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An exercise programme for the management of

lateral elbow tendinopathy
D Stasinopoulos, K Stasinopoulou and M I Johnson

Br J Sports Med 2005 39: 944-947

doi: 10.1136/bjsm.2005.019836

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944

ORIGINAL ARTICLE

An exercise programme for the management of lateral

elbow tendinopathy
D Stasinopoulos, K Stasinopoulou, M I Johnson
...............................................................................................................................
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.
See end of article for Eccentric exercises: Slow progressive eccentric exercises for LET should be performed with the elbow in
authors’ affiliations 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
Correspondence to: experiencing concentric loading and how the ‘‘slowness’’ of eccentric exercises should be defined. Nor
D Stasinopoulos, School of has the treatment regimen of the eccentric exercises of a supervised exercise programme been defined.
Health and Human Stretching exercises: Static stretching is defined as passively stretching a given muscle-tendon unit by
Sciences, Faculty of Health, slowly placing and maintaining it in a maximal position of stretch. We recommend the position should be
Leeds Metropolitan
University, Calverly St, held for 30–45 s, three times before and three times after eccentric exercises during each treatment session
Leeds LS1 3HE, UK; with a 30 s rest interval between each procedure. The treatment region of static stretching exercises when a
d_stasinopoulos@ supervised exercise programme is performed is unknown.
yahoo.gr
Discussion: A well designed trial is needed to study the effectiveness of a supervised exercise programme
Accepted 11 April 2005 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 One of the most common physiotherapy treatments for
lateral epicondylitis and/or tennis elbow, is one of the LET is the exercise programme.11–13 There are two types of
most common lesions of the arm. LET is a degenerative or exercise programme: home exercise programmes and exercise
failed healing tendon response characterised by the increased programmes carried out in a clinical setting. A home exercise
presence of fibroblasts, vascular hyperplasia, and disorga- programme is commonly advocated for LET patients because
nised collagen in the origin of the extensor carpi radialis it can be performed any time during the day without
brevis (ECRB), the most commonly affected structure.1 It is requiring supervision by a physiotherapist. Our clinical
generally a work related or sport related pain disorder usually experience, however, has shown that home exercise pro-
caused by excessive quick, monotonous, repetitive eccentric grammes are rarely effective because patients fail to comply
contractions and gripping activities of the wrist.2 The with the regimen.18 Only exercise programmes performed in a
dominant arm is commonly affected, with a prevalence of clinical setting under the supervision of a physiotherapist
1–3% in the general population.3 Although LET occurs at all appear to be at all effective. For the purposes of this report,
ages, the peak prevalence of LET is between 30 and 60 years ‘‘supervised exercise programme’’ will refer to such pro-
of age.4 5 The proportion of those afflicted by LET is not grammes. Exercise programme advocates claim that this is
influenced by the sex of the patient, but the disorder appears the most effective treatment for LET19–21 and our clinical
to be of longer duration and severity in females.4–6 experience supports this assumption. Further research is
LET is usually defined as a syndrome of pain in the area of needed to confirm this but is beyond the scope of the present
the lateral epicondyle,4 7 8 the main complaints being pain article. The aim of this study is to describe the use and the
and decreased function, both of which may affect activities of effects of exercise programmes in the treatment of LET (as we
daily living. Diagnosis is simple and can be confirmed by tests have already done for Cyriax physiotherapy22).
that reproduce the pain, such as palpation over the facet of
the lateral epicondyle, resisted wrist extension, and resisted EXERCISE PROGRAMMES
middle finger extension.7 The literature on this subject suggests that strengthening and
Although the signs and symptoms of LET are clear and its stretching exercises are the main components of exercise
diagnosis is easy, to date no ideal treatment has emerged. programmes because tendons must not only be strong but
Many clinicians advocate a conservative approach as the also flexible.9 13 20 23
treatment of choice for LET.9–12 Physiotherapy is a conserva- The treatment regimen of home exercise programmes for
tive treatment that is usually recommended for LET other tendinopathies similar to LET is usually once or twice
patients.10 13 14 A wide array of physiotherapy treatments daily for at least 3 months.29–34 The treatment regimen of
have been recommended for the management of LET.10 15–17 supervised exercise programmes is not known with certainty,
These treatments have different theoretical mechanisms of but our experience suggests that such programmes should be
action, but all have the same aim, to reduce pain and improve administered at least three times per week for 4 weeks.18 The
function. Such a variety of treatment options suggests that most likely explanations for this difference in the treatment
the optimal treatment strategy is not known, and more
research is needed to discover the most effective treatment in Abbreviations: ECRB, extensor carpi radialis brevis; LET, lateral elbow
patients with LET. tendinopathy; RCT, randomised controlled trial

