Journal Logo

Flexibility and Rehab Tips

Eccentric Interventions for Lateral Epicondylalgia

Kenas, Andrew DPT, CSCS1; Masi, Michael DPT, CSCS2; Kuntz, Chad DPT, CSCS3

Section Editor(s): Reuter, Ben PhD, CSCS*D, ATC

Author Information
Strength & Conditioning Journal: October 2015 - Volume 37 - Issue 5 - p 47-52
doi: 10.1519/SSC.0000000000000175
  • Free

Abstract

INTRODUCTION AND EPIDEMIOLOGY

Lateral epicondylalgia (commonly referred to as tennis elbow) is a musculoskeletal condition characterized by repetitive microtrauma to the common extensor tendon of the lateral epicondyle (Figure 1) (4,17). Peak incidence occurs between 35 and 55 years of age (14). Prevalence of this condition has been estimated at 1–3% in the general population (4,14,18,19), with the dominant arm affected in more than 70% of cases (4). In a review of elbow tendinopathies, Donaldson et al. (7) found that 9% of tennis players are affected, with novice players affected more than professional players. Furthermore, a systematic review by Bisset et al. (3) found that 15% of workers in highly repetitive hand task industries experience symptoms.

Figure 1
Figure 1:
Common extensor tendon (highlighted in green) Copyright Primal Pictures Ltd.

Researchers have consistently documented the extensor carpi radialis brevis tendon to be most commonly affected, with one-third of patients having involvement of the extensor digitorum tendon (2,8). Classified as an overuse disorder, lateral epicondylalgia can be a frustrating injury that substantially impacts function and presents challenges to the health care industry (3,4). Current conservative treatment methods found in the literature demonstrate poor efficacy and relapse on return to the offending activity (4). Eccentric-based exercise has gained considerable attention for managing this condition (11). Recent literature has emphasized the importance of eccentric exercise as a key component of tendinopathy rehabilitation (10,12). Moreover, a randomized control trial by Svernlov and Adolfsson (16) found that regardless of the duration of symptoms, the most effective therapeutic intervention for lateral epicondylalgia is eccentric training.

Eccentric exercise can be a key component of tendinopathy rehabilitation if integrated at the appropriate stage of injury. Nirschl has defined an ordinal 0–4 staging system for tendon injury, which delineates the clinical manifestations and proposed histological findings of each stage (6). A tendon in stage 0 is defined as healthy and composed of organized collagen in a noninflammatory state. Stage I is the first symptomatic stage, and it is defined by the clinical presentation of acute pain, swelling, local tenderness, warmth, and minimal dysfunction. Stage II is hallmarked by purposeful unloading of the tendon. Clinically, chronic tendinopathy often seen in this stage yields increased dysfunction compared with stage I, in addition to microtears and degenerative changes. Stage III is when chronic structural changes occur including palpable tendon enlargement from increased collagen disorientation and edema, and focal necrosis resulting from vascular compromise. Increased levels of dysfunction are present in stage III, which may or may not yield pain. Stage IV is defined by the complete rupture of the tendon. Gradual eccentric loading to the tendon may counteract the degenerative sequelae at stage III as it has been shown to improve collagen type I synthesis and decrease overall tendon thickness (11,13). Bigland-Richie and Woods (2) found that eccentric exercise results in more force production, less oxygen consumption, and less energy requirements compared with concentric exercise, thus improving remodeling potential of aberrant tendon structure (1). Remodeling occurs through the process of mechanotransduction; a physiologic, cellular response to mechanical loads to promote favorable structural changes (10). Considering eccentric actions are more energy-efficient mechanical stimuli than the concentric counterpart, we can impose more mechanical stimulus per unit of intensity, which may allow the user to work pain free and still be efficacious toward their recovery.

