prominent
  • Type IV- both scapula are symmetrical at rest & during motion; they rotate symmetrically upward with inferior angles rotating laterally away from midline. This indicates scapular control muscles are not stabilizing the scapula.



Types of Winging:

  1. Static winging- winging happens at rest, usually caused by structural deformity of scapula, ribs, clavicle or spine.
  2. Dynamic winging- winging happens with shoulder motion. It can be cause of trapezius weakness or serratus anterior weakness. In case of trapezius weakness, scapula depresses and moves move laterally with inferior angle rotated laterally. In case of serratus anterior weakness, scapula elevates amd move medially with inferior angle rotated medially.


One more clinical syndrome exists which is coined as S.I.C.K scapula

S- Scapular mal-position

I- Inferior angle prominent

C- Coracoid pain

K- Dyskinesia


Clinical assessment of scapula includes evaluating posture, motion, muscular activation and control and corrective maneuvers. Steps for assessment

  1. History taking
  2. Thoracic and cervical posture – trigger points and flexibility
  3. Check for the shoulder posture- trigger points and flexibility
  4. Shoulder strength – especially supraspinatus, infraspinatus, and subscapularis, Serratus anterior, lower trapezius
  5. Shoulder ROM @ 0 and 90 degrees – GIRD
  6. Scapula position @ rest
  7. Scapula position during active abduction and flexion – especially watch descending phase
  8. Scapulothoracic bursitis



Few important tests include Lennie test, Lateral scapular slide test, Scapular assistance test, scapular isometric pinch test, wall push test, Labral tests, impingement tests, tendinitis tests, etc.



  • Kibler B, McMullen J. “Scapular dyskinesis and its relation to shoulder pain”. J Am Acad Orthop Surg. 2003;11:142-151.
  • Magee DJ. “Shoulder. Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012; 231-360.


Static Postural Assessments

Static posture define as how individuals physically present themselves in stance. It is reflected in the alignment of the body.

Posture can be thought of as static or dynamic. Static posture means how individuals physically present themselves in stance which  could be considered the base from which an individual moves. It provides the foundation or the platform from which the extremity moves.

Dynamic posture is reflective of how an individual is able to maintain posture while performing functional tasks.

We will only discuss static posture here.

Systemic approach to assess static posture.

Static postural assessments require a strong visual observation skill from the clinicians. This can be developed with time and practice. Generally, and  static postural assessments begin at the feet and travel upward toward the head. Clinicians should observe from anterior, posterior and Lateral view.

Basic check point of body region that needs to consider while assessment.

  1. Foot and ankle
  2. Knee
  3. Lumbo-pelvic-hip complex (LPHC)
  4. Shoulders
  5. Head/cervical spine

A static postural assessment is a simple yet effective tool to quickly “size up” your client. Consider yourself a detective looking for structural deviations within a kinetic chain. Many muscle imbalances can be easily identify from the deviations noted in the static postural assessment.

Using a static postural assessment on an initial evaluation of your client will give you a “big picture” view of how that individual uses his or her body day in and day out. Consider the body as a road map.

There are several questions in our mind that

  1.  How have these alterations distorted the feedback from the proprioceptors?
  2.  How has the altered alignment affected the function of the soft tissue?
  3. Has the fascia been overloaded?
  4. Have compensatory muscle imbalances been generated creating altered length-tension relationships, altered force production, synergistic dominance, and altered reciprocal inhibition relationships?
  5. How have these changes affected the entire kinetic chain and overall coordination of movement within the limbs and between the limbs and the trunk?

The static postural assessment is the first step in assessing the biomechanical and neuromuscular pieces of the puzzle necessary to create a program for functional re balancing for your client.

By looking on patient’s posture clinicians have easy to identify on Which muscle they have to work regarding condition.  By looking from different view of standing position one should easly identify the over active and under active muscle group. These will help in clinicians to reach functional goal.

Coutrsey : corrective exercise essential  : NASM