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Lateral elbow tendinopathy 945

regimen of exercise programmes may be the compliance of the elbow in full extension, forearm in pronation and with
patients and/or the clinical route/routine. the arm supported, can normally be performed without
overloading the injured tendon, as determined by the
STRENGTHENING EXERCISES patient’s tolerance.1 13 21 23 24 26 28
There are essentially three forms of musculotendinous If the affected arm is not supported, our experience has
contractions that strengthen soft tissue structures such as shown that patients complain of pain in other anatomical
tendons: (i) isometric, (ii) concentric, and (iii) eccentric.24–26 areas distant from elbow joint, such as the shoulder, neck,
Most therapists agree that eccentric contractions appear to and scapula. Furthermore, therapists claim that the elbow
have the most beneficial effects for the treatment of has to be in full extension and the forearm in pronation
LET.1 13 19–21 23 24 27 Moreover, therapists advocate eccentric because, in this position, the best strengthening effect for the
exercises only for the injured tendon and not for all tendons extensor tendons of the wrist is achieved.12 23
in the relevant anatomical region. In the case of LET,
eccentric training should be performed for the extensor Recommendations for the application of eccentric
tendons of the wrist, including the ECRB tendon which LET exercises for the treatment of LET
most commonly affects.19–21 24 26 27 Based on the above evaluation, eccentric exercises for LET
should be performed on a bed with the elbow supported on
Eccentric exercises the bed in full extension, forearm in pronation, wrist in
The three principles of eccentric exercises are: (i) load extended position (as high as possible), and the hand
(resistance); (ii) speed (velocity); and (iii) frequency of hanging over the edge of the bed. In this position, patients
contractions. should flex their wrist slowly until full flexion is achieved,
and then return to the starting position. Patients are
Load (resistance) instructed to continue with the exercise even if they
One of the main principles of eccentric exercises is increasing experience mild pain. However, they are instructed to stop
the load (resistance) on the tendon. Increasing the load the exercise if the pain becomes disabling. They should
clearly subjects the tendon to greater stress and forms the perform three sets of 10 repetitions at each treatment session,
basis for the progression of the programme. Indeed, this with at least a 1 min rest interval between each set. When
principle of progressive overloading forms the basis of all patients are able to perform the eccentric exercises without
physical training programmes. Therapists believe that the experiencing any minor pain or discomfort, the load is
load of eccentric exercises should be increased according to increased using free weights or therabands.
the patient’s symptoms, otherwise the possibility of re-injury However, no literature was retrieved that explained the
is high.1 9 13 19–21 23 24 28 The rate of increase of the load cannot following three issues: (i) how the injured tendon, which is
be standardised among patients during the treatment period loaded eccentrically, returns to the starting position without
although anecdotal evidence in the form of discussion with experiencing concentric loading; (ii) the treatment regimen
therapists suggested that they did not have a protocol to of the eccentric exercises; and (iii) how the slowness of
account for how the injured tendon, which is loaded eccentric exercises should be defined. All these issues should
eccentrically, returns to a starting position without experien- be answered so a complete treatment protocol for exercise
cing concentric loading. Therapists claim that this concentric programmes can be established. The starting and final
loading has no or little effect on the management of the positions of eccentric exercises, the increase in the load,
injured tendon, but, in order to demonstrate the real effects and the degree of mild or disabling pain cannot properly be
of eccentric exercise, clinicians would need ways to avoid standardised because all these are individualised by patients’
concentric loading of the tendon. descriptions of pain experienced during the procedure.