CLINICAL EVIDENCE

Despite a variety of conservative treatment approaches, relapses of lateral epicondylalgia are quite frequent with a recurrence rate of 24% (9). An eccentric treatment intervention initially performed for achilles tendinosis has shown promising results for lateral epicondylalgia. This may be a hypothesized extrapolation as similar changes are noted in both achilles tendinosis and lateral epicondylalgia. In 2007, Croisier et al. performed an intervention study on 92 patients. Two groups of 46 subjects were established with both groups participating in a training program 3 times a week for a 9-week period (4). The control group underwent a passive approach with an emphasis on palliative care, stretching, and deep friction massage. The experimental group performed isokinetic eccentric focused exercise for the wrist extensor and supinator muscle groups in addition to the treatment received by the control group. Pain intensity, strength, tendon integrity, and improvement of disability status were recorded to objectively measure potential and substantial change. The visual analog scale, Cybex Norm Device (Cybex International, Inc.; Medway, MA, USA), a 10 question disability questionnaire, and an ultrasonographic examination were utilized to detect the respective changes. At the conclusion of the experiment, the eccentric group had significantly less pain, mitigated bilateral strength deficits, improved homogenous tendon integrity (e.g., showed evidence of pathology resolution), and improved disability status when compared with the control group. These beneficial correlations may be extrapolated (and modified based on equipment availability) into the clinical setting, and with proper form and technique as described in the practical applications section, and may be useful in improving outcomes.

In a 1998 prospective study, Alfredson et al. investigated eccentric training on athletes diagnosed with chronic Achilles tendinosis. Unlike Croiser et al., they used a treatment protocol consisting of eccentric exercise twice per day, 7 days a week, for 12 weeks (1). Both treatment protocols found similar positive results. The optimal dosage for eccentric training regimes has yet to be delineated, and the effectiveness of various doses remains unclear (11). Croiser et al. chose to perform the exercises 3 times per week to give the tendon a sufficient rest period between successive sessions and subsequently obtained excellent results (4). Therefore, it seems logical that if fewer exercise sessions have similar positive effects in terms of outcome, lower frequency/intensity eccentric exercise protocols should be used (12).

PRACTICAL APPLICATIONS

There are multiple injuries outside of lateral epicondylalgia that may present with lateral elbow pain; therefore, before performing any treatment protocol, it is prudent that the participant be screened and cleared by a qualified health care practitioner. Recommendations for eccentric exercise interventions that may be used in the treatment of lateral epicondylalgia are listed below and adapted from the aforementioned research evidence. It should be noted that the original study used isokinetic machinery, and the following exercises have been adapted to be performed in the clinic or household settings without the demand of expensive equipment. With that being said, in the best effort to emulate the original evidence, there should be no concentric load and each eccentric repetition should be performed in a slow and controlled manner. Ideally, all range achieved with these exercises will be pain free. Some protocols may suggest working within a painful range (15); this, however, may result in decreased compliance or additional injury. Since the mechanism of injury is still only theoretical, it is our evidence-informed recommendation that pain be avoided. Specific exercise parameters are described in Figures 2–5.

Figure 2
Figure 2:
Eccentric wrist extension with dumbbell. Eccentric wrist extension with dumbbell (A) sit with the forearm supported by a surface and the elbow flexed to 60°. Grab dumbbell with pronated grip in full extension. (B) Slowly lower the dumbbell to allow eccentric wrist extension. (C) With uninvolved arm, return wrist to starting position.
Figure 3
Figure 3:
Eccentric wrist extension with twist-bar (A) with the elbow flexed to 90°, hold the bottom end of the twist-bar in maximum wrist extension. (B) Use the uninvolved arm to grab the top of the twist-bar with the palm facing away from you. (C) Flex the uninvolved wrist while holding involved wrist in extension. (D) Bring arms in front of body with elbows in extension while maintaining twist in the twist-bar. (E) Slowly allow twist-bar to “untwist” by allowing involved wrist to move into eccentric wrist extension. Return to starting position.
Figure 4
Figure 4:
Eccentric supination with elastic band (A) anchor, an elastic band to an object at elbow height. With the elbow flexed to 90°, grab the band and supinate the forearm so the palm is facing up. (B) Side-step away from the anchor to add more tension to the band. (C) Slowly allow the forearm to rotate 180° toward a palm down position to allow eccentric supination. Side-step toward the anchor and return to the starting position.
Figure 5
Figure 5:
Eccentric supination with hammer (A) with the elbow flexed to 60°, grab distal end of hammer handle with a neutral grip so the weighted side is on top. (B) Slowly rotate forearm through 90° toward a palm down position to allow eccentric supination. (C) Use uninvolved arm to return hammer to the upright starting position.

