Manipulation in the Treatment of Tennis

0196-6011 /86/0705-0264$02.00/0 THE JOURNAL OF ORTHOPAEO~C AN0 SPORTS PHYSICAL THERAPY Copyright O 1986 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Manipulation in the Treatment of Tennis SHIRLEY KUSHNER, BScPT, BPE,* DAVID C. REID, MD, MCh(Orth), FRCS(C)t With the increasing popularity of tennis there has been an increasing interest in the etiology and treatrnent of lateral epicondylitis. The current pathophysiology is assumed to be related to repeated wrist extension and rotation leading to microtrauma at the common wrist extensor origin with an ultimate change in the histology of the area. Treatment involves exercise, the use of many modalities to treat the area locally, and more specifically when tennis is the etiology a whole variety of functional adaptations as well as a modification of equipment. Specifically, manipulation of the elbow has played a large role in the treatment of resistant tennis elbow and the large number of different named maneuvers has led to a certain amount of confusion. The second half of the paper attempts to review these manipulations including that described by Mills, Cyriax, Kaltenborn, Mennell, and Stoddard. These manipulations seem to fall into two basic varieties: those that seek full extension and those that will produce a varus thrust. The manipulations done with the elbow in extension and the forearm in pronation have the greatest chance of affecting the contractile elements whereas those performed with a varus thrust at the elbow seem to act primarily on the capsular structures causing gapping and restoring joint play. While manipulation may be effective it always must be used in conjunction with a total treatment regime including exercise, modalities, and modification of the activities involved in the etiology. Tennis elbow is a syndrome characterized by an insidious onset of elbow pain brought on by wrist extension with pronation or supination and aggravated by gri~ping.~ It is the repetitive strong synergic and fixator action of the wrist extensors during gripping that seems to give rise to this syndrome. While the increasing popularity of tennis brings its fair share of the tennis elbow syndrome, the etiology includes numerous activities from playing the piano to shoveling snow.' Furthermore, the term "tennis elbow" has been used to describe a multiplicity of conditions of the elbow. These include radiohumeral bursitis, radiohumeral synovitis, irritation of the synovial fringe, degeneration of the annular and collateral ligaments, fibrillation of the articular cartilage, osteoarthrosis of the radiocapitellar joint, osteochondritis dissecans, and radial nerve entrapment.4*7*19~31 Some authors have used this term to describe lateral, medial, and posterior elbow syndrome^.'^-^^ Cyria~,~ in 1936 compiled a list of no fewer than 26 different types of lesions to which tennis elbow had been attributed. A similar extensive list was published in 1979 by Bernhang.' While these reviews seem to involve a wide range of pathology, most authors believe that the condition is an inflammatory overuse syndrome of the wrist extensors at the common extensor origin. PATHOPHYSIOLOGY Repeated wrist extension and rotation may produce "repeated minor trauma" and strains in the common wrist extensor origin at its attachment into the lateral epicondyle.' The tissue attempts repair, but continued muscle contraction pulls the surfaces apart leading to multiple, repetitive tear^.^.^' It has been suggested that a periostitis may occur at the tenoperiosteal j~nction,~ however at surgery, neither Nirschv' nor Goldieg were able to confirm this. Excessive granulation tissue, 'candidate for M.SC.P.T., Department of Physical Therapy, University with free newe endings, has been identified in the of Alberta, Edmonton, Alberta. t subtendinous space.g331 The pathological Associate Professor of Surgery, Department of Orthopaedics. University of Alberta. Edmonton, Alberta. changes in the tendons have been termed "fi-

JOSPT March 1986 broangiomatous hyperplasia" which describes a tissue of poor quality, slow to heal, and painf~l.'~,'~ Should the patient return to the precipitating activity before this inflammatory response has completely subsided, and before achieving sufficient muscle strength and flexibility, a recurrence is likely.15 In the longstanding cases, adhesions may form between the tendon and the joint cap- ~ule.~' As the condition is most common in the fourth decade of life,' it has been linked to poor healing responses and vascular changes in the proximal tendon unit.31 Different parts of the extensor muscle mass may be the major site of pain and pathology. The specific muscle most often implicated clinically and surgically is the extensor carpi radialis brevis with occasional involvement of the extensor digitorum communis, extensor carpi radialis longus, and extensor carpi ulnari~.~,~,'~.~~.~' The possible reason for this more frequent involvement of the extensor carpi radialis brevis is its location as one of the most laterally situated muscles on the lateral epicondyle with slips taking origin from the radial collateral ligament.31v34 The extensor carpi radialis brevis is intimately attached to the joint capsule, which is continuous with the radial collateral ligament and because of this proximity adhesions are more likely. Because of the increasing popularity of tennis, along with other racquet sports, this pastime is now the major etiologic factor in production of lateral epicondylitis. In particular, poor backhand techniques must be implicated. This paper will deal specifically with lateral epicondylitis as opposed to posterior elbow syndromes and the medial epicondylitis or medial tennis elbow (golfer's elbow) which is more prevalent in the professional tennis player and advanced tournament player and is more directly related to the ~erve.