“COMBINED EFFECTIVENESS OF CYRIAX PHYSIOTHERAPY AND

PHONOPHORESIS WITH SUPERVISED EXERCISE IN SUBJECTS WITH

LATERAL EPICONDYALGIA”

By
Ramesh Sada

Dissertation Submitted to
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In Partial Fulfillment
of the Requirement for the Degree of

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MASTER OF PHYSIOTHERAPY [M.P.T]

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Musculoskeletal Disorders and Sports Physiotherapy

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Under the guidance of

Dr. S. Earnest Jacob

LECTURER
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DR. M .V. SHETTY COLLEGE OF PHYSIOTHERAPY

MANGALORE

2013

Rajiv Gandhi University of health sciences, Karnataka.

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DEDICATED
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FAMILY
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LIST OF ABBREVIATIONS USED

CEO:Common extensor origin

DTFM: Deep Transverse Friction Massage

ECRB:Extensor Carpi Radialis Brevis

ECRL: Extensor Carpi Radialis Longus

EDC:Extensor Digitorum Communis

ECU: Extensor Carpi Ulnaris

EMG:Electromyography

Et al:and others

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HHD: Hand Held Dynamometer

HGS:Hand grip Strength

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HVLA:High velocity low amplitude

LE: Lateral epicondyalgia

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LET:Lateral Elbow Tendinopathy

MHz:Mega- Hertz

mW: Mili Watt

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NSAID:Non steroidal anti inflammatory Drugs

PBRN:Posterior branch of Radial Nerve

P Value:Probability

RICE:Rest, Ice, Compression, Elevation

SD:Standard Deviation

TEFS:Tennis elbow Function Scale

TENS:Transcutaneous electrical nerve stimulation

US:Ultrasound

VAS:Visual Analogue Scale

 ABSTRACT

BACKGROUND & PURPOSE:

Lateral epicondylgia is a painful and debilitating musculoskeletal condition that

poses significant challenges to the healthcare industry.

Despite the fact that lateral epicondylalgia has a well-defined clinical presentation,

no ideal treatment strategy has emerged. There is a lack of experimental data

regarding the multimodal approaches with cyriax physiotherapy in bringing up better

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outcome measures on the subjects with lateral epicondylgia. The purpose of this
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study is to find the combined effectiveness of cyriax physiotherapy and

phonophoresis with supervised exercise with lateral epicondylgia.

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METHODOLOGY:

40 subjects those satisfying the inclusion criteria will be recruited for the
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study.Patients were randomly allocated into two groups(20 in each), A and B.Group

A received the experimental treatment of Cyriax physiotherapy and phonophoresis

with supervised exercise whereas Group B received the control treatment of

supervised exercise alone. All participants were seen 3 times a week for 4 weeks for

a total of 12 treatment sessions.

RESULTS

Results from statistical data analysis done on data collected showed that the effect of

HGS, TEFS and VAS improved 37.12%, 43.04% and 59.59% in group Aafter the

treatment whereas HGS, TEFS and VAS improved 22.45%, 19.84% and 41.48% in
group B which showed that group A (Cyriax physiotherapy and phonophoresis with

supervised exercise) experienced greater outcomes for all variables in comparison to

group B (supervised exercise alone).

CONCLUSION:

The study can be concluded as the effect of combined cyriax physiotherapy and

phonophoresis with supervised exercise was highly significant in the subject with

lateral epicondylgia.

KEYWORDS:

Lateral epicondyalgia(LE),Pain,Visual Analouge Scale(VAS),Hand held

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Dynamometer(HHD),Mill,s Manipulation,Deep Transverse Friction

Massage(DTFM),Phonophoresis,Hand grip strength(HGS),Tennis elbow function

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Scale(TEFS).
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 TABLE OF CONTENTS

S.NO. TOPIC PAGE NO.

1 INTRODUCTION 1-14

2 OBJECTIVES 15

3 REVIEW OF LITERATURE 16-53

4 METHODOLOGY 54-64

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5 RESULTS 65-73

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DISCUSSION 74-79

7 CONCLUSION 80
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8 SUMMARY 81-82
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9 BIBLIOGRAPHY 83-97

10 ANNEXURE 98-104
 LIST OF TABLES

Table Topic Page

No. no.

