Cyriax physiotherapy for tennis elbow/lateral epicondylitis
D Stasinopoulos, M I Johnson
Br J Sports Med 2004;38:675–677. doi: 10.1136/bjsm.2004.013573
Tennis elbow or lateral epicondylitis is one of the most
common lesions of the arm with a well defined clinical
presentation, which significantly impacts on the
community. Many treatment approaches have been
proposed to manage this condition. One is Cyriax
physiotherapy. The effectiveness and reported effects of this
intervention are reviewed.
See end of article for
D Stasinopoulos, 16
Orfanidou Street, Athens
Accepted 11 May 2004
ennis elbow (lateral epicondylitis) is one of
the most common lesions of the arm. This
disorder challenges the clinician daily, as it is
an injury that is difficult to treat, is prone to
recurrent bouts, and may last for several weeks
or months. The average duration of a typical
episode of tennis elbow is between six months
and two years.
It is a degenerative or failed healing tendon
response characterised by the increased presence
of fibroblasts, vascular hyperplasia, and disorga-
nised collagen in the origin of the extensor carpi
radialis brevis, the most commonly affected
It is generally a work related or sport related
pain disorder with macroscopic and microscopic
tears in the extensor carpi radialis brevis, usually
caused by excessive quick, monotonous, repeti-
tive eccentric contractions and gripping activities
of the wrist.
The dominant arm is commonly
affected, with a prevalence of 1–3% in the
general population, but this increases to 19% at
30–60 years of age and appears to be more long
standing and severe in women.
It has a well defined clinical presentation, the
main complaints being pain and decreased grip
strength, both of which may affect activities of
daily living. Diagnosis is simple and can be
confirmed by tests that reproduce the pain, such
as palpation over the facet of the lateral
epicondyle, resisted wrist extension, resisted
middle finger extension, and passive wrist
‘‘Such a variety of treatment options suggests
that the optimal treatment strategy is not
Although the signs and symptoms of tennis
elbow are clear and its diagnosis is easy, to date
no ideal treatment has emerged. A myriad of
conservative treatments have been used. Over 40
different methods have been reported in the
These treatments have different theor-
etical mechanisms of action, but all have the
same aim, to reduce pain and improve function.
Such a variety of treatment options suggests that
the optimal treatment strategy is not known, and
more research is needed to discover the most
effective treatment in patients with tennis elbow.
A common intervention is Cyriax physiother-
apy. The purpose of this article is to describe its
use in the treatment of tennis elbow and its
Cyriax and Cyriax
claimed substantial success in
treating tennis elbow using deep transverse
friction (DTF) in combination with Mill’s manip-
ulation, which is performed immediately after
DTF. For it to be considered a Cyriax interven-
tion, the two components must be used together
in the order mentioned. Patients must follow the
protocol three times a week for four weeks.
Deep transverse friction
Although the word friction is technically incor-
rect and would be better replaced by ‘‘massage’’,
this name will be used in this article. DTF is a
specific type of connective tissue massage applied
precisely to the soft tissue structures such as
tendons. It was developed in an empirical way by
Cyriax and Cyriax and is currently used exten-
sively in rehabilitation practice.
It is vital that DTF be performed only at the
exact site of the lesion, with the depth of friction
tolerable to the patient.
The effect is so
localised that, unless the finger is applied to the
exact site and friction given in the right direc-
tion, relief cannot be expected.
be applied transversely to the specific tissue
involved, unlike superficial massage given in the
longitudinal direction parallel to the vessels,
which enhances circulation and return of fluids.
The therapist’s fingers and patient’s skin must
move as a single unit, otherwise subcutaneous
fascia could lead to blister formation or sub-
As a general guideline, DTF is applied for
10 minutes after the numbing effect has been
achieved, every other day or at a minimum
interval of 48 hours, because of the traumatic
hyperaemia induced, to prepare the tendon for
There is only empiri-
cal evidence to support the times suggested
above. Unfortunately, the technique has devel-
oped a reputation for being very painful.
15 17 18
However, pain during friction massage is usually
the result of a wrong indication, a wrong
technique, or an unaccustomed amount of
pressure. If this form of massage is applied
correctly, it will quickly result in an analgesic
effect over the treated area and is not at all
painful for the patient.
On the other hand,
treating clinicians claim this technique places
considerable strain on their hands.
There is very little scientific evidence on mode of action
and effectiveness of DTF. Only a few studies exist, and more
research is urgently needed. However, although the exact
mode of action is not known, some theoretical explanations
have been put forward. It has been hypothesised, with no
scientific proof, that DTF has a local pain diminishing effect
and results in better alignment of connective tissue fibrils.
It is a common clinical observation that application of DTF
leads to immediate pain relief: the patient experiences a
numbing effect during the session, and reassessment
immediately after shows reduction in pain and increase in
strength and mobility.
A number of hypotheses to explain
the pain relieving effect of DTF have been put forward.