~' CLINICAL TESTS Resisted wrist extension and radial deviation preferably with the elbow fully extended will usually cause pain located in the proximal extensor muscle mass. Also, if the fingers are held in flexion and wrist extension resisted, pain may still occur at the elbow. Cyriax5 describes this phenomena as a sign that extensor digitorum communis is not involved in the pathology. He differentiates between extensor carpi radialis longus and brevis involvement by palpating for tenderness which is present far more often at the lateral epicondyle than the supracondylar ridge. MANIPULATION IN TENNIS ELBOW To test for involvement of the extensor digitorum communis the proximal forearm is supported and the index and middle finger fully extended while the therapist attempts to force the extended digits into flexion. This may precipitate tenderness in the elbow region in excess of that experienced with simple resisted wrist extension. Involvement of the extensor digitorum communis is common in tennis players possibly because of the uneven gripping on the racquet handle. A further clinical test involves stretching the extensor muscles by a full passive wrist flexion with elbow extension and forced pr~nation.~ TREATMENT Treatment has been aimed at relief of inflammation, promotion of healing, reducing the overload forces which caused the problem, and increasing upper extremity strength, endurance, and f ~exibility.'~~'~~~~'~~*~~ Treatment has been described with almost all physiotherapy modalities and in addition deep frictions, and joint mobilizations including Maitland's elbow quadrants, splinting, tennis elbow cuffs and braces, anti-inflam- matory medication, and local steroid injections~7,8.12.14.15.19.20,24.28,31 N aturally, in addition to these regimes, slow resumption of exercise and sufficient warm-up are also important. Whatever modality is employed, at some point exercise will form a mainstay of the treatment. Complete rest is seldom indicated. Reduced physical activity leads to reduction in strength. On resuming activity, a recurrence of the condition may be precipitated by stresses of a lesser magnitude than those causing the initial insult.16 There has been recent reference to the use of an isokinetic dynamometer which can be used to assess ag0nist:antagonist ratios and endurance in the affected and unaffected lirnb~.'~.~~ Furthermore, the device can be employed as part of the progressive rehabilitation for strengthening the entire upper extremity at different speeds. Parameters have been established for wrist strength.33 The normal ratio of wrist extensors to flexors is 52%. The ratio of ulnar deviators to radial deviators is 82%. Wrist flexors and radial deviators are the strongest muscle groups followed by ulnar deviators and wrist extensors as the weakest group. Maintaining the normal, or even increasing the ratio of wrist extensor power, may be a factor in prophylaxis and rehabilitation of tennis elbow. Eccentric training, in which greater tensile force is produced on the tendon, has recently been

266 KUSHNER AND REID JOSPT Vol. 7, No. 5 reported as effective in the treatment of tennis elbow when combined with passive stretching.16 The nature of the force producing the injury is eccentric on a muscle with decreased flexibility. It is therefore thought that the strengthening program should include stretching and a graded eccentric component in order to prevent muscle ~verloading.~ Similarly, good results have also been achieved using strengthening exercises for the wrist extensors with the elbow initially in flexion, with gradual progression to elbow extension over a number of treatment sessions as resolution of the pain permits. Prior to allowing the patient to return to active tennis playing, pulleys may be used for resistance with the patient using an arm action that duplicates backhand, forehand, and the serve. Every effort is made to observe proper tennis form even while carrying out this exercise.15 During the serve the racquet head may travel at 300-350 mph until impact, when it rapidly slows to 150 mph causing-marked stress on the forarm pr~nators.'~.~' The tremendous forces induced while hitting a tennis ball may be reduced by attention to the techniques of performing the various strokes. The appropriate selection of racquet and racquet handle size as well as adjustment of string tension to 52-55 Ib using 16-gauge nylon, which holds the tension longer than gut, may be valuable. Attention to playing surfaces with different speeds and the avoidance of heavy wet balls are small but important details.25331 A midsized graphite racquet absorbs the shock of impact well and has a larger "benevolent zone," an area where little torque is produced on impact, than the traditional racquet. Also a light racquet of 12-1 2.5 oz assists the player in getting around quickly on the shots, which helps hitting in a position of strength, by avoiding late hitting.1833' Furthermore, attention to equipment and techniques in other sports and activities can prove equally useful. As far as tennis is concerned, reintroduction to playing can be graduated by going through a sequence of activity starting initially from the front line with gentle volleying, using only forearm ground strokes. The next stage includes playing from the service line subsequently adding the service, and finally, when it is established that the pain is not going to return, adding the backhand stroke. In an effort to prevent recurrences, tennis lessons may be one of the most useful prophylactic treatment techniques. The popularization of the two handed backhand stroke will assist to reduce the forces through the forearm. In addition, it should be recalled that one of the most important factors in the development of tennis elbow is frequency of play, with 45% of those inflicted playing daily.