5.1 AGE WISE DISTRIBUTION OF SUBJECTS 65

5.2 GENDER WISE DISTRIBUTION OF SUBJECTS 66

5.3 AEESEEMENT AND COMPARISON OF ALL PARAMETERS BEFORE 67

THE TREATMENT

5.4 COMPARISON OF HGS BEFORE AND AFTER THE TREATMENT 68

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WITHIN THE GROUPS

5.5 COMPARISON OF EFFECT OF HGS BETWEEN THE GROUPS 68

5.6
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COMPARISON OF TEFS BEFORE AND AFTER THE TREATMENT 69
WITHIN THE GROUPS
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5.7 COMPARISON OF EFFECT OF TEFS BETWEEN THE GROUPS 70

5.8 COMPARION OF VAS BEFORE AND AFTER THE TREATMENT 71

WITHIN THE GROUPS
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5.9 COMPARION OF EFFECT OF VAS BETWEEN THE GROUPS 71

5.10 EFFECTS OF AGE ON THE TREATMENT 72

5.11 EFFECTS OF GENDER ON THE TREATMENT 73

LIST OF FIGURES

Sl No. Topic Page no.

1.1 PATHOLOGY IN LATERAL EPICONDYALGIA 4

4.1 DTFM TECHNIQUE FOR TENNIS ELBOW 62

4.2 MILLS MANIPULATION FOR TENNIS ELBOW 62

4.3 PHONOPHORESIS FOR TENNIS ELBOW 63

4.4 STATIC SRETCHING FOR ECRB 63

ECCENTRIC STRENGTHENING EXERCISES FOR WRIST
4.5 EXTENSORS 64
ASSESING HAND GRIP STRENGTH USING HAND HELD
4.6 DYNAMOMETRY 64

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5.1 AGE WISE DISTRIBUTION OF SUBJECTS 66
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5.2 GENDER WISE DISTRIBUTION OF SUBJECTS
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5.3 COMPARISON OF HGS BEFORE AND AFTER THE TREATMENT 69
BETWEEN THE GROUPS
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5.4 COMPARISON OF TEFS BEFORE AND AFTER THE TREATMENT 70

BETWEEN THE GROUPS

COMPARISON OF VAS BEFORE AND AFTER THE TREATMENT

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5.5 BETWEEN THE GROUPS 72

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INTRODUCTION
Musculoskeletal conditions are the most common self-reported work-related

disease,with high costs incurred from long-term disability1.Medial and lateral

epicondylalgia is relatively common among working-age individuals in the general

population2.Lateral epicondylagia has been found to be the second most frequently

diagnosed musculoskeletal disorder of the upper extremities in a primary health care

setting3.

The syndrome of persistent disabling pain in the elbow, predominantly in the radio

humeral joint, is called as tennis elbow, lateral epicondylitis,or lateral

epicondylalgia4-6. The definite cause of tennis elbow is not yet known.

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It is degenerative or failed healing tendon response characterized by the increased

presence of fibroblasts, vascularhyperplasia, and disorganized collagen in the origin

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of Extensor carpi radialis brevis (ECRB), the most commonly affected structure7.

The first description of symptoms indicating a painful condition in the Common

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extensor origin (CEO) was given in 1873 by Runge, who called the condition

writer’s cramp. The term TE was introduced in 1882 by Morris, but Momberg (1910)
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was likely the first person to describe the condition in detail8.Occupation related

epicondylar pain was described as early as 1896 by Bernhardt (Goldie, 1964;

Nirschl, 1992;Runeson and Haker, 2002).Consequently, the term epicondylitis is an

inaccurate descriptor of the disorder, prompting the use of a more generalized term

such as “epicondylgia”9.The preffered nomenclature is Lateral epicondyalgia,as the

suffix ‘-algia’ denotes pain; the pathophysiology of the condition is less commonly

inflammation(‘-itis’)or degeneration (-osis’) than it is predominantly hyperalgesia

and pain(‘-algia’)10.

It is generally a work related or sports related pain disorder usually caused by

excessive quick, monotonous, repetitive eccentric contractions and gripping activities

of wrist11.It can interface with the affected person’s ability to function at work,

recreation and home and imposes a financial cost on the community12.

The syndrome is seen mainly in those whose work involes repetitive movement of

the forearm and hand. It is reported that 7.4% of workers in highly repetitive hand

task industries, household activities and 40% to 50% of tennis players in the USA are

at some time affected by it13. LE also known as Tennis elbow which is a misnomer

since it occurs in non tennis players also14.

The etiology of LE has not been fully elucidated but on current evidence it would

appear that the condition in its chronic form is not one of acute inflammation15.Any

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activity involving wrist extension and /or supination can be associated with overuse

or misuse or micro-trauma at the vicinity of the Extensor carpi radialis brevis muscle
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is postulated to be the cause of this clinical entity although acute onset traumatic

injuries do occur16. Boyer and Hasting17 suggested that most of the cases diagnosed
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as LE is most commonly an idiopathic or the result of a work related ‘repetitive

strain injury’.

