Lateral Epicondyle Tendinopathy Toolkit: Appendix B - Manual Therapy

Cyriax-Type Physiotherapy Treatment (Viswas et al 2012[1])

Figures 1 and 2 and the accompanying descriptions are the components of this treatment approach.

Deep Transverse Friction Massage (DTFM)

  • Patient’s elbow is supported in a 90 degrees flexion, fully supinated position.
  • DTFM is applied with the thumb at the common extensor tendon just anterior to the epicondyle.
  • Frictions were applied for 10 minutes prior to the Mill’s manipulation.

Fig 1 of LET App B
    Figure 1

Mill’s Manipulation

  • Patient is in sitting with arm in abduction, internal rotation such that the olecranon faces upwards, forearm fully pronated and wrist in flexion. Therapist’s one hand supports the wrist flexion, the other hand placed over the olecranon.
  • Maintaining this position the therapist applies a high velocity, low amplitude thrust through the olecranon.

LET Appendix B Fig2.png
    Figure 2

Elbow Mobilization with Movement (MWM)

  • Patient is in supine with their arm by their side, elbow extended and forearm pronated.
  • A lateral glide is applied to the radius and ulna with the therapist’s hands or using a belt around the therapist’s shoulders.
  • The patient then either grips or extends the wrist against resistance as long as this is now pain-free.
  • 6-10 repetitions are performed in a single treatment session.

Fig 3 of LET App B
    Figure 3

Spinal Mobilization/Manipulation

Lateral Glide Mobilization (Vicenzino et al 1996[2])

  • Mobilizing hand wraps around the head and neck to the level of the C5/6 segment.
  • A Grade III lateral glide is applied contralateral to the effected side.
  • A depression force is applied to the ipsilateral shoulder girdle.

Fig 4 of LET App B
    Figure 4

Passive Intervertebral Mobilization (Cleland et al 2005[3])

Passive Physiological Mobilization

  • Grade III or IV mobilization of hypomobile segment found on assessment.

Fig 5 of LET App B
    Figure 5

Passive Intervertebral Mobilization (Cleland et al 2005[3])

Passive Accessory Mobilization

  • Grade III or IV mobilization of the hypomobile segment found on assessment.

Fig 6 of LET App B
    Figure 6

Cervical Manipulative Thrust (Fernández-Carnero et al 2008[4])

  • Cervical spine is locked using side flexion towards and rotation away from the side to be manipulated.
  • The high velocity, low amplitude thrust was directed superior and medially towards the opposite eye.

  • NOTE: This technique should only be used by those who have been instructed in its use, and only following a complete assessment of the cervical arterial system.

Fig 7 of LET App B
    Figure 7

Download Lateral Epicondyle Tendinopathy Toolkit: Appendix B - Manual Therapy


Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates, & Alison Hoens.

A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.

June 2013


  1. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. The Scientific World Journal. 2012.
  2. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. Nov 1996; 68(1): 69-74.
  3. 3.0 3.1 Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal of Manual & Manipulative Therapy. 2005; 13(3): 143-151.
  4. Fernández-Carnero J, Fernández-De-Las-Peñas C, et al. Immediate hypoalgesic and motor effects after a single cervical manipulation in subjects with lateral epicondylalgia. Journal of Manual & Manipulative Therapy. 2008; 31(9): 675-681.