*' Sufficient rest between playing sessions is important. Surgery has been reserved for those individuals with a chronic painful problem, with a failure to respond to a well carried out conservative treatment program.i. 2,7,28,30,31, ROLE OF MANIPULATION Physiotherapists usually manipulate in the treatment of tennis elbow when other methods have failed. This may be because of the unpredictability of the results with this method of treatment. The rest of this paper will review the six most commonly used types of manipulation for tennis elbow and evaluate the rationale behind their use (Table 1). MILLS' MANIPULATION Mills' manipulation, described in 1928, is the most well known and commonly used manipulation for this condition and because of its historical importance is described in some detsi~.~~ He wrote that the inability to treat tennis elbow was a source of great discredit to surgeons, while osteopaths and lay manipulators were curing patients by the hundreds. He described the condition as having an insidious onset, with a tender spot proximal or distal to the lateral epicondyle, and pain on full wrist and finger flexion. He also described pain on gripping even something as light as a teacup. It is worthwhile noting that he found "that on superficial examination, all movements were complete." However, when he flexed the wrist and fingers in elbow pronation, the patient could not attain full elbow extension. If the patient could extend the elbow fully, "there was a distinct feeling of resistance and the process was painful." By contrast in the unaffected elbow, extension in pronation was full and painless. This gave him the idea that forcing the restricted movement might be an effective treatment, especially when "nonmedical manipulators" were having such good results. He believed an anaesthetic of nitrous oxide to be preferable in acute cases and, in chronic cases, essential. This was because few patients would allow him to use the force necessary to cure a chronic case where there were firm

JOSPT March 1986 MANIPULATION IN TENNIS ELBOW 267

268 KUSHNER AND REID JOSPT Vol. 7, No. 5 adhesions. He "wrenched" the arm with the wrist and fingers flexed and the forearm fully pronated, forcing the elbow into hyperextension while pressing the opposing thumb on the tender spot by the epicondyle. In his first patient this produced a "snap like a pistol shot" and the anaesthetist insisted that he had broken the patient's arm. He described the cure as dramatic. Not all cases had such an audible snap, but if not, a click or snap was always palpable under the thumb. Mills did not suggest that the patient have any "aftertreatment" which he felt would suggest an incomplete manipulation. Rather, he recommended a few days rest from tennis may be indicated in an elbow sore from the manipulation. He encouraged the patient to return to the game as soon as possible. Mills was uncertain as to the pathology of tennis elbow. He claimed to be affecting adhesions in the chronic cases, but because adhesions did not explain the acute cases, he felt that he was manipulating something which was out of place. This, Mills felt, was a torn part of the "orbicular ligament" of the radial head. He drew an analogy between this condition and the displaced "semilunar cartilage of the knee." Torn knee menisci interfered with knee extension; similarly, the torn orbicular ligament prevented full elbow extension by slipping between the radial head and the capitellum. Just as Sir Robert Jones was reducing the displaced meniscus by manipulation, he felt that the torn bit of annular ligament could also be successfully reduced. In 1937, Mills described in more detail the signs and symptoms of tennis elbow.23 At this time he described three locations of maximal tenderness: 1) over the radiohumeral joint, 2) on the epicondyle, and 3) in the muscle belly. He stated that the loss of range may be slight and no more than a springy resistance to complete extension not felt in the opposite limb. This slight limitation in range of motion was the essential indication for manipulation. However, he cautioned that any gross limitation of extension would suggest a more serious lesion than tennis elbow. Mills now added a 2- week rest from activity following manipulation with daily exercises in order to maintain the required full range of motion. His success was not so dramatic in patients with epicondylar tenderness compared to those with the joint variety of tennis elbow. He did not manipulate those with only muscle tenderness. He wrote that relief of pain in patients with epicondylar tenderness was possibly due to rupturing of "tense bands" which had previously been painful on being stretched. In patients with joint tenderness, he reiterated that fraying of the orbicular ligament and