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ORIGINAL ARTICLE
An exercise programme for the management of lateral
elbow tendinopathy
D Stasinopoulos, K Stasinopoulou, M I Johnson
...............................................................................................................................
See end of article for
authors’ affiliations
.......................
Correspondence to:
D Stasinopoulos, School of
Health and Human
Sciences, Faculty of Health,
Leeds Metropolitan
University, Calverly St,
Leeds LS1 3HE, UK;
d_stasinopoulos@
yahoo.gr
Accepted 11 April 2005
.......................
Br J Sports Med 2005;39:944–947. doi: 10.1136/bjsm.2005.019836
Background: Home exercise programmes and exercise programmes carried out in a clinical setting are
commonly advocated for the treatment of lateral elbow tendinopathy (LET), a very common lesion of the
arm with a well-defined clinical presentation. The aim of this study is to describe the use and effects of
strengthening and stretching exercise programmes in the treatment of LET.
Eccentric exercises: Slow progressive eccentric exercises for LET should be performed with the elbow in
extension, forearm in pronation, and wrist in extended position (as high as possible). However, it is
unclear how the injured tendon, which is loaded eccentrically, returns to the starting position without
experiencing concentric loading and how the ‘‘slowness’’ of eccentric exercises should be defined. Nor
has the treatment regimen of the eccentric exercises of a supervised exercise programme been defined.
Stretching exercises: Static stretching is defined as passively stretching a given muscle-tendon unit by
slowly placing and maintaining it in a maximal position of stretch. We recommend the position should be
held for 30–45 s, three times before and three times after eccentric exercises during each treatment session
with a 30 s rest interval between each procedure. The treatment region of static stretching exercises when a
supervised exercise programme is performed is unknown.
Discussion: A well designed trial is needed to study the effectiveness of a supervised exercise programme
for LET consisting of eccentric and static stretching exercises. The issues relating to the supervised exercise
programme should be defined so that therapists can replicate the programme.
L
ateral elbow tendinopathy (LET), commonly referred to as
lateral epicondylitis and/or tennis elbow, is one of the
most common lesions of the arm. LET 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 (ECRB), the most commonly affected structure.
1
It is
generally a work related or sport related pain disorder usually
caused by excessive quick, monotonous, repetitive eccentric
contractions and gripping activities of the wrist.
2
The
dominant arm is commonly affected, with a prevalence of
1–3% in the general population.
3
Although LET occurs at all
ages, the peak prevalence of LET is between 30 and 60 years
of age.
45
The proportion of those afflicted by LET is not
influenced by the sex of the patient, but the disorder appears
to be of longer duration and severity in females.
4–6
LET is usually defined as a syndrome of pain in the area of
the lateral epicondyle,
478
the main complaints being pain
and decreased function, 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, and resisted
middle finger extension.
7
Although the signs and symptoms of LET are clear and its
diagnosis is easy, to date no ideal treatment has emerged.
Many clinicians advocate a conservative approach as the
treatment of choice for LET.
9–12
Physiotherapy is a conserva-
tive treatment that is usually recommended for LET
patients.
10 13 14
A wide array of physiotherapy treatments
have been recommended for the management of LET.
10 15–17
These treatments have different theoretical 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 LET.
One of the most common physiotherapy treatments for
LET is the exercise programme.
11–13
There are two types of
exercise programme: home exercise programmes and exercise
programmes carried out in a clinical setting. A home exercise
programme is commonly advocated for LET patients because
it can be performed any time during the day without
requiring supervision by a physiotherapist. Our clinical
experience, however, has shown that home exercise pro-
grammes are rarely effective because patients fail to comply
with the regimen.
18
Only exercise programmes performed in a
clinical setting under the supervision of a physiotherapist
appear to be at all effective. For the purposes of this report,
‘‘supervised exercise programme’’ will refer to such pro-
grammes. Exercise programme advocates claim that this is
the most effective treatment for LET
19–21
and our clinical
experience supports this assumption. Further research is
needed to confirm this but is beyond the scope of the present
article. The aim of this study is to describe the use and the
effects of exercise programmes in the treatment of LET (as we
have already done for Cyriax physiotherapy
22
).
EXERCISE PROGRAMMES
The literature on this subject suggests that strengthening and
stretching exercises are the main components of exercise
programmes because tendons must not only be strong but
also flexible.
9132023
The treatment regimen of home exercise programmes for
other tendinopathies similar to LET is usually once or twice
daily for at least 3 months.
29–34
The treatment regimen of
supervised exercise programmes is not known with certainty,
but our experience suggests that such programmes should be
administered at least three times per week for 4 weeks.
