Professional Papers _______________________________________________________

Manipulative management of tennis elbow
Franklin Schoenoltz, DC, DABCO Arcadia, California
Tennis elbow or lateral epicondylitis is produced by sudden or repeated trauma involving extension of the wrist and outward rotation of the forearm. The most common cause of elbow pain is inflammation of the common extensor tendon at its insertion on the lateral epicondyle. This is usually the result of sudden uncontrolled stress or repetitive stresses that exceed the tolerance of the tissues. It is a common occurrence in tennis players, golfers and other athletes, but, of course, appears in a wide variety of other activities involving the same mechanism. If the condition is chronic, it is because of painful tears from the healed scars. Pathology There are three stages of this condition. The first involves an injury of recent origin when an effusion of blood and tissue fluids results in local hyperemia. The second state involves early repair, where the damaged structures are being replaced by vascular repair tissues at the periosteal tears. The third phase involves permanent repair in which the granulation tissue becomes avascular fibrous tissue. In considering these three states of repair, it is easy to understand how a periositis occurs at the point where the tendon is torn from the periosteum, with resulting myofascitis and fibrositis of the muscle. Diagnosis Frequently the patient will point directly to the site of the inflammation, tear or scar. He will often complain of

Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228 East Foothill Blvd. In Arcadia, California. He has taught diversified technique and undergraduate orthopedics at the Los Angeles College of Chiropractic in Glendale, California, from 1964-1976. Presently, Dr Schoenholtz is the secretary-treasurer of the Board of Regents at LACC. He has authored numerous articles including “Soft Tissue Pain Sites in the Lower Back Area,” 1968; “A Guide to the Lectures in Chiropractic Orthopedics,” 1976; “A Historical Review of Manipulative Therapy,” 1977, and “The Diagnosis and Conservative Treatment of the Lumbar Disc Syndrome,” 1978.

pain in the elbow, generally localized to the outer side which may radiate along the back of the forearm (figure 1). A positive sign is that the pain may recur with resisted extension at the wrist (figure 2). Palpation will usually reveal an acutely tender area over the lateral epicondyle and also at the radial tuberosity (figure 3). Pleximeter percussion over the posterior aspect of the epicondyle or the olecranon process will not produce any sensation of pain. Such maneuvers help to rule out pathologic changes in the bone. X-ray examination of the area is usually negative and reveals no pathologic changes. Examination of the neurologic and vascular aspects is normal. Treatment Manipulation is used to pull apart the two edges of the tear and relieve tension on the painful scar lying between the edges, imitating the mechanism of spontaneous recovery. This motion allows the self-perpetrating post-traumatic inflammation to subside with permanent lengthening of the tendon. This approach was described by Mills (figure 4). His intention was to shift the annular ligament, which he viewed as

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 ACA Journal of Chiropractic.”

Figure 1. Muscles which produce extension of the wrist and outward rotation of the hand.

Figure 2. Wrist extension against resistance resulting in pain is a positive indication of lateral epicondylitis.

Figure 3. Palpation will reveal tenderness at the site of lateral epicondyle.

out of place. Cyriax added to this concept by stating that the annular ligament applies the greatest possible stretching tension to the extensor carpi radialis muscles. As a result, the manipulative procedure should be carried out with a sharp jerk, in order to open the tear in the tendon and relieve tension on the tendon scar by converting a tear, shaped like “V,” into separation of the torn surfaces, ie, a “U.” Mills’ manipulation must not be performed unless the elbow can be fully extended and without pain. If this procedure is attempted without proper technique, such as the patient’s wrist not being held fully flexed during the procedure, an exacerbation of symptoms may result. The joint may have to be rested for a period of one to two weeks until it recovers and treatment may safely resume again. Ultrasound therapy has been used over the site of the lesion as a precursor to manipulation in order to dissipate the existing adhesions in the area of the lateral epicondyle. This modality is effective in reducing the hypertonicity of the extensor muscle group as well as producing hyperemia which tends to soften the fibrotic scar tissue that manipulation proposes to rupture. This author’s treatment program consists of ultrasound sonations using a petroleum coupling agent. The intensity varies from 1 to 1.5 watts per centimeter. A very slow, gliding, rotating movement is made with the transducer over the lateral epicondyle area. The length of time for each session is 7 ½ minutes. It is recommended that 9 to 12 ultrasound treatments be scheduled. Manipulation is introduced during the fourth therapy session and continued until the eighth or ninth session. Discretionary latitude should be used to determine the frequency of the treatment program. Variations in treatment must be made according to the patient’s reaction, which may change from visit to visit. In addition, corrective measures should be employed, particularly if the cause, whether occupational or recreational, might continue. Case Report #1 Mr A. N. spontaneously developed a lateral epicondylitis. The pain persisted for a period of four weeks. While he was using a screwdriver and applying a forced tight grip on the handle, his symptoms became much worse. Mr A. N. went to see his physician and received two injections of cortisone without any relief of symptoms. The patient came to the author’s office for treatment approximately two weeks later with symp-

Figure 4. Mills’ Manipulation. The doctor stands behind the patient and brings the patient’s forearm to full pronation and fully flexes his wrist. The thrust is a quick movement in the direction illustrated. This manipulation may produce mild discomfort at the instant of its performance. It should be preceded by ultrasound to induce analgesia.

toms of pain and tenderness over the lateral epicondyle of the humerus and radiating pain into the forearm. The patient was treated twice a week for a period of five weeks. His condition remained stable without any improvement until the seventh visit, at which time symptoms started to abate. The patient was fully recovered and discharged after the tenth visit. Case Report #2 While playing tennis, Mr J. S. developed an acute lateral epicondylitis. The condition became accumulatively severe as he continued to play the game. His symptoms involved pain directly over the lateral epicondyle with complaints of a generalized aching over the dorsum of the forearm and a sensation of paresthesia over the dorsum of the hand. Prior to treatment, the author restricted the patient from playing tennis for three months. Treatment was initiated eight weeks after the onset of the injury, with three visits per week for a period of

four weeks. Because of complaints of soreness when the patient attempted to extend his arm during daily activities, a padded elbow support was recommended to be worn during waking hours for a period of three weeks. The rationale for using the support was that it would absorb some of the force of the maximal contraction of the extensor muscles, relieving stress on the common extensor tendon and providing padded protection to the inflamed area. The patient responded well to the treatment and was discharged with minimal residual symptoms. The patient was seen six weeks later for further evaluation and was pronounced asymptomatic.

Sources Aldes, Ultrasonic Radiation, Epicondylitis, 1956. Cyriax, Orthopedic Medicine, 1976. Mills, British Medical Journal, 1:12, 1928. Steiner, “Tennis Elbow,” AOA Journal, 1976. Turek, Orthopedics, 1976. Zohn/Mennell, Musculoskeletal Pain, 1976.

Copyright Abba Schoenholtz & American Equilibration Society Compendium Volume 15 1980 All Rights Reserved