nipping of it between the bones was limiting extension. CYRIAX'S FIRST MANIPULATION In 1936, Cyria~,~ while acknowledging the usefulness of Mills' original manipulation, described a method of mobilization which could be done in the sitting position. Deep friction was applied to the tender area at the anterior part of the lateral epicondyle for 5-1 0 minutes. The elbow was fully extended, and the forearm supinated (Fig. 1). The therapist placed one hand on the inner side of the elbow to stabilize and the other on the outer wrist to apply the thrust. The forearm was then passively adducted to the varus position with a sharp jerk. A crack was usually heard but was not considered essential for an effective manipulation. Cyriax advocated this treatment regime three times a week until the patient was well and this was in contrast to Mills who felt that a single treatment was frequently sufficient. Cyriax reported that an average of four, with a range of one to nine, treatments was usually necessary. The patient could resume the "offending work or play" by the time the treatment ceased. He believed that anesthesia was valueless except in that pain was avoided. He pointed out that no muscles were capable of opposing the varus manipulation and therefore nothing further would be achieved by using an anesthetic. Because of the position of the wrist and the direction of the thrust it is unlikely that this manipulation can influence the contractile elements. Rather, the forces would likely be dissipated in the capsule and collateral ligament. Fig. 1. Cyriax's first manipulation consists of a varus thrust on the fully extended elbow with the forearm fully supinated.

JOSPT March 1986 MANIPULATION IN TENNIS ELBOW 269 CYRIAX'S SECOND MANIPULATION throsis, the presence of a loose body, or with traumatic arthritis limiting elbow extension. He did Cyriax later discontinued the use of his initially not, however, specify whether the elbow range of described manipulation and advocated the use of motion be checked in pronation or supination. Full the modified Mills' He discussed elbow extension in supination does not necessaridentification of the lesion by palpation. Tenderily imply that range of motion will be full in pronaness at the anterior portion of the lateral humeral tion. epicondyle over the origin of the common exten- Currently, Cyriax advises manipulation with the sor tendon was termed the tenoperiosteal variety patient sitting, shoulder abducted and internally and was present in 90% of the cases. Symptoms rotated forearm fully pronated with the olecranon of the muscle belly at the level of the neck of the facing the ~eiling.~ The physiotherapist stands radius were seen in 8% of the cases. Tenderness behind the patient supporting.the fully flexed wrist at both the supracondylar ridge and over the head and with slight flexion at the patient's elbow. The of the radius constituted 1 O/O each. He postulated therapist's other hand is on the olecranon. Tenthe pathology in the most common tenoperiosteal sion is maintained at the wrist while a full extenvariety as being a tear between the origin of sion thrust is given at the elbow (Fig. 2). The extensor carpi radialis brevis and the periosteum treatment is given once each visit for 4 to 12 of the lateral humeral epicondyle. It was sugsession^.^ He cautions that if poor manipulation gested that as the tear began to unite, the patient is performed by failing to maintain full wrist flexion, continued to use the wrist pulling the healing the thrust is absorbed mainly by the elbow joint surfaces apart. This resulted in a painful scar with potentially causing traumatic arthrosis. Depending a "self-perpetuating inflammati~n."~ Symptoms on the magnitude of the thrust, full wrist flexion occurred when the condition reached the chronic probably does little in protecting the joint from inflammatory stage. such a manipulation if this is really a serious He felt the natural history of the tenoperiosteal consideration. variety was to spontaneously resolve within 1 year in those patients under the-age of 60 and within 2 years in those'individuals over 60 years of age. He postulated that the cure resulted from a gradual widening of the gap between the two edges until the surfaces were no longer opposed and the tension on the scar ceased. He felt the gap then filled with fibrous tissue and healed with permanent lengthening. This data on pathophysiology is supported with surprisingly little firm data. Manipulation was intended to pull apart the two edges of the tear bringing about healing with permanent lengthening in the tenoperiosteal variety of tennis elbow. Cyriax continued to advocate deep frictions prior to the treatment for 10-1 5 minutes in order to provide a reactive hyperemia, analgesia, and some softening of the scar. Cyriax opposed an anaesthetic because he felt that full muscle relaxation prevented the traction from falling on the tendon and the joint would take the full brunt of the force. In addition, the manipulation was over so quickly that an anaesthetic was not necessary, and since repeated treatments were often necessary, repeated anaesthesia was unacceptable. He was very insistent that if full range of motion was not present at the joint each manipulati0n9 traumatic thrust on the fully extended elbow. The shoulder IS ~nternally arthritis could be precipitated. He that rotated and abducted. Flxatron 1s ach,eved over the fully flexed manipulation was out of the question in OSteOar- and pronated wrist.

