Here's a post I wrote on this last year. You might find it helpful:
Having personally dealt with this condition for many years, I'm reasonably familiar with the literature and have come to the conclusion that medicine has no idea of what constitutes the best nonoperative (and in many cases, surgical) treatment modality for tennis elbow. Most doctors still believe it is an inflammatory process (it isn't), and the literature is all over the place with some studies showing steroid injections are efficacious for long term improvement and others showing they're not. Some studies have demonstrated the efficacy of prolotherapy and recommend it be used as a front line therapy and others suggest it should only be used as a second line therapy, or not at all. It's the same thing with the various physiotherapies and other treatments. Doctors can't even agree on a name - is it lateral epicondylitis, epicondylalgia, epicondylosis? Is only
chronic epicondylitis epicondylosis or was it always epicondylosis? The only thing most of the published studies have in common is that they consist of poorly designed trials and doctors are left in the unfortunate position of having to give recommendations based more on their clinical experience than hard evidence.
During my own battle with tennis elbow, I tried every nonoperative treatment that was available or recommended to me. Some treatments worked for a while and others didn't, but even when a treatment was helpful, the tennis elbow always returned. Surgery was recommended as the next step but before committing to that, I decided to give exercises one final try. I had read a few studies on eccentric loading that were getting good results in patients with chronic tendinitis, so I devised my own program using very light weights for high repetitions that concentrated on the eccentric portion of the lift. My goal was to do enough repetitions to give a good "burn," then rest for 30 seconds and do another set until I had completed 3 sets of two different exercises. I did this every other day, increasing the weight progressively as strength increased.
To my utter amazement, I started getting improvement - quickly at first, then slower over time until I reached the 5 or 6 month mark where I noticed no further improvement. At that point, I had probably achieved about 90 - 95% improvement and stopped the exercises. I've been able to maintain that level of improvement to this day and for the most part, tennis elbow is no longer an issue for me.
What convinced me to try eccentric loading exercises - or at least helped reassure me that it wouldn't cause more harm - were studies that suggested the traditional inflammatory model was wrong, i.e., the belief that lateral epichondylitis is the result of macroscopic or microscopic tears at the common tendon of the wrist extensor muscles due to chronic overuse. This traditional view has never been substantiated and the literature seems to show that it's not an inflammatory process.
Nirschl et al published on his histopathological examination of lateral epicondylitis in the 70's, showing the affected tendon (extensor carpi radialis brevis) was characterized by disorganized and immature collagen, a dense population of fibroblasts, and an absence of inflammatory cells which he believed were characteristic of a degenerative process rather than an inflammatory one. Newer studies have similar histological findings including at least one that found normal levels of E2 prostaglandin - not what you would expect in an inflammatory condition.
In closing, I'm not recommending/suggesting my approach to anybody else - the evidence to date has shown eccentric exercise is likely a useful management for tendinopathy but there is still no consensus.
Regards
CBS
Int J Sports Phys Ther. 2014 May;9(3):365-70.
Clinical outcomes of the addition of eccentrics for rehabilitation of previously failed treatments of golfers elbow.
Tyler TF,
Nicholas SJ1,
Schmitt BM1,
Mullaney M2,
Hogan DE2.
Abstract
INTRODUCTION AND PURPOSE:
Eccentric training of the wrist extensors has been shown to be effective in treating chronic lateral epicondylosis. However, its efficacy in the treatment of medial epicondylosis has yet to be demonstrated. The objective of this study was to assess the effectiveness of a novel eccentric wrist flexor exercise added to standard treatment for chronic medial epicondylosis in patients who did not respond to previous therapeutic interventions for this disorder.
NUMBER OF SUBJECTS:
20.
MATERIALS/METHODS:
Patients (13 men, 7 women; age 49±12 yr) with chronic medial epicondylosis who had failed previous treatment for this disorder (physical therapy 7, cortisone injection 7, PRP 1, NSAIDS 15) were prescribed isolated eccentrics in addition to wrist stretching, ultrasound, cross-friction massage, heat and ice. The specific isolated eccentric wrist flexor strengthening exercise performed by the patients involved twisting a rubber bar (Flexbar, Hygenic Corportation, Akron OH) with concentric wrist flexion of the noninvolved arm and releasing the twist by eccentrically contracting the wrist flexors of the involved arm (3 × 15 twice daily). A DASH questionnaire was recorded at baseline and again after the treatment period. Treating clinicians were blinded to baseline DASH scores. Treatment effect was assessed using paired t-test. Based on previous work it was estimated that with a sample of 20 patients there would be 80% power to detect a 13 point improvement in DASH scores (p<.05).