Exercise parameters—Perform eccentric exercises 3 times per week with 24–48 hours between bouts of eccentric work to allow for proper recovery. As stated previously, the Alfredson protocol suggests performing exercise twice daily, however, the Crosier et al. study had similar outcomes with a much lower frequency. Therefore, we propose using the lower intensity protocol to prevent the user from potentially exercising through a painful stimulus such as delayed onset muscle soreness. The study from Crosier et al. was performed for 9 weeks, however, a benefit may be derived from incorporating this routine into one's typical regimen for greater durations given the tendency for recurrence. Each exercise session should consist of 1 wrist supination and 1 wrist extension exercise for 2 sets of 10 repetitions each. Exercise intensity should originally equate to 30% of the users eccentric 1 repetition maximum and progress gradually per the participant's tolerance to 80% 1 repetition maximum toward the end of the 9 weeks. Each eccentric contraction should endure approximately 4–6 seconds without variation in speed throughout the repetition.

CONCLUSION

The current literature has shown great promise for the rehabilitation specialist to use eccentric exercise to restore function, decrease pain, and improve performance (4,5,14). Eccentric exercise should be an integral component of any lateral epicondylalgia rehabilitation program (11), not only because evidence suggests eccentric work to be superior to conventional interventions but also because it is based off sound physiological principles (3,4,13,14,16,17). Although isokinetic, eccentric training has been shown to be an effective treatment option, it may be too expensive or impractical for many facilities. Therefore, the aforementioned protocol based off the Crosier et al. study is a practical treatment option to incorporate in the lateral epicondylalgia rehabilitation program for use by the health care professional (17).

REFERENCES

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 26: 360–366, 1998.
2. Bigland-Ritchie B, Woods JJ. Integrated electromyogram and oxygen uptake during positive and negative work. J Physiol 260: 267–277, 1976.
3. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 39: 411–422, 2005.
4. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med 41: 269–275, 2007.
5. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 28: 3–19, 2014.
6. Davenport TE, Kulig K, Matharu Y, Blanco CE. The EdUReP model for nonsurgical management of tendinopathy. Phys Ther 85: 1093–1103, 2005.
7. Donaldson O, Vannet N, Gosens T, Kulkarni R. Tendinopathies around the elbow part 1: Lateral elbow tendinopathy: Lateral elbow tendinopathy. Shoulder Elb 5: 239–250, 2013.
8. Goguin JP, Rush FR. Lateral epicondylitis. What is it really? Curr Orthop 17: 386–389, 2003.
9. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med 7: 234–238, 1979.
10. Khan KM, Scott A. Mechanotherapy: How physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med 43: 247–252, 2009.
11. Lorenz D. Eccentric exercise interventions for tendinopathies. Strength Cond J 32: 90–98, 2010.
12. Meyer A, Tumilty S, Baxter GD. Eccentric exercise protocols for chronic non-insertional achilles tendinopathy: How much is enough? Scand J Med Sci Sports 19: 609–615, 2009.
13. Nirschl R. Elbow tendinosis/tennis elbow. Clin Sports Med 11: 851–870, 1992.
14. Söderberg J, Grooten WJ, Äng BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: A randomized-controlled trial: Eccentric training and lateral epicondylalgia. Scand J Med Sci Sports 22: 797–803, 2012.
15. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop 208: 65–68, 1986.
16. Svernlöv B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 11: 328–334, 2001.
17. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial. J Shoulder Elbow Surg 19: 917–922, 2010.
18. Vicenzino B. Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Man Ther 8: 66–79, 2003.
19. Walker Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population: Prevalence of upper Limb musculoskeletal Disorders. Arthritis Care Res 51: 642–651, 2004.
© 2015 by the National Strength & Conditioning Association