270 KUSHNER AND REID JOSPT Vol. 7, No. 5 Cyriax's description of the pathology of scarring at the tenoperiosteal junction is probably more widely accepted at the present time than Mills' original concept for torn annular ligaments. KALTENBORN'S MANIPULATION Kaltenborn13 describes a manipulative technique for lateral epicondylitis similar to the one which Cyriax described in 1936. The patient is seated on a chair with the shoulder foward flexed, the elbow extended, and the forearm supinated. The therapist's foot is placed on the chair so that the patient's medial elbow is against the therapist's medial knee. Both Cyriax and Kaltenborn produce a varus stress on the elbow, but Kaltenborn achieves this by distal fixation and a proximal thrust to the medial side of the elbow while in sitting or supine (Fig. 3). Kaltenborn suggests that performing the manipulation in supine enables greater patient relaxation and thus the therapist is able to exert more traction to the radius, hence, increasing the joint distraction. He agrees with Cyriax that the patient must have full elbow extension before this manipulation is performed and, like Cvriax, does not s~ecifv whether this should. 3. Kaltenborn's manipulation. The patient's arm is held in ow extension and forearm su~ination secured bv the therapist9s left hand and body. The 'varus thrust is apgied to the elbow producing lateral gapping. be tested in supination or pronation. The manipulation causes lateral gapping of the joint. When compared to an extension thrust it appears to be more traumatic in that the elbow joint only has very limited motion into adduction. While there is no significant mechanical stress on the musculotendinous junction the gapping possibly restores joint play which may have been lost due to the pathology. If the extensor carpi radialis brevis has slips originating from the capsular ligament, it may stretch these slips from their origin. It would be interesting to know why Cyriax abandoned this type of manipulation in favor of Mills' maneuver. STODDARD'S MANIPULATION St~ddard~~ developed a manipulation for use in chronic cases of tennis elbow. He uses it to break down adhesions at the extensor digitorum communis origin. In the early stages, when an inflammatory component is present, he has found manipulation to be ineffective. He mentions that hydrocortisone is often effective but does recommend manipulation in recurrent cases where repeated hydrocortisone injections are not advisable or when the patient has been adversely affected by prior injections. Thus, his indications for manipulation are 1) resistant cases, 2) when the inflammatory component of the lesion has subsided, 3) when there is no pain at rest, 4) when there is no stiffness after rest, 5) when there is no fibrositis present, and 6) when pain is only provoked with active use of the extensor muscles. Stoddard agrees that Mill's manipulation is theoretically reasonable due to the stretch it exerts on the extensor digitorum, but from the practical point of view he claims it does not work. He suggests that a sharp varus thrust by adduction of the forearm is more effective. The patient is supine, the shoulder 90 abducted, and the therapist sitting on the plinth next to the affected side. The therapist's forearm rests on the anterior aspect of the patient's affected arm with the fingers palpating the elbow. The therapist then locates the fibers of the middle portion of the extensor digitorum communis tendon (Fig. 4A). This is done by resisting finger extension while palpating "the insertion of these fibres into the radial collateral ligament."32 Once the fibers are found, the therapist's index finger remains over them. The therapist's other hand moves the patient's forearm into different degrees of supination and pronation while palpating until a maximal sense of tension is felt in the extensor digitorum

JOSPT March 1986 MANIPULATION IN TENNIS ELBOW 27 1 Fig. 4. Stoddard's manipulation. A, Location of the most involved portion of the extensor digitorum communis by resisted finger extensionend palpation; B, adduction gapping produced in the fully extended elbow with arm in supination. communis. Stoddard found most tension just short of full supination. This is not necessarily true and warrants an anatomic study. While the therapist's index finger remains on the site of maximal tension, adduction gapping of the forearm on the arm is performed by a varus maneuver which Stoddard feels separates adhesions binding the extensor digitorum communis to the radial collateral ligament. (Fig. 4B). A review of the literature has failed to find