18
The
most likely explanations for this difference in the treatment
Abbreviations: ECRB, extensor carpi radialis brevis; LET, lateral elbow
tendinopathy; RCT, randomised controlled trial
944
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regimen of exercise programmes may be the compliance of
patients and/or the clinical route/routine.
STRENGTHENING EXERCISES
There are essentially three forms of musculotendinous
contractions that strengthen soft tissue structures such as
tendons: (i) isometric, (ii) concentric, and (iii) eccentric.
24–26
Most therapists agree that eccentric contractions appear to
have the most beneficial effects for the treatment of
LET.
1 13 19–21 23 24 27
Moreover, therapists advocate eccentric
exercises only for the injured tendon and not for all tendons
in the relevant anatomical region. In the case of LET,
eccentric training should be performed for the extensor
tendons of the wrist, including the ECRB tendon which LET
most commonly affects.
19–21 24 26 27
Eccentric exercises
The three principles of eccentric exercises are: (i) load
(resistance); (ii) speed (velocity); and (iii) frequency of
contractions.
Load (resistance)
One of the main principles of eccentric exercises is increasing
the load (resistance) on the tendon. Increasing the load
clearly subjects the tendon to greater stress and forms the
basis for the progression of the programme. Indeed, this
principle of progressive overloading forms the basis of all
physical training programmes. Therapists believe that the
load of eccentric exercises should be increased according to
the patient’s symptoms, otherwise the possibility of re-injury
is high.
1 9 13 19–21 23 24 28
The rate of increase of the load cannot
be standardised among patients during the treatment period
although anecdotal evidence in the form of discussion with
therapists suggested that they did not have a protocol to
account for how the injured tendon, which is loaded
eccentrically, returns to a starting position without experien-
cing concentric loading. Therapists claim that this concentric
loading has no or little effect on the management of the
injured tendon, but, in order to demonstrate the real effects
of eccentric exercise, clinicians would need ways to avoid
concentric loading of the tendon.
Speed (velocity)
Another basic principle of successful eccentric exercises is the
speed (velocity) of contractions. Stanish et al,
24
Fyfe and
Stanish,
26
and Stanish et al
21
state that the speed of eccentric
training should be increased in every treatment session, thus
increasing the load on the tendon to better simulate the
mechanism of injury, which usually occurs at relatively high
velocities. However, other therapists claim that eccentric
contractions should be performed at a slow velocity to avoid
the possibility of re-injury.
113192023
We concur with this
latter opinion because, in contrast to traumatic events which
produce rapid eccentric forces, low velocity eccentric loading
presumably does not exceed the elastic limit of the tendon
and generates less injurious heat within the tendon.
1
Therapists do not define the ‘‘slowness’’ of eccentric
exercises. The most likely explanation for this lack of
definition is the therapists’ claim that in order to avoid pain,
patients perform the eccentric exercises slowly anyway.
Nevertheless, when an exercise programme treatment proto-
col is developed, the slowness of eccentric exercises should be
defined. Failure to do so will make it difficult for therapists to
replicate the exercise programme and put it into practice.
Frequency of contractions
The third principle of eccentric exercises is the frequency of
contractions. Sets and repetitions can vary in the literature,
but therapists claim that three sets of ten repetitions, with
the elbow in full extension, forearm in pronation and with
the arm supported, can normally be performed without
overloading the injured tendon, as determined by the
patient’s tolerance.
1132123242628
If the affected arm is not supported, our experience has
shown that patients complain of pain in other anatomical
areas distant from elbow joint, such as the shoulder, neck,
and scapula. Furthermore, therapists claim that the elbow
has to be in full extension and the forearm in pronation
because, in this position, the best strengthening effect for the
extensor tendons of the wrist is achieved.
12 23
Recommendations for the application of eccentric
exercises for the treatment of LET
Based on the above evaluation, eccentric exercises for LET
should be performed on a bed with the elbow supported on
the bed in full extension, forearm in pronation, wrist in
extended position (as high as possible), and the hand
hanging over the edge of the bed. In this position, patients
should flex their wrist slowly until full flexion is achieved,
and then return to the starting position. Patients are
instructed to continue with the exercise even if they
experience mild pain. However, they are instructed to stop
the exercise if the pain becomes disabling. They should
perform three sets of 10 repetitions at each treatment session,
with at least a 1 min rest interval between each set. When
patients are able to perform the eccentric exercises without
experiencing any minor pain or discomfort, the load is
increased using free weights or therabands.