Pain relief during and after DTF may be due to modulation
of the nociceptive impulses at the level of the spinal cord: the
‘‘gate control theory’’. The centripetal projection into the
dorsal horn of the spinal cord from the nociceptive receptor
system is inhibited by the concurrent activity of the
mechanoreceptors located in the same tissues.
to Cyriax and Cyriax,
DTF also leads to increased destruction
of pain provoking metabolites, such as Lewis’s substances.
This metabolite, if present in too high a concentration, causes
ischaemia and pain. It has also been suggested that a
10 minute DTF treatment of a localised area may give rise to
lasting peripheral disturbance of nerve tissue, with local
Another mechanism by which reduction
in pain may be achieved is through diffuse noxious inhibitory
controls, a pain suppression mechanism that releases
endogenous opiates. The latter are inhibitory neurotransmit-
ters which diminish the intensity of the pain transmitted to
In addition, the application of DTF can produce therapeutic
movement by breaking down the strong cross links or
adhesions that have been formed, softening the scar tissue
and mobilising the cross links between the mutual collagen
fibres and the adhesions between repairing connective tissue
and surrounding tissues.
14 16 20 22
Moreover clinicians claim,
without support from clinical studies, that the rhythmical
transverse stress of DTF stimulates fibre orientation with the
result of enhancing tensile strength.
Finally, DTF produces vasodilatation and increased blood
flow to the area. This may facilitate the removal of chemical
irritants and increase the transportation of endogenous
opiates, resulting in a decrease in pain.
14 16 20 22
Absolute contraindications to DTF are few. It is never
applied to active infections, bursitis and disorders of nerve
structures, ossification and calcification of the soft tissues, or
active rheumatoid arthritis, and care is required if there
is fragile skin or the patient is having anticoagulant
DTF for tennis elbow is applied as follows.
patient comfortably with the elbow fully supinated and in 90
of flexion. Locate the anterolateral aspect of the lateral
epicondyle (facet of the lateral epicondyle, where the
extensor carpi radialis brevis inserts, the most common site
of pain in patients with tennis elbow, as mentioned in the
introduction), and identify the area of tenderness. Apply DTF
with the side of the thumb tip, applying the pressure in a
posterior direction on the teno-osseous junction. Maintain
this pressure while imparting DTF in a direction towards your
fingers, which should be positioned on the other side of the
elbow for counter pressure. DTF is applied for 10 minutes
after the numbing effect has been achieved, to prepare the
tendon for Mill’s manipulation.
Mill’s manipulation is the most common manipulative
technique used by physiotherapists.
12 13 23
Cyriax and Cyriax
state that it should be performed immediately after the DTF
provided that the patient has a full range of passive elbow
extension. If passive elbow extension is limited, the
manipulative thrust will affect the elbow joint, rather than
the common extensor tendon, possibly causing traumatic
It is defined as a passive movement performed at
the end of range—that is, once all the slack has been taken
up—and is a minimal amplitude, high velocity thrust.
aim of this technique, again without properly designed
controlled studies to prove this, is to elongate the scar tissue
by rupturing adhesions within the teno-oseous junction,
making the area mobile and pain free.
Mill’s manipulation for tennis elbow should be conducted
Position the patient on a chair with a backrest
and stand behind the patient. Support the patient’s arm
under the crook of the elbow with the shoulder joint
abducted to 90
and medially rotated. The forearm will
automatically fall into pronation. Place the thumb of your
other hand in the web space between the patient’s thumb
and index finger and fully flex the patient’s wrist and pronate
the forearm. Move the hand supporting the crook of the
elbow on to the posterior surface of the elbow joint and,
while maintaining full wrist flexion and pronation, extend
the patient’s elbow until you feel that all the slack has been
taken up in the tendon. Step sideways to stand behind the
patient’s head, taking care to prevent the patient from
leaning away either forwards or sideways, which would
reduce the tension on the tendon. Apply a minimal
amplitude, high velocity thrust by simultaneously side
flexing your body away from your arms and pushing smartly
downwards with the hand over the patient’s elbow.
Cyriax and Cyriax
cautioned that, if poor manipulation is
performed by failing to maintain full wrist flexion, the thrust
is absorbed mainly by the elbow joint, potentially causing
traumatic arthritis. Depending on the magnitude of the
thrust, full wrist flexion probably does little to protect the
joint from such a manipulation if this is a really serious
This manoeuvre is conducted once only at each treatment
session because it is not a comfortable procedure for the
patient, and the effects of treatment often become fully
apparent over the following few days.
Studies in which Cyriax physiotherapy for tennis
elbow has been used
Computerised searches were performed using Medline (from
1966 to March 2004), Embase (from 1988 to March 2004),
Cinahl (from 1982 to March 2004), Index to Chiropractic
literature (from 1992 to March 2004), and Chirolars (from
1994 to March 2004) databases. Only English language
publications were considered. The search terms ‘‘tennis
elbow’’, ‘‘lateral epicondylitis’’, ‘‘Cyriax physiotherapy’’,
‘‘treatment’’, ‘‘management’’, ‘‘physiotherapy’’, ‘‘randomised
control trials’’ were used individually or in various combina-
tions. Other references identified from existing reviews and
other papers cited in the publications were searched.