support for Stoddard's belief that this muscle originates from the radial collateral ligament. Rather, the extensor carpi radialis brevis and supinator are reported to blend with this ligament.'0,11,'7,34,35 Furthermore, the muscles have a fairly significant excursion during movement of the wrist and fingers and it is difficult to see how any significant force is exerted on the contractile elements unless the fingers and wrist are fully flexed. MENNELL'S MANIPULATION Mennell uses a manipulation similar to Mill's in order to tear "a painful scar in the common exten- sor tendon."21 He does not specify which muscle in particular is affected. His manipulation differs from Mill's in that the starting position is the fully flexed elbow (Fig. 5A). He then brings the elbow into full extension maintaining maximum wrist flexion and forearm pronation with the thumb resting over the painful area (Fig. 5B). He suggests injecting the painful area with a local anesthetic to make the procedure more comfortable, since the patient will experience an acute transitory pain as the scar tears. It is difficult to see the purpose of taking this manipulation from full flexion, particularly since a rapid motion may allow too much force to be built up throughout the range with the joint having to take the full brunt of the manipulation. Only the last degrees of range are normally involved in any manipulation as the slack is normally taken up prior to the thrust.20 Mennell's illustrations show the patient standing. The maneuver done with the patient in lying or seated for support would usually ensure better relaxation and prevent the patient from pulling away in midmanipulation, which may negate any positive effect. B II flexed elbow and wrist and forearm pronated; B, as the elbow is extended, an extensor thrust is applied to the joint.

272 KUSHNER AND REID JOSPT Vol. 7, No. 5 SUMMARY The actual performance of Mill's manipulation has not changed markedly since it was first described in 1928; however, its indications and purposes have. Mill's original papers, as well as five different other manipulations for tennis elbow, have been reviewed. Therapists will choose the type of manipulation that fits in with their concept of the pathophysiology and that they can technically do well. Some therapists may try a series of manipulations, until a successful result is accomplished. Several attempts at a manipulation without success is a sign to explore another modality of treatment. The Mill's manipulation as described by Cyriax, and for the indications which Cyriax describes, has the most potential to stretch the affected tendon with the least potential for harm to the joint. For this manipulation, the patient is well supported and the movement is of small amplitude and is done in a direction which is natural to the movement of the elbow joint as well as in the direction of the muscle fibers. The manipulations fall into two basic varieties: those that seek full extension and those which will produce a varus thrust. The manipulations done in extension with pronation have the greatest chance of affecting the contractile elements. By contrast, those with a varus thrust at the elbow act primarily on the capsular structures causing gapping and restoring joint play. Prior to manipulation, therapists should be aware of the indications for this type of treatment, inherent dangers, and be clear as to what is to be accomplished. Also, to manipulate without considering other aspects of treatment is an error. Manipulation must be used in conjunction with a total treatment regime of stroke and equipment modification exercises and modalities. In particular, where tennis is the etiological agent, the major considerations have been outlined. The authors would like to thank Barbara Robinson, David Lamb, and Andrew Lessing-Turner for their advice and assistance. REFERENCES 1. Baumgard SH. Schartz DR: Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 10:233-236.1982 2. Bemhand AM: The many causes of tennis elbow. NY State J Med 79:1363-1366.1979 3. Curwin S, Stanish W: Tendinitis: Its Etiology and Treatment. Toronto: Collamore Press, 1984 4. Cyriax JH: The pathology and treatment of tennis elbow. J Bone Joint Surg 18:921-940,1936 5. Cyriax J: Textbook of Orthopaedic Medicine, Diagnosis of Soft Soft Tissue Lesions, Ed 6. Vol 1. London: Bailliere Tindall, 1975 6. Cyriax H, Russell G: Textbook of Orthopaedic Medicine, Treatment by Manipulation, Massage and Injection. Ed 9, Vol 2. London: Bailliere Tindall. 1977 7. Friedlander HL, Reid RL, Cape RF: Tennis elbow. 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