Putman and Cohen reported that the activities, in which the load is greater than that
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which can be withstood by the muscle origin either form an individual load or more

commonly over a period or time are responsible for causing Lateral epicondyalgia

and that these injuries can either from concentric or eccentric contraction.

Although L.E. occurs at all ages, the peak prevalence of L.E. is between 30 and 60

years of age18, 19. Lateral epicondylitis occurs much more frequently than medial-

sided elbow pain, with ratios reportedly ranging from 4:1 to 7:1 [20-22].The commonly

affected arm is the dominant arm, with a prevalence of 1–3% in the general

population,but the incidence rapidly increases to 19% between 30–60 years of age

and seems to be more severe and long-standing in women 18,19.The typical patient is a
man or woman aged 30-55 years who either is a recreational athlete or one who

engages in rigorous daily activities.It has been shown that 50% of club tennis player

older than aged 30 years have experienced symptoms characteristics of LE at aleast

once23.About 7% patients per 1000 per year attending general medical

practices24.The condition is largely self limiting, duration of lateral epicondyalgia is

highly variable, ranging from 6 months to several years prone to recurrent bouts and

symptoms seem to resolve between 6 months to 2 years in most patients25.

Maximum area of tenderness is approximately 1-2cm distal to the lateral epicondyle

in ECRB tendon. Pain may radiate to lateral aspect of forearm. Examination reveals

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increased in pain by resisted wrist extension especially with forearm pronation and

wrist radially deviated (Mill’s test). Resisted extension of the middle finger is also

painful26.
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ANATOMY:
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The elbow is a hinge synovial joint made up of the humerus, ulna and radius. The

unique positioning and interaction of the bones in the joint allows for a small amount
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of rotation as well as hinge action. This rotation is easily noticed during activities

such as hand-to-mouth eating motions27, 28

The articular surface of thelower end of the humerus are mainly capitulum and the

trochlear articulates with the upper end of the radius (humero-radial) and upper end of

ulna (humero-ulnar) respectively27.Elbow is intermediate joint of the upper limp

consists the mechanical link between the first segment, the upper arm and the second

segment, the forearm of the upper limp29.The humero-ulnar joint, humero-radial joint

and superior radio-ulnar joints are enclosed in a single joint capsule. Anteriarly the

proximal attachment of the capsule is just above the coronoid process and radial

fossae; distally it is inserted into ulna on the margin of the coronoid process and into
 annular ligament. Laterally the capsule attaches to the radius and blends with the

fibers of the lateral collateral ligament. Medially the capsule blends with the fibers of

the medial collateral ligament.Posteriourly the capsule is attached to the humerus

along the upper edge of the olecranon fossa.The capsule is fairly large, loose and

weak anteriorly and posteriorly, but the ligaments enforces its sides30,31.Most Hinge

joints in the body have collateral ligaments and the elbow is no exception. Collateral

ligaments are located on the medial and lateral sides of the hinge joints to provide

medial and lateral stability to the joint and to keep joint surfaces in opposition. The

two main ligaments associated with the elbow joints are the medial (ulnar) andlateral

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(radial) collateral ligaments30, 31.

In Lateral Epicondylitis, pain and tenderness occurs over the common extensor
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origin (lateral epicondyle) of the muscles of the forearm.The superficial muscles

arising from the common extensor origin are: Extensor Carpi Radialis Brevis,
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Extensor Carpi Radialis Longus, Extensor Carpi Ulnaris, Extensor Digitorum

Communis, Extensor Digiti Minimi and Brachioradialis.The deep muscles of the

back of forearm include Supinator, Extensor Indicis, Extensor Pollicis Brevis,

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Abductor Pollicis Longus, and Extensor Pollicis Longus.

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FIGURE 1.1: SHOWWS PATHOLOGY IN LATERAL EPICONDYLGIA

BLOOD SUPPLY:

The arterial blood supply for the ECRB mainly comes from the radial recurrent

artery. The posterior branch of the radial collateral artery, and the interosseous

recurrent artery, also contributes.The vascularisation is seen as a network of small

vessels on the surface of the tendon.The deep part of the origin is almost avascular,

and some regions are described as“Hypo vascular zones” (Schneeberger and

Masquelet, 2002; Bales.et al., 2007).

