Manual therapy is a modality used for rehabilitation assessment and treatment of various conditions. The American Physical Therapy Association (APTA) describes manual therapy as “designed to improve tissue extensibility, increase range of motion, induce relaxation, mobilize or Manipulating Soft Tissues and Joints to Regulate Pain and Reduce Soft Tissue Swelling Inflammation or Restriction”. It describes practical techniques used in rehabilitation to treat various conditions such as:
- manual lymphatic drainage
- manual traction
- passive range of motion
Manual therapy is one of the oldest documented modalities , and its use and governance have undergone many changes over the years. It is often advocated for the evaluation and treatment of epicondylitis .
Cyriax-Type Physiotherapy Treatment
Cyriax and Cyriax recommend deep lateral friction massage combined with the Mill maneuver for the treatment of tennis elbow . In order for a therapeutic intervention to be labeled as Cyriax Physiotherapy, the two aforementioned therapeutic components must be used in combination specified order. In this protocol, the person must adhere to this intervention 3 times a week for 4 weeks.  Figures 1 and 2 and the accompanying description are an integral part of this approach.
A 2012 study by Viswas et al found that Cyriax physical therapy was effective in reducing pain associated with LET
Deep Transverse Friction Massage (DTFM) The patient’s elbow is supported in a fully supinated position in 90 degrees of flexion. DTFM is applied with the thumb at the common extensor tendon anterior to the epicondyle. Apply rubbing 10 minutes before Mill operation. picture 1個
Mill Maneuver The patient is seated, the arm is abducted and internally rotated, the olecranon is facing upward, the forearm is fully pronated, and the wrist is flexed. With one hand of the therapist supporting the wrist flexed, the other hand rests on the olecranon. hold this position The therapist applies high-speed, low-amplitude thrusts through the olecranon. figure 2
Elbow Mobilization with Movement (MWM)
Mobilization is a manual therapy technique that forms part of Mulligan’s concept. MWM is the simultaneous application of continuous assisted mobilization applied by the therapist and active physiologic motion applied by the patient to the end-of-range. Passive Range End Overpressure Then stretch or stretch without pain.
The patient lies supine with the arm extended to the side, the elbow extended, and the forearm pronated. Slide laterally toward the radius and ulna with the therapist’s hand or with the belt on the therapist’s shoulder. The patient then grasps or extends the wrist against resistance as As long as there is no pain right now. 6-10 repetitions are performed in one session. image 3
Spinal mobilization and manipulation are widely used techniques in which force is applied to the joints of the spine to treat pain in the back and neck of the extremities. Although the exact underlying mechanism is not fully understood, treating dysfunctional areas of the spine can restore spine function Structural integrity reduces pain and initiates the body’s natural healing process. 
Lateral sliding mobilization (Vicenzino et al. 1996) wraps the hand around the head and neck to the level of the C5/6 segment. Apply a Class III lateral slide on the affected side side to side. Apply pressure to the affected side with the ipsilateral shoulder girdle. Figure 4
Cervical spine thrusts (Fernández-Carnero et al 2008 ) use lateral flexion and rotation away from the side being manipulated to lock the cervical spine. High-velocity, low-amplitude thrusts are directed upward and inward toward the contralateral eye. NOTE: This technique should For use only upon instruction for use and only after a thorough evaluation of the carotid system. Figure 5
Passive intervertebral mobilization (Cleland et al 2005 ) Passive physiologic mobilization is grade III or IV mobilization of undermobilized segments identified during assessment. Image 6
Passive Intervertebral Mobilization (Cleland et al 2005)Passive Accessory MobilizationGrade III or IV mobilization of the hypomobile segment on assessment. 圖 7
There is mixed evidence to support the use of manual therapy for LET. The evidence is summarized below; for more information see Part D – Evidence summary for physiotherapy interventions.
Elbow Joint Mobilisations
- Acute phase – There is little clinical evidence for or against the use of elbow mobilization in the acute phase.
- Chronic phase – There is substantial clinical evidence to support the use of elbow mobilization (MWM and Mill’s maneuver). Modest effect sizes were demonstrated across all time horizons (both short-term and long-term). MWM showed good results in terms of pain grip strength and function. Mill’s maneuver is effective for pain but not for pain-free grip strength. Using Mill’s operations to improve functionality is unclear.
Spinal Mobilization Techniques
- Acute Phase – There is little clinical evidence or expert opinion on the use of spinal mobilization/manipulation in patients with acute LET.
- Chronic Phase – Solid clinical evidence supports the use of cervical and thoracic spine mobilization/manipulation in the treatment of LET to improve pain, increase PPT grip strength and function in the short term. In one study, stronger effects were seen when support and support were provided empathetic approach. Nerve mobilization techniques (radial nerve) have been demonstrated.
Soft Tissue Techniques
- Acute – Limited clinical evidence supports the use of soft tissue techniques as stand-alone therapy.
- Chronic stage – Clinical evidence is weak to support the use of soft tissue techniques such as rubbing in combination with other treatment modalities. NOTE: Most studies examining the effects of friction include manipulative +/- movements using the Mill.
- Lateral Epicondylar Tendinopathy Toolkit Page
- Section B – Clinical Assessment of LET
- Section C – Outcome Measures
- Section D – Summary of the Evidence
- Section E – Exercise Prescription
- Section G – LASER Dosage Calculation
- Section H – Braces, Splints and Taping
- UBC Lateral Epicondyle Tendinopathy Toolkit
- Pettman E. A history of manipulative therapy. Journal of Manual & Manipulative Therapy. 2007 Jul 1;15(3):165-74.
- Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research. 2008 Jul;466(7):1539-54.
- Landesa-Piñeiro L, Leirós-Rodríguez R. Physiotherapy treatment of lateral epicondylitis: A systematic review. Journal of back and musculoskeletal rehabilitation. 2022 Jan 1;35(3):463-77.
- Cyriax HJ, Cyriax JP. Cyriax’s Illustrated Manual of Orthopaedic Medicine. Oxford, UK: Butterworth-Heinemann; 1983
- Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. British Journal of Sports Medicine. 2004;38(6):675–677
- 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.
- Pfluegler G, Kasper J, Luedtke K. The immediate effects of passive joint mobilisation on local muscle function. A systematic review of the literature. Musculoskeletal Science and Practice. 2020 Feb 1;45:102106.
- 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.
- 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.
- 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.