Tennis Elbow – Treatment of Pain Mechanisms

While some presentations of Tennis Elbow may be due to local tendon structure
changes alone, many are not. The old term Epicondylitis suggests an inflammatory
condition based on tendon changes, eg as with Tendinitis. This terminology is now
defunct and the term Epicondylalgia is used instead. The new terminology describes a
condition based on altered pain mechanisms. If altered pain mechanisms are identified
by your physiotherapist, treatments can be aimed at reversing the altered behaviour of
the ‘pain system’, based on the specific requirements of each patient.

The 2 main treatments used are Mobilisations with Movement (MWM), and neck
mobilisations. MWM are used when patients display a more pronounced change in
the strength of grip needed to produce pain, than the direct pressure over the painful
site needed to produce symptoms. Neck mobilisations are used when the opposite is
true (Vicenzino 2003).

Mobilisations with Movement (MWM)

Brian Mulligan created this treatment concept in 1999. The aim is to glide a joint or
tissue near the site of discomfort, while the patient actively moves the joint or painful
structure. All movements should immediately be pain-free and should be repeated
for 3 sets of 10 repetitions. The pain-free stimulus is suggested to desensitize the
local nerves by changing the constant pain, or nociceptive, signal to a more normal
mechanical, sensory one. Below is a picture of one of our team, Tom, demonstrating
the technique. The object in the patient’s hand is used to grip against while the glide
is being performed. The grip pressure before pain is recorded and will improve as
treatment progresses:

Tennis Elbow Treatment
Movement with Manipulation












Should the treatment prove effective at increasing the pain-free grip strength, then a
home exercise mimicking the intervention will be prescribed. MWM treatment may
also be prescribed with strengthening exercises. Bisset et al (2006) produced a study
comparing MWM and exercise over 8 sessions, against steroid injection and a wait-
and-see policy. Follow-up was at 6 weeks and between 3-12 months. There was a
significant advantage to MWM and exercise over wait-and-see at 6 weeks, and over
steroid injection at 12 months. There was also a 90% reduction in recurrences of
the condition in the MWM and exercise group, compared to steroid injection at 12

Neck Mobilisations

While the exact mechanisms of how this treatment works remain open to debate,
clinically results prove encouraging. The neck is split into spinal levels, which supply
nerve roots that are responsible for the sensation and muscle power of specific parts
of the upper limbs. Studies have shown that mobilisations of the C5/6 level for a
period of 3×30 seconds, with a 60 second rest in-between, can improve the pain-free
movement of the Radial Nerve, and decrease the sensitivity of the painful area in
Tennis Elbow patients (Vicenzino et al 1996 & 1998, Elvey 1986). The Radial Nerve
passes close to the site of Tennis Elbow and if hypersensitive, is a frequent cause
of symptoms. The C5/6 level is also responsible for the sensations to the patchwork
of skin around the outer elbow, and so any injury to this area may produce altered,
painful sensations to develop. Mobilisations of this spinal level may help to normalise
the sensations felt at the elbow, thus helping to alter the abnormal pain mechanism.
Below is a picture of Tom demonstrating the neck mobilisation technique:

Treatment for Tennis Elbow
Neck Mobilisations












If the symptoms are improved post-treatment your therapist will prescribe a set
of home exercises designed to maintain the gains that have been made. Treatment
sessions may take place once or twice per week during the early stages of rehab,
depending on the severity of the presenting problem.


Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B (2006) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ; 333:939

Elvey R (1986) Treatment of arm pain associated with abnormal brachial plexus tension. Australian Journal of Physiotherapy 32: 225–230

Vicenzino B, Collins D, Wright A (1996) The initial effects of a cervical spine manipulative
physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 68: 69–74

Vicenzino B, Collins D, Benson H, Wright A (1998) An investigation of the interrelationship between manipulative therapy induced hypoalgesia and sympathoexcitation. J Manipulative Physiol There; 21:448-453

Vicenzino B (2003) Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Manual Therapy; 8(2); 66-79

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