Eccentric Exercise Technique Offers Easy, Affordable Intervention for Chronic Lateral Epicondylitis

Nancy A. Melville

July 16, 2009

July 16, 2009 (Keystone, Colorado) — Eccentric exercises with a simple wrist-extending rubber cylinder could help alleviate pain for people with chronic lateral epicondylitis and offer a practical, cost-effective alternative to treatments such as cortisone injections, topical nitric oxide, and isokinetic dynamometry, according to a study presented here at the American Orthopaedic Society for Sports Medicine 35th Annual Meeting.

It is thought that up to 3% of the population suffers from lateral epicondylitis, and, despite its nickname of tennis elbow, people don't have to play tennis to be affected by the condition, investigators noted. The pain can be caused by something as simple as lifting a coffee cup.

Timothy F. Tyler, PT, ATC, a clinical research associate at the Nicholas Institute of Sports Medicine and Athletic Trauma in New York City, and colleagues randomized patients with pain from chronic lateral epicondylitis resulting from tennis or golf that lasted at least 6 weeks and who had undergone no previous surgical treatment into 2 groups: an eccentric group of 6 men and 5 women (average age, 47 ± 2 years); and a standard-treatment group of 4 men and 6 women (average age, 51 ± 4 years).

Both groups received wrist-extensor stretching, ultrasound, cross-friction massage, and heat and ice therapy. The standard-treatment group performed isotonic wrist-extensor strengthening, and the eccentric group performed isolated eccentric wrist-extensor strengthening using a rubber cylinder, called the Flexbar (Hygenic Corp).

The exercises involved twisting the cylinder with concentric wrist flexion of the noninvolved arm, and releasing the twist with eccentric wrist extension of the involved arm. The exercise was performed in 3 sets of 15 repetitions daily, and the intensity increased over the treatment period.

Results were recorded at baseline and after the treatment period using a Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and a visual analog pain scale (VAS). Tenderness was recorded with a hand-held myometer just distal to the lateral epicondyle, and wrist and middle finger extension strength was measured with a hand-held dynamometer.

The eccentric group reported an improvement of 76% in their DASH score; the standard-treatment group reported an improvement of 12% (P = .01). VAS improvement was 81% for the eccentric group and 22% for the standard-treatment group (P = .002), tenderness was improved by 70% in the eccentric group and 4% in the standard-treatment group (P = .003), and strength of the wrist and middle finger was improved 72% in the eccentric group and 11% in the standard-treatment group (P = .032).

"The eccentric group had a significant improvement in the amount of disability [reported in the DASH score], compared to the standard-treatment group, and there was also a significant decrease in pain, compared to the standard-treatment group," Mr. Tyler told Medscape Orthopaedics.

"As for wrist extension, there was a percent deficit from the involved to noninvolved arm, with a significant increase in strength and decrease in deficit between the eccentric [and] standard-treatment groups," he added. "And there was a marked reduction in tenderness in the eccentric group."

Mr. Tyler noted that physical-therapy facilities are not always accessible or affordable. The wrist-extensor device, which he said sells for $8, represents a highly valuable therapy for many.

"Around the country and the world, it's just not always possible to send patients to physical-therapy centers with highly expensive isokinetic devices. So our suggestion is that this device can be a valuable alternative."

"In our study, we found that the device can reduce pain and tenderness while increasing strength in the wrist extensors, and patients can achieve increased function," Mr. Tyler noted.

Spero G. Karas, MD, a comoderator at the session who was not involved in Mr. Tyler's study, said the findings appear to support the technique's benefits in improving pain from chronic lateral epicondylitis.

"Eccentric loading of tendons has been a well-recognized method of treating tendinopathy," Dr. Karas, assistant professor of orthopaedics at Emory Healthcare Sports Medicine, in Atlanta, Georgia.

"The exercise Tyler and his coauthors described is a simple, home-based program that eliminates the need for expensive machines and can be done in the convenience and comfort of the patient's home," he said.

"Of course, more research will be required to fully evaluate the efficacy of the technique. However, the early results appear to be promising, as they are safe, simple, and highly effective."

The Flexbars used in the study were donated by the manufacturer, Hygenic Corp. Mr. Tyler and Dr. Karas have disclosed no relevant financial relationships.

American Orthopaedic Society for Sports Medicine (AOSSM) 35th Annual Meeting: Abstract 8345. Presented July 11, 2009.

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