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Professional Papers _______________________________________________________ 
Manipulative management of tennis elbow
Franklin Schoenoltz, DC, DABCO Arcadia, California
 ACA Journal of Chiropractic /June 1978
Copyright American Equilibration Society 1980. Copyright Abba Schoenholtz
“Authorization granted to the American Equilibration Society for reprint in their Compendium 15, by the ACAJournal of Chiropractic.”
Tennis elbow or lateral epicondylitis is produced by sud-den or repeated trauma involving extension of the wristand outward rotation of the forearm.The most common cause of elbow pain is in
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amma-tion of the common extensor tendon at its insertion onthe lateral epicondyle. This is usually the result of suddenuncontrolled stress or repetitive stresses that exceed thetolerance of the tissues. It is a common occurrence intennis players, golfers and other athletes, but, of course,appears in a wide variety of other activities involving thesame mechanism. If the condition is chronic, it is becauseof painful tears from the healed scars.
Pathology
There are three stages of this condition. The
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rstinvolves an injury of recent origin when an effusion of blood and tissue
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uids results in local hyperemia.The second state involves early repair, where the dam-aged structures are being replaced by vascular repairtissues at the periosteal tears.The third phase involves permanent repair in which thegranulation tissue becomes avascular
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brous tissue.In considering these three states of repair, it is easyto understand how a periositis occurs at the point wherethe tendon is torn from the periosteum, with resultingmyofascitis and
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brositis of the muscle.
Diagnosis
Frequently the patient will point directly to the site of the in
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ammation, tear or scar. He will often complain of pain in the elbow, generally localized to the outer side whichmay radiate along the back of the forearm (
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gure 1). A positive sign is that the pain may recur with resisted ex-tension at the wrist (
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gure 2). Palpation will usually reveal anacutely tender area over the lateral epicondyle and also at theradial tuberosity (
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gure 3).Pleximeter percussion over the posterior aspect of theepicondyle or the olecranon process will not produce anysensation of pain. Such maneuvers help to rule out pathologicchanges in the bone.X-ray examination of the area is usually negative and re-veals no pathologic changes. Examination of the neurologicand vascular aspects is normal.
Treatment
Manipulation is used to pull apart the two edges of thetear and relieve tension on the painful scar lying between theedges, imitating the mechanism of spontaneous recovery. Thismotion allows the self-perpetrating post-traumatic in
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amma-tion to subside with permanent lengthening of the tendon.This approach was described by Mills (
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gure 4). His inten-tion was to shift the annular ligament, which he viewed as
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228East Foothill Blvd. In Arcadia, California. He has taught diversi
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edtechnique and undergraduate orthopedics at the Los Angeles Collegeof Chiropractic in Glendale, California, from 1964-1976. Presently,Dr Schoenholtz is the secretary-treasurer of the Board of Regentsat LACC. He has authored numerous articles including “Soft TissuePain Sites in the Lower Back Area,” 1968; “A Guide to the Lectures inChiropractic Orthopedics,” 1976; “A Historical Review of ManipulativeTherapy,” 1977, and “The Diagnosis and Conservative Treatment of the Lumbar Disc Syndrome,” 1978.
 
out of place. Cyriax added to this concept by statingthat the annular ligament applies the greatest possiblestretching tension to the extensor carpi radialis mus-cles. As a result, the manipulative procedure should becarried out with a sharp jerk, in order to open the tearin the tendon and relieve tension on the tendon scar byconverting a tear, shaped like “V,” into separation of thetorn surfaces, ie, a “U.” Mills’ manipulation must not be performed unless theelbow can be fully extended and without pain. If thisprocedure is attempted without proper technique, suchas the patient’s wrist not being held fully
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exed dur-ing the procedure, an exacerbation of symptoms mayresult. The joint may have to be rested for a period of one to two weeks until it recovers and treatment maysafely resume again.Ultrasound therapy has been used over the site of the lesion as a precursor to manipulation in order todissipate the existing adhesions in the area of the later-al epicondyle. This modality is effective in reducing thehypertonicity of the extensor muscle group as well asproducing hyperemia which tends to soften the
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broticscar tissue that manipulation proposes to rupture.This author’s treatment program consists of ultra-sound sonations using a petroleum coupling agent. Theintensity varies from 1 to 1.5 watts per centimeter. A very slow, gliding, rotating movement is made with thetransducer over the lateral epicondyle area. The lengthof time for each session is 7 ½ minutes.It is recommended that 9 to 12 ultrasound treat-ments be scheduled. Manipulation is introduced duringthe fourth therapy session and continued until theeighth or ninth session.Discretionary latitude should be used to determinethe frequency of the treatment program. Variationsin treatment must be made according to the patient’sreaction, which may change from visit to visit. In addi-tion, corrective measures should be employed, particu-larly if the cause, whether occupational or recreational,might continue.
Case Report #1
Mr A. N. spontaneously developed a lateral epicon-dylitis. The pain persisted for a period of four weeks.While he was using a screwdriver and applying a forcedtight grip on the handle, his symptoms became muchworse. Mr A. N. went to see his physician and re-ceived two injections of cortisone without any relief of symptoms. The patient came to the author’s of 
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ce fortreatment approximately two weeks later with symp-Figure 1. Muscles which produce extension of the wrist and outwardrotation of the hand.Figure 2. Wrist extension against resistance resulting in pain is a positiveindication of lateral epicondylitis.Figure 3. Palpation will reveal tenderness at the site of lateral epicon-dyle.Figure 4. Mills’ Manipulation. The doctor stands behind the patient andbrings the patient’s forearm to full pronation and fully
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exes his wrist.The thrust is a quick movement in the direction illustrated. This manipu-lation may produce mild discomfort at the instant of its performance. Itshould be preceded by ultrasound to induce analgesia.
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