Active Release Techniques (ART) Tennis Elbow

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Patient Guide:  Lateral Epicondylalgia (LE) aka Tennis Elbow.

  1. Research shows Myofascial Release is better than standard therapies.
  2. Do isometric (no movement) exercises before eccentric (slowly lower) exercises.
  3. There is some inflammation in some tendon problems, ice may help after heavy use.
  4. MRI may be better than diagnostic ultrasound in identifying LE.
  5. Elbow mobilizations have been shown to help.
  6. Steroid injections don’t provide long-term benefit.

Two recent studies found Active Release Techniques (ART) and Myofascial Release to be effective in treating chronic tennis elbow, compared to conventional therapy.  New research into exercises for tennis elbow have showed promising results.

The inflammation debate

Over the last few decades, LE stopped being considered a tendinitis because little evidence of inflammatory markers were found.  Tendinopathy became the new term of choice, but recent research found convincing evidence that the inflammatory response is a key component of chronic tendinopathies like LE.

A small handful of tendons are especially susceptible to tendinosis:  the shoulder rotator cuff (swimmer’s shoulder), the patellar tendon (runner’s knee), the Achilles tendon (Achilles’ heel) and the medial elbow flexor (golf elbow).

What causes the pain?

In a nutshell, tendinosis involves too much tendon breakdown and not enough repair. When repetitive micro trauma damages cells, they create new collagen which is structurally different.

Isometrics before eccentrics

Isometric exercises with different amounts of wrist and finger flexion should be tried first.

Eccentric exercises with a band for LE are often helpful and easy to learn, and there is some positive research about the FlexBar® (video).

Research on interventions

2002 RCT found 83% cases of LE resolved at 52 weeks with no intervention

Active Release Techniques (ART) and Myofascial Release have been evaluated in 1 2 RCTs and 1 2 case reports recently. The RCTs above reinforce the use of  long duration holds of either release technique, especially when treating tendons and musculotendinous junctions. (A recent RCT found myofascial release effective in treating plantar fasciitis, which is a similar enthesopathy.)  Anecdotally, I have found a focus treating the wrist extensors over the head of the radius to be important as well as the supinator.

Mulligan’s Mobilization with Movement (MWM) combines the use of active motion and passive manual mobilization which involves repeated gripping and sustained lateral glide to the elbow for 5 to 10 seconds.  MWM for treating LE has been extensively researched 1 2 3 4, and impressive reductions in pain were found in the short to medium-term.

Corticosteroid injections were found to provide worse outcomes than placebo in a 2013 study.  “There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief” – 2014 review. Note: (A recent study found steroid injections were helpful in Achilles tendinopathy.)

Exercises helped relieve pain in the short-term compared to no intervention 2011 study.

MRI vs. ultrasonography

2014 review concluded, “power doppler ultrasonography and real-time sonoelastography (is) expensive, and …this technology did not significantly add to the sensitivity and specificity of Gray-scale Ultrasonography”.

There is evidence on MRI signs of oedema on the asymptomatic side of many LE patients.  Thickening or partial tearing was not found on the asymptomatic side.


There is plenty of good evidence that manual therapy is effective in treating tennis elbow.  Give it a try in combination with an exercise program.


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I have treated the public and professional athletes for 19 years, using soft tissue work, Chiropractic, and prescribing the latest research based rehabilitation. I teach workshops in the North East of England to health professionals.