Speed (velocity) STRETCHING EXERCISES

Another basic principle of successful eccentric exercises is the Even though a variety of stretching techniques, such as
speed (velocity) of contractions. Stanish et al,24 Fyfe and ballistic, static, and proprioceptive neuromuscular facilitation
Stanish,26 and Stanish et al21 state that the speed of eccentric movements, have been proposed to increase flexibility, there
training should be increased in every treatment session, thus is a concern as to which stretching techniques and/or
increasing the load on the tendon to better simulate the procedures should be used for optimal gains in flexibility.
mechanism of injury, which usually occurs at relatively high Flexibility has been defined as the range of motion possible
velocities. However, other therapists claim that eccentric about a single joint or through a series of articulations.35 36
contractions should be performed at a slow velocity to avoid Therapists claim that static stretching, an extremely effective
the possibility of re-injury.1 13 19 20 23 We concur with this and simple stretching procedure, is the most widely used
latter opinion because, in contrast to traumatic events which stretching technique.9 13 21 24 26 37
produce rapid eccentric forces, low velocity eccentric loading
presumably does not exceed the elastic limit of the tendon Static stretching exercises
and generates less injurious heat within the tendon.1 Static stretching is defined as passively stretching a given
Therapists do not define the ‘‘slowness’’ of eccentric muscle-tendon unit by slowly placing it in a maximal
exercises. The most likely explanation for this lack of position of stretch and sustaining it there for an extended
definition is the therapists’ claim that in order to avoid pain, period of time.13 38 This maximal stretching position is
patients perform the eccentric exercises slowly anyway. determined by the moderate discomfort and/or pain that
Nevertheless, when an exercise programme treatment proto- the patient experiences.21 36 37 Static stretching exercises are
col is developed, the slowness of eccentric exercises should be individualised by patient feedback as to the discomfort and/
defined. Failure to do so will make it difficult for therapists to or pain experienced during the procedure.
replicate the exercise programme and put it into practice. Therapists advocate static stretching exercises only for the
injured tendon and not for all tendons in the anatomical
Frequency of contractions region. In the case of LET, static stretching should be
The third principle of eccentric exercises is the frequency of performed for the ECRB tendon, the site most commonly
contractions. Sets and repetitions can vary in the literature, affected by LET.20 21 24 The best stretching position result for
but therapists claim that three sets of ten repetitions, with the ECRB tendon is achieved with the elbow in extension,

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946 Stasinopoulos, Stasinopoulou, Johnson