RESULTS:
The pathology was in the dominant arm of 18 patients and recurrent in 10. Primary symptomatic activities were golf (14), tennis (2), basketball (1), weight lifting (1), and general activities of daily living (2).
There was a significant improvement in outcomes following the addition of isolated eccentrics (Pre DASH 34.7±16.2 vs. Post DASH 7.9±11.1, p<.001). For the 18 patients involved in sports, the sports module of the DASH score improved from 73.9±28.9 to 13.2±25.0, p<.001). Physical therapy visits ranged from 1-22 with an average of 12±6 and, average treatment duration of 6.1±2.5 wks (range 1-10). Home exercise program compliance was recorded for each subject (15 full, 3 mostly, 1 occasionally, 1 none).
CONCLUSIONS:
The outcome measure for chronic medial epicondylosis was markedly improved with the addition of an eccentric wrist flexor exercise to standard physical therapy. Given the inconsistent outcomes for patients previously treated with chronic medial epicondylosis the addition of isolated eccentrics seems warranted based on the results of this study.
CLINICAL RELEVANCE:
This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic medial epicondylosis.
Clin Rehabil. 2013 Jul 23. [Epub ahead of print]
Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Is eccentric exercise an effective treatment fo... [Clin Rehabil. 2013] - PubMed - NCBI
Cullinane FL, Boocock MG, Trevelyan FC.
Abstract
Objective: To establish the effectiveness of eccentric exercise as a treatment intervention for lateral epicondylitis.Data sources ProQuest, Medline via EBSCO, AMED, Scopus, Web of Science, CINAHL.
Review methods: A systematic review was undertaken to identify randomized and controlled clinical trials incorporating eccentric exercise as a treatment for patients diagnosed with lateral epicondylitis. Studies were included if: they incorporated eccentric exercise, either in isolation or as part of a multimodal treatment protocol; they assessed at least one functional or disability outcome measure; and the patients had undergone diagnostic testing. The methodological quality of each study was assessed using the Modified Cochrane Musculoskeletal Injuries Group score sheet.
Results: Twelve studies met the inclusion criteria. Three were deemed 'high' quality, seven were 'medium' quality, and two were 'low' quality. Eight of the studies were randomized trials investigating a total of 334 subjects. Following treatment, all groups inclusive of eccentric exercise reported decreased pain and improved function and grip strength from baseline. Seven studies reported improvements in pain, function, and/or grip strength for therapy treatments inclusive of eccentric exercise when compared with those excluding eccentric exercise. Only one low-quality study investigated the isolated effects of eccentric exercise for treating lateral epicondylitis and found no significant improvements in pain when compared with other treatments.
Conclusion: The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy programme for improved outcomes in patients with lateral epicondylitis.
J Shoulder Elbow Surg. 2010 Sep;19(6):917-22.
Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Addition of isolated wrist extensor ec... [J Shoulder Elbow Surg. 2010] - PubMed - NCBI
Tyler TF, Thomas GC, Nicholas SJ, McHugh MP.
[Link to full article:
http://www.thera-bandacademy.com/elements/clients/docs/Tyler et al JSES 2010__201009DD_123442.pdf]
Abstract
BACKGROUND: Isokinetic eccentric training of the wrist extensors has recently been shown to be effective in treating chronic lateral epicondylosis. However, isokinetic dynamometry is not widely available or practical for daily exercise prescription. Therefore, the objective of this study was to assess the efficacy of a novel eccentric wrist extensor exercise added to standard treatment for chronic lateral epicondylosis.
MATERIALS AND METHODS: Twenty-one patients with chronic unilateral lateral epicondylosis were randomized into an eccentric training group (n = 11, 6 men, 5 women; age 47 +/- 2 yr) and a Standard Treatment Group (n = 10, 4 men, 6 women; age 51 +/- 4 yr). DASH questionnaire, VAS, tenderness measurement, and wrist and middle finger extension were recorded at baseline and after the treatment period.
