Therapeutic Management of Lateral Epicondyalgia; Tennis Elbow Pain

Tennis elbow pain can be acute or a chronic pain on the outside of the elbow. Lateral elbow pain may radiate to arm or forearm, can cause joint stiffness and strength deficits. The most common and important line of treatment is to start with rest (RICE-rest, ice, compression and elevation). However, these merely treat the symptoms and underlying causes are still present. So, relapsing of pain and/or injury is common. Various forms of treatments are advocated for tennis elbow. Manual therapy and exercise therapy are evidenced as the most effective approach for treating tennis elbow.

The aim of therapeutic management:

  • To reduce pain and inflammation.
  • Helps to induce healing process.
  • Restoration of normal joint ROM and function.
  • To enhance restoration of normal muscle length, strength and movement pattern so as to maintain normal musculoskeletal alignment and functions.
  • Restoration of any biomechanical alteration such as cervical joint alignment or function and hence enhance the restoration of neural dynamics of the upper limb.

Manual Therapy

Cyriax Physiotherapy

  • A combination of deep transverse friction massage with Mill’s Maneuver.
  • Three times a week for four weeks
  • Deep Transverse friction massage (DTFM)

DTFM is a specific connective tissue friction massage applied with the thumb at extensor tendon just anterior to the epicondyle. Patient is in supine lying position. Elbow supported in a 90 degrees flexion and fully supinated position. Deep transverse friction massage is applied for 10 minutes prior to Mill’s maneuver. It helps to maintain the mobility within the soft tissue structures, reduces pain (pain gate theory), softens scar tissue, increases blood flow.

  • Mill’s Manipulation:

This is a small amplitude high-velocity thrust maneuver performed at the end of elbow extension. Patient sits with arm in abduction, internal rotation (olecranonn faces upwards), forearm fully pronated and wrist in flexion. Therapist standing behind stabilizes patient’s wrist in full flexion, while places another hand over olecranon. Maintaining this position therapist applies a quick thrust at the end range of elbow extension. Thus, pain-free full ROM of elbow extension is the prime criteria to perform this manipulation. The aim of the maneuver is to elongate scar tissue by rupturing adhesions developed within the teno-osseous junction which, in turn, improves joint mobility, reduces pain and enhances healing.

Elbow mobilization with movement (MWM):

Mulligan’s concept of joint mobilization. Patient in sitting position with their arm by side, elbow extended and forearm pronated. Therapist applies lateral glide to the radius and ulna by the hand or using a belt. Patient then extends the wrist against resistance or holding weights until the movement is now pain-free.  6-10 reps per session.

Exercise Therapy

Evidence suggests that exercise therapy is the best and consider the primary mode of treatment for lateral epicondylalgia, tennis elbow. It is necessary to restore normal musculoskeletal function and thereby curing the causative factor of pain. Therefore, strength, flexibility and endurance exercises are important to start immediately after the pain and inflammation are under control.

Stretching exercises:

Stretching of extensor muscles of forearm especially, extensor carpi radialis brevis muscle. Method; palmar flexion of the wrist with pain-free range of elbow extension. Hold in nonpainful range for 10-30 seconds. Repeat 5-10 times per session, 4-5 times per day.

Strengthening exercises:

With some improvement in terms of pain and range of motion following RICE and stretching exercises, strengthening exercises for wrist extensors are introduced slowly. Eccentric exercises are evidenced to be more effective. Numerous studies have suggested starting strengthening training with forearm in supination or wrist facing upwards rather than wrist facing downwards. Isotonic and isometric weight training are also important as per the need of patient’s work or sporting style. Strength training based on progressive overload principle with properly designed  (SMART) exercise program.


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