Lateral epicondylitis is the most common cause of pain in elbow, due to repetitive wrist extension or gripping activities. This condition is also described as a chronic symptomatic degeneration of the extensor tendon of forearm commonly extensor carpi radialis brevis at the attachment area of humeral epicondyle. (1) Tennis elbow is common in individuals who undergo repetitive wrist extension, radial deviation, and forearm supination. The histological findings of lateral epicondylitis consist of granulation tissue, micro-rupture, fibroblasts abundance, UN structured collagen, vascular hyperplasia, and lack of inflammatory cells within the tissue (lymphocytes, macrophages, neutrophils). (2) Lateral epicondylitis can occur in any age group but is more common between 30-50 years of age. (3) Many previous reports conducted in different countries described that there is 2-14% prevalence of lateral epicondylitis in working population and only 5% of people suffering from tennis elbow relate this injury to the tennis. (4) Evidence from a systematic review published in 2019 described the prevalence rate of 1-3% in the general population and 7% in the handy workers group with equal gender distribution. (5) There are many treatment options for lateral epicondylitis. Initially it is treated by conservative treatment (1) Recently in 2021, R Manandhar et al conducted an RCT reported positive results using combination of Movement with mobilization and Eccentric exercises regarding pain and functional disability.(8) BL Woodley et al in 2018 published his systematic review which concluded that limited level of evidence exists on the effectiveness of eccentric strengthening exercises to standard physiotherapy protocols. Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of tendinopathy of the common wrist extensor tendon of the lateral elbow (LET. (9) If pain do not resolve with conservative treatment then further treatment options will be extracorporeal shock wave therapy, cortisone injections and surgery.(6) In an RCT of Ju-hyun Lee et all in 2018 ,the effects of eccentric control exercise for tennis elbow showed useful effects for pain and functional activity was improved with a p value of 0.05.(7) Timothy Tyler et al recently conducted a cross sectional study in 2021 to compare standard physiotherapy treatment to Tyler twist exercises which are a new treatment protocol for wrist extensor strengthening using 2-3 colored twistable rubber bands This study suggested that Tyler twist exercise could be effective strength training protocol and once learnt can be performed by the patient at home without any supervision.(9)

To treat lateral epicondylitis platelet rich plasma has gained popularity. To enhance wound healing, bone healing and tendon healing, platelets release high concentration of platelet-derived growth factors. It is difficult to draw clear conclusions on PRP for lateral epicondylitis because some available studies have reported conflicting results. Manipulative techniques fall into two basic varieties in the treatment of lateral epicondylitis; those that will produce a thrust and those that seek full extension. To effect the contractile element the manipulations performed in extension with pronation have the greatest chance. Forced extension of elbow with the wrist and fingers fixed and the forearm promoted is the most common procedure known as mill's manipulation. Manipulations are painful procedures and require 2 weeks of rest after application.(11) With a high success rate, injections are one of the most popular methods utilized .Physical therapy is initiated when the condition becomes chronic or not responding to initial treatment. Ultrasound, phonophoresis, electrical stimulation,, manipulation, soft tissue mobilization , neural tension, friction massage , augmented soft tissue mobilization and stretching and strengthening techniques are the common rehabilitation modalities utilized for the treatment. (12) Proper evidence behind Tyler twist wrist extensor exercises in the management of lateral epicondylitis is sparse and there are less number of studies with limited methodological designs. There are no previous randomized control trials conducted to see the effects of Tyler twist exercises in contrast to standard physiotherapy treatment using combined tools for pain , grip strength and functional activity According to the literature review, there had been lack of reporting of compliance and adherence to the exercise programs, with only four studies documenting exercise adherence, So, the additional benefit of this protocol is that it can be performed as part of a home program and does not involve continued medical supervision when learned properly. So, this study will focus on effects of Tyler twist exercise to standard physiotherapy protocol.