RESULTS: Groups did not differ in terms of duration of symptoms (Eccentric 6 +/- 2 mo vs Standard 8 +/- 3 mos., P = .7), number of physical therapy visits (9 +/- 2 vs 10 +/- 2, P = .81) or duration of treatment (7.2 +/- 0.8 wk vs 7.0 +/- 0.6 wk, P = .69).
Improvements in all dependent variables were greater for the Eccentric Group versus the Standard Treatment Group (percent improvement reported): DASH 76% vs 13%, P = .01; VAS 81% vs 22%, P = .002, tenderness 71% vs 5%, P = .003; strength (wrist and middle finger extension combined) 79% vs 15%, P = .011.
DISCUSSION:
All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy. This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic lateral epicondylosis.
Rheumatology (Oxford). 2008 Oct;47(10):1493-7.
The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. The mechanism for efficacy of eccentri... [Rheumatology (Oxford). 2008] - PubMed - NCBI
Rees JD, Lichtwark GA, Wolman RL, Wilson AM.
Abstract
OBJECTIVE: Degenerative disorders of tendons present an enormous clinical challenge. They are extremely common, prone to recur and existing medical and surgical treatments are generally unsatisfactory. Recently eccentric, but not concentric, exercises have been shown to be highly effective in managing tendinopathy of the Achilles (and other) tendons. The mechanism for the efficacy of these exercises is unknown although it has been speculated that forces generated during eccentric loading are of a greater magnitude. Our objective was to determine the mechanism for the beneficial effect of eccentric exercise in Achilles tendinopathy.
METHODS: Seven healthy volunteers performed eccentric and concentric loading exercises for the Achilles tendon. Tendon force and length changes were determined using a combination of motion analysis, force plate data and real-time ultrasound.
RESULTS: There was no significant difference in peak tendon force or tendon length change when comparing eccentric with concentric exercises. However, high-frequency oscillations in tendon force occurred in all subjects during eccentric exercises but were rare in concentric exercises (P < 0.0001).
CONCLUSION: These oscillations provide a mechanism to explain the therapeutic benefit of eccentric loading in Achilles tendinopathy and parallels recent evidence from bone remodelling, where the frequency of the loading cycles is of more significance than the absolute magnitude of the force.
Acta Orthop Scand. 2000 Oct;71(5):475-9.
In vivo investigation of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. In vivo investigation of ECRB tendons with... [Acta Orthop Scand. 2000] - PubMed - NCBI
Alfredson H, Ljung BO, Thorsen K, Lorentzon R.
Abstract
We used the microdialysis technique to study concentrations of substances in the extensor carpi radialis brevis (ECRB) tendon in patients with tennis elbow. In 4 patients (mean age 41 years, 3 men) with a long duration of localized pain at the ECRB muscle origin, and in 4 controls (mean age 36 years, 2 men) with no history of elbow pain, a standard microdialysis catheter was inserted into the ECRB tendon under local anesthesia. The local concentrations of the neurotransmitter glutamate and prostaglandin E2 (PGE2) were recorded under resting conditions. Samplings were done every 15 minutes during a 2-hour period. We found higher mean concentrations of glutamate in ECRB tendons from patients with tennis elbow than in tendons from controls (215 vs. 69 micromoL/L, p < 0.001). There were no significant differences in the mean concentrations of PGE2 (74 vs. 86 pg/mL). In conclusion, in situ microdialysis can be used to study certain metabolic events in the ECRB tendon of the elbow.
Our findings indicate involvement of the excitatory neurotransmitter glutamate, but no biochemical signs of inflammation (normal PGE2 levels) in ECRB tendons from patients with tennis elbow.
J Bone Joint Surg Am. 1979 Sep;61(6A):832-9.
Tennis elbow. The surgical treatment of lateral epicondylitis. Tennis elbow. The surgical treatment of... [J Bone Joint Surg Am. 1979] - PubMed - NCBI
Nirschl RP, Pettrone FA.
Abstract
Of the 1,213 clinical cases of lateral tennis elbow seen during the time period from December 19, 1971, to October 31, 1977, eighty-eight elbows in eighty-two patients had operative treatment.
The lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis. A specific surgical technique was employed, including exposure of the extensor carpi radialis brevis, excision of the identified lesion, and repair. The results at follow-up were rated as excellent in sixty-six elbows, good in nine, fair in eleven, and failed in two. There was an over-all improvement rate of 97.7 per cent, and 85.2 per cent of the patients returned to full activity including rigorous sports
