Dr. James Cyriax was a pioneer in orthopaedic medicine, especially when it comes to manual therapy. Maybe I'll talk more about the guy in another post. For now let's just leave it at he was a bit of a guru. Anyway, the Cyriax method for tennis elbow involves the following:
Deep Transverse Frictions (DTF) - This is the application of force to the muscle fibres, perpendicular to their arrangement. With regards to tennis elbow, it is applied to the tenoperiostal junction of the extensor carpi radialis brevis (ECRB) for 10 minutes. The theory behind DTF is it can reduce abnormal fibrous adhesion, making scar tissue more mobile as well as help normal soft tissue fibres realign. There is also the suggestion that it can increase blood flow to the area and enhance normal healing by preventing abnormal scaring with the breakdown of cross bridges2.
Mills Manipulation: A Mill's manipulation is the application of a low-amplitude, high velocity thrust of elbow joint into extension with the wrist fully flexed and pronated (see below). It sounds quite dramatic, but it's not as violent as one may think5. It should only be applied if the patient is able to reach full end range extension passively. "If passive elbow extension is limited, the manipulative thrust will affect the elbow joint, rather than the extensor tendon, possibly causing traumatic arthritis.9".
Low level light therapy (LLLT) is somewhat debated in it's efficacy. However, a 2008 systematic review1 found that LLLT is safe and may be effective when given is the correct dosage and also when added to an exercise regimen. There are plenty of conflicted studies and reviews. So let's say the jury is out on this one.
Taping for tennis elbow has been shown to significantly improve pain free grip strength12 and wrist extension strength8 immediately after application. In all honesty, this is one of my favourite treatment options. It should be used as an adjunct to other therapies. It is very simple to apply. Those braces that you buy in the store, they mimic what the tape will do, but they are not as applied with as much precision.
With exercise, there is a little bit of conflicting evidence. It depends on the type of exercise. Studies have shown that a home exercise program (HEP) is rarely effective, but mainly due to poor patient compliance. Too be fair, there is scant research on the effects of a HEP on tennis elbow. A difficulty with an HEP is the progression of exercises, intensity, and frequency11. Most programs would advocate the use of eccentric exercises in the HEP. The theory being that eccentric exercise stress the muscolotendinoous junction more, encouranging new fibrosis tissue, making it more resistant to damage4.
A supervised exercise program has been shown to be the most effective conservative treatment for tennis elbow by . The program consisted of slow progressive eccentric exercises for the wrist extensors, particularly the ECRB. Static stretching was performed before and after the exercise session. 10 repetitions were performed in three sets at a controlled, physical therapy supervised environment. Stretching was performed in 6 sets of 30secs - 3 sets before exercises, 3 sets after. Load was increased once the patient was able to do the exercise without pain. The results showed that the supervised exercise program drastically reduced pain in the short, medium, and long term.
Injection TherapyIf conservative treatment fails, there are other options. One of which is injection therapy. Within injection therapy there are also a large number of options. There is scant evidence on injection therapies, but it is promising. Below I'll give a brief overview of them. The conclusion for the following will be drawn by a 2013 systematic review by Krogh et al6.
Acupuncture is a tricky one, given the variability in the studies on acupuncture and tennis elbow. However, there seems to be strong evidence advocating its use for short term pain relief11.
1. Prolotherapy: Prolotherapy is the injection of an irritant in the the affected area. Irritants used for tennis elbow typically include hyperosmolar dextrose and morrhuate sodium solution7.
2. Polidocanol: Polidocanol is a sclerosing agent that essential causes the destruction of blood vessels which will then be replaced by tissue. it is typically used in varicose veins.
3. Glucocorticoid (steroid): Steroid injections are the most common injection for tennis elbow. They are given to reduce inflammtion (uh-oh, didn't I say that there's little to no inflammation present with chronic tennis elbow?)
4. Autologous Blood: Use of the patients own blood, injected into the site. The platelets in the blood contain a growth factor associated with healing.