forearm in pronation, and wrist in flexion and with ulnar Exercise programmes appear to reduce pain and improve
deviation, according to the patient’s tolerance.23 function, reversing the pathology of LET although there is a
Recommendations for the optimal time for holding this lack of good quality evidence to confirm that physiological
stretching position vary, ranging from as little as 3 s to as effects translate into clinically meaningful outcomes.
much as 60 s.39–43 Therapists believe that a stretch for 30–45 s
is most effective for increasing tendon flexibil-
STUDIES IN WHICH EXERCISE PROGRAMMES FOR
ity.13 21 23 24 26 37 42
LET HAVE BEEN USED
A static stretch should be repeated several times per
An electronic search for clinical studies was carried out in six
treatment session, although the first stretch repetition results
databases: Medline (from 1966 to February 2005), EMBASE
in the greatest increase in muscle-tendon unit length.13 23 35–38
(from 1988 to February 2005), Cinahl (from 1982 to February
Taylor et al38 report that more than 80% of a muscle-tendon
2005), Index to Chiropractic Literature (from 1992 to
unit length can be obtained after the fourth repetition of a
February 2005), SportDiscus (from 1990 to February 2005),
static stretch. Stanish et al ,24 Fyfe and Stanish,26 and Stanish
and CHIROLARS (from 1994 to February 2005). The
et al21 claim that six repetitions of static stretching exercises
following key words were used individually or in various
should be performed in each treatment session, divided into
combinations: ‘‘tennis elbow’’, ‘‘lateral epicondylitis’’, ‘‘lat-
an equal number of repetitions, with three before and three
eral epicondylalgia’’, ‘‘rehabilitation’’, ‘‘treatment’’, ‘‘man-
after eccentric training. Clinicians suggest a 15–45 s rest
agement’’, ‘‘exercise programme’’, ‘‘exercise therapy’’,
interval between each repetition.13 37 However, there is no
‘‘clinical studies’’, and ‘‘randomized controlled clinical
information concerning the treatment regimen for static
studies’’.
stretching exercises. As was described in the eccentric
Only English language publications were considered. An
exercises section, this information is available for home
attempt was made to identify other references from existing
exercise programmes based on other tendinopathies similar
reviews, books, and other papers cited in the publications
to LET and for a supervised exercise programme based on the
searched. Additional reports were sought from the reference
authors’ experience.
sections of papers that were retrieved, following contact with
Logically, it would seem that increasing tissue temperature
experts in the field, from the Cochrane Collaboration clinical
before stretching would increase the flexibility of the muscle-
trial register (last search February 2005) and from internet
tendon unit; however, many therapists believe that stretching
sites. Unpublished reports and abstracts were included in the
with or without a warm up yields the same results.37 41
review.
Although no previously published trials have examined the
Recommendations for the application of static effectiveness of supervised exercise programmes for LET, a
stretching exercises for the treatment of LET home exercise programme has been used in some previously
Based on the previously reported evaluation, static stretching published clinical trials on LET46–52 and was the sole
exercises for LET should be applied slowly with the elbow in treatment in one previously published randomised controlled
extension, forearm in pronation, wrist in flexion and with trial (RCT).46 A home exercise programme was only part of
ulnar deviation according to the patient’s tolerance, in order the treatment approach in other studies47–52 and, therefore, it
to achieve the best stretching position result for the ECRB was not possible to establish with certainty the degree to
tendon, which is the injured tendon in LET. This position which the home exercise programmes contributed to the
should be held for 30–45 s, three times before and three overall results.
times after the eccentric exercises during each treatment In the only previously published RCT,46 the effectiveness of
session with a 30 s rest interval between each procedure. No a home exercise programme was compared with ultrasound.
literature was found to establish the treatment regimen of Pienimaki et al46 found that the home exercise programme
static stretching exercises for exercise programmes. The static was a more effective treatment than ultrasound at the end of
stretching exercises will be individualised by the patient’s the treatment. However, their treatment protocol (type of
description of the discomfort and pain experienced during exercises, intensity, frequency, duration of treatment) was
the procedure. totally different to that employed in the present report and
research should continue to investigate the long term effects
HOW EXERCISE PROGRAMMES WORK of their treatment methods.
How an exercise programme relieves pain remains uncertain. Therefore, there is clearly a need for a well designed trial to
It is claimed that eccentric training results in tendon study the effectiveness of an exercise programme for LET
strengthening by stimulating mechano-receptors in tenocytes consisting of eccentric and static stretching exercises.
to produce collagen, which is probably the key cellular Previously published randomised and non-randomised trials
mechanism that determines recovery from tendon inju- found that such a home exercise programme reduced the
ries.19 20 32 In addition, eccentric training may induce a pain in patellar33 and Achilles tendinopathy,29–32 34 respec-
response that normalises the high concentrations of glycosa- tively. However, home exercise programmes were performed
minoglycans. It may also improve collagen alignment of the once or twice a day for approximately 3 months in all
tendon and stimulate collagen cross-linkage formation, both previously published studies. In contrast, Stasinopoulos and
of which improve tensile strength19 20 28 32 as supported by Stasinopoulos53 administered a supervised exercise pro-
experimental studies on animals.44 gramme three times per week for 4 weeks for the manage-
It has also been proposed that the positive effects of ment of patellar tendinopathy with resulting pain reduction.
exercise programmes for tendon injuries may be attributable Thus, it seems that a supervised exercise programme may
to either the effect of stretching, with a lengthening of the give good clinical results in a shorter period of time than a
muscle-tendon unit and consequently less strain experienced home exercise programme. The most likely explanation for
during joint motion, or the effects of loading within the this difference is that a supervised exercise programme
muscle-tendon unit, with hypertrophy and increased tensile achieves a higher degree of patient compliance. Therefore, it
strength in the tendon.29 Ohberg et al45 believe that, during is preferable to study the effectiveness of a supervised
eccentric training, the blood flow is stopped in the area of exercise programme for the management of LET in a future
damage and this leads to neovascularisation, the formation of trial. Unanswered issues relating to exercise programmes
new blood vessels, which improves blood flow and healing in need to be examined in a study where: (i) the non-injured
the long term. extremity is used to return the injured extremity to the

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Lateral elbow tendinopathy 947

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