INNERVATION:

The muscles composing the CEO are innervated by the radialis nerve (C6-C7). The

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sensory innervation is sparsely described in the literature, and there is no complete

picture. The roles of the sympathetic and parasympathetic nerves are unclear. A local
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dysfunction of the sympathetic nervous system has been shown in the dermal micro-

vascular bed overlying the enthesis in TE (Smith et al., 1994).

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RANGE OF MOTION:

The active flexion of the elbow with supinated forearm ranges from 00-1350 to 00-
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1450.

Passive range of flexion is from 00-1500to 00-1600.

ROM of the elbow joint is not affected in Lateral Epicondylitis.

PATHOLOGY AND PATHOMECHANICS:

The pathophysiology of lateral epicondylitis is non-inflammatory, chronic

degenerative changes of the origin of the extensor carpi radialis brevis (ECRB)

muscle are identified in surgical pathology specimens32 .It is unclear if the pathology

is affected by prior injection of corticosteroid.

ECRL and ECRB work to counteract the flexion moment generated at the wrist by

the digital and wrist flexors. Increased muscle activities of the wrist extensors
maintain the wrist in a position of slight extension, allowing the digital flexors to

function near their ideal length-tension relationship, and thus generate maximal grip

strength (Snijders et al., 1987). As the name imply, the muscles originating from the

CEO extend the fingers and the wrist, but seldom with high forces. The high forces

are achieved when the grip is used, and there is a need to stabilise the wrist (Lieber

and Friden, 1998; Shiri et al., 2006).The maximum muscle strain on ECRB is

obtained during elbow extension, forearm pronation, and wrist flexion-ulnar

deviation (Briggs and Elliott, 1985; Takasaki et al., 2007). This is important to keep

in mind when the working position is evaluated ergonomically, and during stretching

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exercises. During the so called “working position”, the ECRB passes straight from

the epicondyle to the forearm. Working position is defined as elbow flexion and
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semi-pronated wrist. The ECRB-muscle and the other wrist and finger extensor

muscles have special biomechanical properties due to the fact that they act over more
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than one joint. The CEO is proximal to the axis of rotation for flexion and extension

at the elbow, and is subjected to shearing stress in all movements of the forearm. The

head of the radius is rotating under the ECRB-tendon during pronation of the
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forearm; this will contribute to the forces applied to this region (Briggs and Elliott,

1985). The undersurface of the CEO is also vulnerable to abrasion against the lateral

edge of the capitulum of humerus during elbow motion (Bunata et al, 2007).

The current interest in racquet, paddle tennis, squash and tennis predisposing large

numbers of the population to the possibility of elbow injuries.The use of a racquet

greatly increases the length of the forearm lever (resistance arm) and subjects the

elbow complex structures to great stresses33. The classic lateral epicondylitis is

caused by repeated forceful contractions of the wrist extensors, primarily ECRB. The

tensile stress created at the origin of the ECRB may cause microscopic tears that lead
to inflammation of the lateral epicondyle.Repeated tensile stress on the elastic tendon

may result in microscopic tears at the musculotendinous junction and result in

tendinitis33.The primary pathological process involved in this condition is tendinosis

of the extensor carpi radialis brevis (ECRB) tendon, usually within 1-2 cm (0.5-1

inch) of its attachments to the common extensor origin at the lateral epicondyle.

CLINICAL PRESENTATION:

1. Tenderness over the lateral aspect of the forearm – lateral epicondyle,

extensor tendons, muscle belly which may radiate into the forearm.

2. Decreased grip strength and pain on gripping.

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3. Decreased strength and pain on active wrist extension.

4. Pain on resisted radial deviation and extension of the middle finger.

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5. May disturb sleep when severe.

6. In chronic stage – usually a loss of end range elbow extension or adduction with
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extension (due to intimate relationships between ECRB and capsule/ligaments of the

elbow complex).
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7. The condition may be irritable (can be “Stirred up” easily), onset may be gradual

or related to a specific incident (insidious or traumatic) 29.

DIAGNOSE OF LATERAL EPICONDYALGIA

Non-articular causes of elbow pain include muscle strains,ligamentous injuries,

epicondylitis, olecranon bursitis, and compressive neuropathies. Overuse and trauma

commonly cause these conditions. The history and physical examination differentiate

them from an intra-articular process such as synovitis. To diagnose lateral

epicondylalgia there are some tests that should be positive to be certain of the right

diagnosis. Active and passive movements of the elbow are rarely decreased, though

some pain could occur with complete extension, especially if the forearm is pronated
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. Swelling is also seldom present. This diagnosis could be difficult if one is not

used to examining the patient according to the criteria for lateral epicondylalgia.

