Lateral Epicondyle Tendinopathy Toolkit: Section E - Exercise Prescription

Original Editor - Rishika Babburu for BC Physical Therapy Tendinopathy Task Force:

Dr. Joseph Anthony, Paul Blazey, Dr. Allison Ezzat, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates and Alison Hoens

Top Contributors - Evan Thomas, Rishika Babburu, Kim Jackson, Admin, Wanda van Niekerk and Vidya Acharya  

Introduction

Exercises for lateral epicondyle tendinopathy (LET) should be chosen according to patient preference, and the clinical evaluation.

There is a large volume of clinical evidence that consistently supports the use of exercise for management of chronic LET. Studies evaluating strength-based exercise have demonstrated improvement in symptoms regardless of the muscle contraction-type (e.g. concentric, eccentric or isometric). Some evidence suggests that eccentric exercises may provide superior pain relief, but providing an exercise that the patient can tolerate (isometric, concentric or eccentric) is the most important consideration.

The summary of interventions suggests (see section D) that clinicians strongly consider using local and upper limb kinetic chain exercises to support patients suffering from chronic LET. The following are examples of exercises to consider based upon the available literature

Concentric/Eccentric Home Exercise Program

Isotonic contraction includes Concentric and Eccentric contraction of muscles.

Eccentric exercise:

• Eccentric exercises involve lengthening of the muscle.
• Negative force of a muscle contraction (i.e. negative work)
• Beneficial for tendons
• Causes delayed onset muscle soreness
• Should take no less than 4 seconds

Concentric exercise:

• Concentric exercises involve shortening of muscle length.
• Positive force of a muscle contraction (i.e. positive work)
• Used to build endurance and increase tolerance to exercise
• Should take no longer than 3 seconds

Frequency: Daily, for 3-months

Intensity: Resistance will be dictated by patient’s current capacity (e.g. 1 Repetition Maximum - RM)

• Water can be used as resistance if you do not have weights available. 1 litre of water = approx’ 1kg.
• An option is to increase resistance by 0.1 kg (100ml water) weekly or as tolerated by the patient.

Time: Aim is to complete 3 sets of 15 reps (approx. 65% of 1RM) once per day.

Technique:

• Forearm should be supported in pronation with elbow in some flexion
• Lift the weight by extending the wrist, then lower. Keep your forearm in contact with the surface al all times

Isometric Home Exercise Program

Isometric exercise include muscle contraction without any movement or change in muscle length

Frequency: Once daily for 8-weeks

Intensity: Start at 20% Maximum Voluntary Contraction (MVC) progressively adding 5% every two weeks

Time: 30 seconds for 4 repetitions per day (30 secs rest between reps)

In the protocol the reps were reduced to 3 but the contraction time increased to 45 seconds on alternating weeks. This was to generate a slow progression in the time-under-tension placed upon the lateral epicondyle tendon.

Technique:

• Forearm should be supported in pronation with elbow flexed to 90^o, wrist in 30^o extension. use your unaffected hand to place the weight in the affected hand.
• Participant is instructed to hold the position for the allotted amount of time, before again removing the weight wit the unaffected hand.

Eccentric-only Home Exercise Program

Frequency: 3 times per week, for 4-weeks

Intensity: Unclear

Time: 30s lowering phase for each repetition. Repeated for 10 repetitions and 3 sets. Take 1 minute between sets.

Patients are instructed to raise the wrist as high as possible, using the opposite hand to support into the top position before performing a slow lowering (eccentric) contraction.

Note that the prescription outlined would create 300-seconds of time-under-tension per set of exercise.

Patients are also advised that this should elicit some mild pain, and to increase the level of resistance once the pain had gone, therefore maintaining mild pain for the 4-week intervention. They are to cease exercise if the pain became disabling.

Technique:

• Holding a weight on the affected side, extend the wrist using the unaffected hand.[ADD IMAGE]
• Allow the wrist to slowly flex (eccentric contraction of the wrist extensors).

The “Tyler Twist” Eccentric Wrist Extensor Exercise

Frequency: Daily, approximately 6 weeks.

Intensity: Increase resistance by using a thicker bar when the exercise is pain-free.

Time: Each rep should consist of around 4 seconds in the final phase of holding the wrist in a flexed position. This should be repeated for 3 sets of 15 once daily. 30 second rest between sets.

Steps in the Tyler-twist

• i. Hold the bar in the hand of the affected arm with the unaffected arm above (as shown
• ii. With the affected wrist in full extension, twist the bar with the unaffected hand.
• iii. Stretch both arms out so the elbows are fully extended
• iv. Slowly allow the affected wrist to bend into flexion, allowing for an eccentric load of the wrist extensors

Figure 3A Figure 3B Figure 3C Figure 3D Figure 3E

Resources

• Lateral Epicondyle Tendinopathy Toolkit page
• LET Section B - Clinical Assessment of LET
• LET Section C - Outcome Measures
• LET Section D - Summary of the Evidence
• LET Section F - Manual Therapy
• LET Section G - LASER Dosage Calculation
• LET Section H - Braces, Splints and Taping
• UBC Lateral Epicondyle Tendinopathy (LET) Toolkit