HISTORY: An 18-year-old high school athlete was referred to physical therapy with a medical diagnosis of bilateral triceps brachii tendonitis after a four-month history of progressive bilateral elbow pain. There was no history of trauma or significant medical history. The patient was involved in several sports including football and weightlifting. Patient described aggravating factors to be throwing with high velocity, weight lifting, and rock climbing; rest from physical activity was only alleviating factor reported. PHYSICAL EXAMINATION: Examination in the outpatient physical therapy clinic revealed elbow AROM within functional limits in all planes. PROM revealed elbow pain with overpressure into flexion bilaterally with R+ greater than L+. Resisted strength testing revealed no side-to-side strength deficits but elbow pain with elbow extension bilaterally. Uncompromised vascular system, with 2+ radial pulses bilaterally. Flexibility testing revealed tightness of latissimus dorsi and pectoralis major/minor muscle groups bilaterally. No pain was reported with direct palpation to triceps brachii tendons bilaterally. Positive tinel’s of radial nerve over distal humerus bilaterally. Spinal mobility assessment revealed severe hypomobility throughout thoracic spine with reproduction of bilateral elbow pain with posteroanterior mobilizations at C7 and T1. Upper limb nerve tension tests revealed positive neural tension of radial and median nerves bilaterally. Increased thoracic kyphosis and bilateral forward shoulders was noted with observation of posture. DIFFERENTIAL DIAGNOSIS:1.Triceps brachii tendinopathy 2. Double crush syndrome 3. Radial nerve entrapment. TEST AND RESULTS: No imaging taken FINAL/WORKING DIAGNOSIS: Double crush syndrome TREATMENT AND OUTCOMES: 1. Thoracic manipulation to C7/T1 and T1/T2 in supine position 2. Spinal mobility exercises 3. Radial nerve sliders 4. Pectoralis major/minor and latissimus dorsi stretches 5. Periscapular strengthening exercises 6. Return to weightlifting, throwing, and climbing with no elbow pain after 4 visits.



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