However, no literature was retrieved that explained the
following three issues: (i) how the injured tendon, which is
loaded eccentrically, returns to the starting position without
experiencing concentric loading; (ii) the treatment regimen
of the eccentric exercises; and (iii) how the slowness of
eccentric exercises should be defined. All these issues should
be answered so a complete treatment protocol for exercise
programmes can be established. The starting and final
positions of eccentric exercises, the increase in the load,
and the degree of mild or disabling pain cannot properly be
standardised because all these are individualised by patients’
descriptions of pain experienced during the procedure.
STRETCHING EXERCISES
Even though a variety of stretching techniques, such as
ballistic, static, and proprioceptive neuromuscular facilitation
movements, have been proposed to increase flexibility, there
is a concern as to which stretching techniques and/or
procedures should be used for optimal gains in flexibility.
Flexibility has been defined as the range of motion possible
about a single joint or through a series of articulations.
35 36
Therapists claim that static stretching, an extremely effective
and simple stretching procedure, is the most widely used
stretching technique.
91321242637
Static stretching exercises
Static stretching is defined as passively stretching a given
muscle-tendon unit by slowly placing it in a maximal
position of stretch and sustaining it there for an extended
period of time.
13 38
This maximal stretching position is
determined by the moderate discomfort and/or pain that
the patient experiences.
21 36 37
Static stretching exercises are
individualised by patient feedback as to the discomfort and/
or pain experienced during the procedure.
Therapists advocate static stretching exercises only for the
injured tendon and not for all tendons in the anatomical
region. In the case of LET, static stretching should be
performed for the ECRB tendon, the site most commonly
affected by LET.
20 21 24
The best stretching position result for
the ECRB tendon is achieved with the elbow in extension,
Lateral elbow tendinopathy 945
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forearm in pronation, and wrist in flexion and with ulnar
deviation, according to the patient’s tolerance.
23
Recommendations for the optimal time for holding this
stretching position vary, ranging from as little as 3 s to as
much as 60 s.
39–43
Therapists believe that a stretch for 30–45 s
is most effective for increasing tendon flexibil-
ity.
13 21 23 24 26 37 42
A static stretch should be repeated several times per
treatment session, although the first stretch repetition results
in the greatest increase in muscle-tendon unit length.
13 23 35–38
Taylor et al
38
report that more than 80% of a muscle-tendon
unit length can be obtained after the fourth repetition of a
static stretch. Stanish et al ,
24
Fyfe and Stanish,
26
and Stanish
et al
21
claim that six repetitions of static stretching exercises
should be performed in each treatment session, divided into
an equal number of repetitions, with three before and three
after eccentric training. Clinicians suggest a 15–45 s rest
interval between each repetition.
13 37
However, there is no
information concerning the treatment regimen for static
stretching exercises. As was described in the eccentric
exercises section, this information is available for home
exercise programmes based on other tendinopathies similar
to LET and for a supervised exercise programme based on the
authors’ experience.
Logically, it would seem that increasing tissue temperature
before stretching would increase the flexibility of the muscle-
tendon unit; however, many therapists believe that stretching
with or without a warm up yields the same results.
37 41
Recommendations for the application of static
stretching exercises for the treatment of LET
Based on the previously reported evaluation, static stretching
exercises for LET should be applied slowly with the elbow in
extension, forearm in pronation, wrist in flexion and with
ulnar deviation according to the patient’s tolerance, in order
to achieve the best stretching position result for the ECRB
tendon, which is the injured tendon in LET. This position
should be held for 30–45 s, three times before and three
times after the eccentric exercises during each treatment
session with a 30 s rest interval between each procedure. No
literature was found to establish the treatment regimen of
static stretching exercises for exercise programmes. The static
stretching exercises will be individualised by the patient’s
description of the discomfort and pain experienced during
the procedure.
HOW EXERCISE PROGRAMMES WORK
How an exercise programme relieves pain remains uncertain.
It is claimed that eccentric training results in tendon
strengthening by stimulating mechano-receptors in tenocytes
to produce collagen, which is probably the key cellular
mechanism that determines recovery from tendon inju-
ries.
19 20 32
In addition, eccentric training may induce a
response that normalises the high concentrations of glycosa-
minoglycans. It may also improve collagen alignment of the
tendon and stimulate collagen cross-linkage formation, both
of which improve tensile strength
19 20 28 32
as supported by
experimental studies on animals.
44
It has also been proposed that the positive effects of
exercise programmes for tendon injuries may be attributable
to either the effect of stretching, with a lengthening of the
muscle-tendon unit and consequently less strain experienced
during joint motion, or the effects of loading within the
muscle-tendon unit, with hypertrophy and increased tensile
strength in the tendon.