There are several differential diagnoses, such as radial nerve entrapment,

radiocapitellar chondromalacia or osteochondritis dissecans capitulum, that could be

mistakenly given.

A diagnosis that is not correct could mean that the wrong treatment would be given

to the patient, which may worsen the symptoms or leave the patient with no effectual

treatment at all. Incorrect diagnosis could also mean that all of the patients in a study

may not have the right diagnosis.

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• Pain upon palpation of the lateral epicondyle and the common extensor origin.

• The “chair lifting test” or the “coffee cup test” in which the patient feels pain at the
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lateral epicondyle when picking up a full cup of coffee35.

• “Mills’ test” in which full pronation combined with complete wrist and finger
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flexion prevents full elbow extension or, at least, a feeling of resistance at the elbow

and pain at the epicondyle 36.

• “Maudsley’s test” or the “middle-finger test”, in which resisted extension of the

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middle finger when the elbow is fully extended and the forearm is pronated causes

pain at the lateral epicondyle 37.

DISABILITIES FROM LATERAL EPICONDYALGIA

Histopathological findings indicate that tennis elbow is a degenerative

condition,called tendinosis, of the common extensor tendon, with the extensor carpi

radialis brevis tendon more commonly implicated as the primary location of

tendinosis. Despite the absence of inflammation, patients with tennis elbow still

present withPain38 which affects the grip-strength in the hand. Musculus extensor

carpi radialis brevis has its origin on the lateral epicondyle of humerus and insertion
in the base of the third metacarpal bone. The muscle has a combined function as it

flexes the elbow but also dorsal extends and radial deviates the hand at wrist. The

extensor carpi radialis brevis tendon has a unique anatomic location that makes its

undersurface vulnerable to contact and abrasion against the lateral edge of the

capitulum during elbow motion39.As an extension of pain and decreased gripstrength,

work may not be suitable for the patient, resulting in sick-leave.

INTERVENTION:

Lateral Epicondyalgia could result in sick-leave absence, which costs society, the

employer and the employee substantial money.A cost-effective way to treat the

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patient is recommending that the patients train at home to gain the strength they need

to function at work or in their spare time.

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It is a painful and debilitating condition which requires early intervention if optimal

recovery is to be made40.Even though tennis elbow has well-defined clinical features,

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no proper treatment intervention has emanated41.The treatment of Lateral

epicondyalgia,a widely–used model of musculoskeletal pain in the evaluation of

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many physical therapy treatments,remains somewhat enigma.More than 90% of

people respond to conservative treatment.Very few people require surgery for Lateral

Epicondyalgia.In literature, more than 40 different methods have been documented

for the treatment of tennis elbow42.Conventional treatment43 for tennis elbow has

focused primarily on the pain management by anti-inflammatory medication,

ultrasound, phonophoresis44,or iontophoresis.Various treatments have been attempted

for tennis elbow including corticosteroid injection45,drug therapies,laser46-49electrical

stimulation50,51,ergonomics52,53,Tapping,counterforce,bracing54acupuncture55-56, and

splintage4.Surgical treatment is indicated in 5–10%57of patients who did not improve

from their symptoms with conservative treatment approach.The theoretical

 mechanism of actions of these treatment interventions differs widely,but the entire

treatments' goal is to improve function and reduce pain41.Even though numerous

studies have been conducted on treatment of this clinical condition, till date the most

effective management strategy is not agreed58.For the treatment of tennis elbow, both

medical and physiotherapeutic interventions have been reported in research

literature59.

Recurrence of Tennis elbow can be prevented by using braces to support the

wrist,changing technique or equipment,or modifying jobs and activities if possible.

Warming up before activities will help prevent problems too. Gently stretch the

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forearm and wrist before performing any sport or activity that can cause or aggravate

Lateral Epicongyalgia.
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Despite the fact that lateral epicondylalgia has a well-defined clinical presentation,

no ideal treatment strategy has emerged.Although conservative treatment of this

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condition has been the subject of numerous studies, there is no agreement as to the

most effective management strategy60.Many clinicians advocate a conservative

approach; however, a plethora of interventions both medical and physiotherapeutic

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have been reported59.Regardless of the variety of treatment options, all have the same

goal: to reduce pain and improve function61.Specific manipulation therapy for

chronic L.E.produces uniquely characteristic hypoalgesia including cyriax

technique.and phonophoresis with supervised exercise.

CYRIAX TECHNIQUE:

Cyriax and Cyriax suggested the use of deep transverse friction massage in

combination with mill's manipulation for the treatment of tennis elbow62.In order to

label the treatment intervention as Cyriax physiotherapy, both the treatment

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