5. Platelet-rich Blood: Same as autolgous blood injection, expect the blood is first centrifuged to separate platelets, which are then extracted to be injected into the site.
6. Botulinum Toxin (botox): The second most common injection for tennis elbow. Botox is a neurotoxin that prevents the release of acetylcholene at the neuromuscular junction, preventing the contraction of muscle - essentially a muscle relaxant effect.
7. Glycosaminoglycan: Glycgosaminoglycan is used, more or less, as a joint lubricant to increase the function of a joint. Not a typical injection for Tennis elbow.
8. Hyaluronic Acid: Hyaluronic acid is found naturally in the body in high contrations in the eyes and joints. With regards to injection therapy, it is used as to cushion and lubricate joints and other tissues.
In the systematic review by Krogh et al. a couple of interesting conclusions were found. First, while glucocorticoid injections were the most common, they were not found to be beneficial when compared to a placebo. Secondly, botulinum toxin - the second most common - were almost always high risk and caused temporary paralysis of finger extension. Finally, of all the options looked in the review, only prolotherapy and hyaluronic acid were found to be more beneficial than a placebo injection with a low enough risk bias. Autologous blood and platelet-rich blood injections were also found to be beneficial, however were considered to be of higher risk.
Other studies have found that glucocorticoid injection are effective in reducing pain in the short term (4-8 weeks).
There are a number of surgical techniques used, but all aim to release the extensor carpi radialis brevis/common extensor tendon. This can either be done through an open procedure, a percutaneous procedure, or an arthroscopic procedure. While it appears that the more minimally evasive procedures - arthroscopic or percuteneous release - have a shorter return to activity time, all are viable and effective treatment options for tennis elbow. That being said, why would you go the open route if the other ways are less invasive, and just as or more effective? For example, one study found that those undergoing a percutaneous release returned to work on average 3 weeks sooner than those who underwent an open procedure3.
So there you have it. Sure there may be other treatment options, but these are the ones I am most familiar with. If you have any questions or the like you can leave them in the comments section below. If you liked this article and would like to read more like it then please subscribe .
1. Bjordal, J. M., et al. (2008). A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord, 9 (75), doi:10.1186/1471-2474-9-75.
2. Brosseau, L., et al. (2009). Deep transverse friction massage for treating tendinitis (Review). Cochrane Database Syst Rev, 1, CD003528.
3. Dunkow, P. D., Jatti, M., and Muddu, B. N. (2004). A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Joint Surg [Br], 86-B (5), 701-704.
4. Finestone, H. M., and Rabinovitch, D. L. (2008). Tennis elbow no more: practical eccentric and concentric exercises to heal the pain. Can Fam Physician, 54 (8), 1115-1116.
5. Goyal, M., Kumar, A., Monga, M., and Moitra, M. (2013). Effect of Wrist Manipulation & Cyriax Physiotherapy Training on Pain & Grip Strength in Lateral Epicondylitis Patients. Journal of Exercise Science and Physiotherapy, 9 (1), 17-22.
6. Krogh, T. P., et al. (2013). Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med, 41 (6), 1435-1446.
7. Rabago, D., Best, T. M., Zgierska, A. E., Zeisig, E., Ryan, M., and Crane, D. (2009). A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med, 43 (7), 471-481.
8. Shamsoddini, A. and Hollisaz, M. T. (2013). Effects of Taping on Pain, Grip Strength and Wrist Extension Force in Patients with Tennis Elbow. Trauma Mon, 18 (2), 71-74.
9. Stasinopoulos, D. and Johnson, M. I. (2004). Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med, 38, 675-677.
10. Stasinopoulos, D. and Stasinopoulos, I. (2006). Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis. Clin Rehabil, 20 (1), 12-23.
11. Trinh, K. V., Phillips, S. D., Ho, E., and Damsma, K. (2004). Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology, 43 (9), 1085-1090.
12. Vicenzino, B., Brooksbank, J., Minto, J., Offord, S., and Paungmali, A. (2003). Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. Journal of Orthopaedic & Sports Physical Therapy, 33 (7), 400-407.