29
Ohberg et al
45
believe that, during
eccentric training, the blood flow is stopped in the area of
damage and this leads to neovascularisation, the formation of
new blood vessels, which improves blood flow and healing in
the long term.
Exercise programmes appear to reduce pain and improve
function, reversing the pathology of LET although there is a
lack of good quality evidence to confirm that physiological
effects translate into clinically meaningful outcomes.
STUDIES IN WHICH EXERCISE PROGRAMMES FOR
LET HAVE BEEN USED
An electronic search for clinical studies was carried out in six
databases: Medline (from 1966 to February 2005), EMBASE
(from 1988 to February 2005), Cinahl (from 1982 to February
2005), Index to Chiropractic Literature (from 1992 to
February 2005), SportDiscus (from 1990 to February 2005),
and CHIROLARS (from 1994 to February 2005). The
following key words were used individually or in various
combinations: ‘‘tennis elbow’’, ‘‘lateral epicondylitis’’, ‘‘lat-
eral epicondylalgia’’, ‘‘rehabilitation’’, ‘‘treatment’’, ‘‘man-
agement’’, ‘‘exercise programme’’, ‘‘exercise therapy’’,
‘‘clinical studies’’, and ‘‘randomized controlled clinical
studies’’.
Only English language publications were considered. An
attempt was made to identify other references from existing
reviews, books, and other papers cited in the publications
searched. Additional reports were sought from the reference
sections of papers that were retrieved, following contact with
experts in the field, from the Cochrane Collaboration clinical
trial register (last search February 2005) and from internet
sites. Unpublished reports and abstracts were included in the
review.
Although no previously published trials have examined the
effectiveness of supervised exercise programmes for LET, a
home exercise programme has been used in some previously
published clinical trials on LET
46–52
and was the sole
treatment in one previously published randomised controlled
trial (RCT).
46
A home exercise programme was only part of
the treatment approach in other studies
47–52
and, therefore, it
was not possible to establish with certainty the degree to
which the home exercise programmes contributed to the
overall results.
In the only previously published RCT,
46
the effectiveness of
a home exercise programme was compared with ultrasound.
Pienimaki et al
46
found that the home exercise programme
was a more effective treatment than ultrasound at the end of
the treatment. However, their treatment protocol (type of
exercises, intensity, frequency, duration of treatment) was
totally different to that employed in the present report and
research should continue to investigate the long term effects
of their treatment methods.
Therefore, there is clearly a need for a well designed trial to
study the effectiveness of an exercise programme for LET
consisting of eccentric and static stretching exercises.
Previously published randomised and non-randomised trials
found that such a home exercise programme reduced the
pain in patellar
33
and Achilles tendinopathy,
29–32 34
respec-
tively. However, home exercise programmes were performed
once or twice a day for approximately 3 months in all
previously published studies. In contrast, Stasinopoulos and
Stasinopoulos
53
administered a supervised exercise pro-
gramme three times per week for 4 weeks for the manage-
ment of patellar tendinopathy with resulting pain reduction.
Thus, it seems that a supervised exercise programme may
give good clinical results in a shorter period of time than a
home exercise programme. The most likely explanation for
this difference is that a supervised exercise programme
achieves a higher degree of patient compliance. Therefore, it
is preferable to study the effectiveness of a supervised
exercise programme for the management of LET in a future
trial. Unanswered issues relating to exercise programmes
need to be examined in a study where: (i) the non-injured
extremity is used to return the injured extremity to the
946 Stasinopoulos, S tasinopoulou, Johnson
www.bjsportmed.com
starting position; (ii) the subjects perform the eccentric
contractions from full flexion to full extension counting to
30; and (iii) the treatment regimen is carried out three times
a week for 4 weeks. Such a trial will be completed in the near
future.
CONCLUSIONS
Although exercise programmes are commonly used in the
treatment of LET, more research is needed to assess, firstly,
their effectiveness and, secondly, the mechanism of action of
both their components.
Authors’ affiliations
.....................
D Stasinopoulos, M I Johnson, School of Health and Human Sciences,
Faculty of Health, Leeds Metropolitan University, Leeds, UK
K Stasinopoulou, School of Medicine, National and Kapodistriako,
University of Athens, Athens, Greece
Competing interests: none declared
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What is already known on this topic
Exercise programme consisting of eccentric and static
stretching exercises are claimed to be an effective treatment
for the management of LET.
What this study adds
Future well designed trials are needed to establish the relative
and absolute effectiveness of eccentric and static stretching
exercises for LET.
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