Moreover, we tried to identify further citations from the
reference sections of papers retrieved, by contacting experts
in the field, and from the Cochrane Collaboration, an
international network of experts who search journals for
relevant citations, but we did not find any more studies.
Unpublished reports and abstracts were not considered.
Only one study was found in which Cyriax physiotherapy
had been used in the management of tennis elbow. Verhaar
compared the effects of corticosteroid injections with
Cyriax physiotherapy in treating patients with tennis elbow.
The results showed that the corticosteroid injection was
significantly more effective on the outcome measures (pain,
function, grip strength, and global assessment) than Cyriax
physiotherapy at the end of the treatment, but at the follow
676 Stasinopoulos, Johnso n
up one year after the end of treatment, there were no
significant differences between the two treatment groups.
This study is not helpful for practicing physiotherapists,
because most do not use injections to manage this condition.
It is better to compare Cyriax physiotherapy with other
physiotherapy treatments in order to assess its effects. In two
only DTF was used to treat patients rather than all
the components of Cyriax physiotherapy. Therefore we do not
know if Cyriax physiotherapy, which is mainly based on
clinicians’ claims, is effective as the sole treatment for tennis
elbow or if it is better than other methods. Randomised
controlled trials are needed to confirm the clinicians’ claims.
Although Cyriax physiotherapy is commonly used in the
treatment of tennis elbow, more research is needed to assess
firstly its effectiveness and secondly the effects of both its
D Stasinopoulos, Centre of Rheumatology and Rehabilitation, Leeds
Metropolitan University, Leeds, UK
M I Johnson, Leeds Metropolitan University
Conflict of interest: none declared
1 Murtagh J. Tennis elbow. Aust Fam Physician 1988;17:90–5.
2 Kraushal B, Nirschl R. Current concepts review: tendinosis of the elbow (tennis
elbow). Clinical features and findings of histological immunohistochemical and
electron microscopy studies. J Bone Joint Surg 1999;81:259–85 .
3 Pienimaki T, Tarvainen T, Siira P, et al. Progressive strengthening and
stretching exercises and ultrasound for chronic lateral epicondylitis.
4 Vasseljen O. Low-level laser versus traditional physiotherapy in the treatment
of tennis elbow. Physiotherapy 1992;78:329–34.
5 Allander E. Prevalence, incidence and remission rates of some common
rheumatic diseases and syndromes. Scand J Rheumatol 1974;3:145–53.
6 Vicenzino B, Wright A. Lateral epicondylalgia. I. A review of epidemiology,
pathophysioogy, aetiology and natural history. Physical Therapy Reviews
7 Haker E. Lateral epicondylalgia: diagnosis, treatment and evaluation. Critical
Reviews in Physical and Rehabilitation Medicine 1993;5:129–54.
8 Kamien M. A rational management of tennis elbow. Sports Med
9 Cyriax HJ, Cyriax JP. Cyriax’s illustrated manual of orthopaedic medicine.
Oxford: Butterworth-Heinemann, 1983.
10 Kesson M, Atkins E. Orthopaedic medicine: a practical approach. Oxford:
11 Noteboom T, Cruver S, Keller A, et al. Tennis elbow: a review. J Orthop
Sports Phys Ther 1994;19:357–66.
12 Selvier T, Wilson J. Methods utilized in treating lateral epicondylitis. Physical
Therapy Reviews 2000;5:117–24.
13 Wright A, Sluka K. Nonpharmacological treatments for musculoskeletal pain.
Clin J Pain 2001;17:33–46.
14 Chamberlain G. Cyriax’s friction massage: a review. J Orthop Sports Phys
15 De Bruijn R. Deep transverse friction: its analgesic effect. Int J Sports Med
16 Gregory M, Deane M, Mars M. Ultrastructural changes in untraumatised
rabbit skeletal muscle treated with deep transverse friction. Physiotherapy
17 Woodman RM, Pare L. Evaluation and treatment of soft tissue lesions of the
ankle and forefoot using the Cyriax approach. Phys Ther 1982;62:1144–7.
18 Ingham B. Transverse friction massage for the relief of tennis elbow. Phys
19 Stratford P, Levy D, Gauldie S, et al. The evaluation of phonophoresis and
friction massage as treatments for extensor carpi radialis tendinitis: a
randomized controlled trial. Physiother Can 1989;41:93–9.
20 Goats GC. Massage: the scientific basis of an ancient art. Part 2. Physiological
and therapeutic effects. Br J Sports Med 1994;28:153–6.
21 Kaada B, Torsteinbo O. Increase of plasma beta-endorphins in connective
tissue massage. Gen Pharmacol 1989;20:487–9.
22 Walker H. Deep transverse frictions in ligament healing. J Orthop Sports Phys
23 Kushner S, Reid D. Manipulation in the treatment of tennis elbow. J Orthop
Sports Phys Ther 1986;7:264–72.
24 Verhaar J, Walenkamp H, Mameren H, et al. Local corticosteroid injection
versus cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg
Cyriax physiotherapy for tennis elbow 677