Dry Needling, Manipulation and Stretching vs. Manual Therapy, Exercise and Ultrasound for Lateral Epicondylalgia

Inclusion Criteria: 1. Adult between 18 and 60 years old that is able to speak English. 2. Report of at least 6 weeks of elbow (i.e. lateral epicondyle) and dorsal forearm pain, consistent with lateral epicondylitis: 3. Patient has not had physical therapy, massage therapy, chiropractic treatment or injections for elbow pain in the last 6 months: 4. Diagnosis of lateral epicondylitis, defined as two of more of the following: 1. Pain on palpation over the lateral epicondyle and the associated common extensor unit 2. Pain on gripping a hand dynamometer 3. Pain with stretching or contraction of the wrist extensor muscles Exclusion Criteria: 1. Report of red flags to manual physical therapy to include: severe hypertension, infection, uncontrolled diabetes, peripheral neuropathy, heart disease, stroke, chronic ischemia, edema, severe varicosities, tumor, metabolic disease, prolonged steroid use, fracture, RA, osteoporosis, severe vascular disease, malignancy, etc. 2. Report of Previous surgery of the elbow, history of elbow dislocation, elbow fracture and/or tendon rupture 3. Report of systemic neurological disorders and/or neurological deficits to include the following: 1. Nerve root compression (muscle weakness involving a major muscle group of the upper extremity, diminished upper extremity deep tendon reflex, or diminished or absent sensation to pinprick in any upper extremity dermatome) 2. Cervical spinal stenosis (exhibited bilateral upper extremity symptoms) 3. Central nervous system involvement (hyperreflexia, sensory disturbances in the hand, intrinsic muscle wasting of the hands, unsteadiness during walking, nystagmus, loss of visual acuity, impaired sensation of the face, altered taste, the presence of pathological reflexes) 4. History of whiplash injury within the previous 6 weeks 4. History of surgery to the head/neck or affected upper extremity. 5. Psychiatric disorders or cognitively impaired 6. Pregnancy