Tennis Elbow: Both Concentric and Eccentric Exercise Helps

A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Mar 14. [Epub ahead of print] Peterson M, Butler S, Eriksson M, Svärdsudd K.

Abstract
Objective:To analyse treatment effects of eccentric vs. concentric graded exercise in chronic tennis elbow.Design:Randomized controlled trial.Setting:Primary care in Uppsala County, Sweden.Subjects:A total of 120 subjects with tennis elbow lasting more than three months were recruited from primary care and by advertisement.Intervention:Eccentric (n = 60) or concentric exercise (n = 60), by lowering or lifting a weight, at home daily, for three months with gradually increasing load.Main measures:Pain during muscle contraction and muscle elongation, as well as strength, was assessed at baseline and after one, two, three, six, and 12 months. Function and quality of life was assessed at baseline and after three, six and 12 months.Results:The eccentric exercise group had faster regression of pain, with an average of 10% higher responder rate at all levels of pain reduction, both during muscle contraction and elongation, (p < 0.0001 and p = 0.006, respectively). Significant differences were found in Cox’s analysis from two months onwards (HR 0.78, 95% confidence interval (CI) 0.63-0.96, p < 0.02). This represents an absolute pain reduction of 10% in the eccentric vs. the concentric group and a number-needed-to-treat of 10. The eccentric group also had a greater increase of muscle strength than the concentric (p < 0.02). The differences persisted throughout the follow-up period. There were no significant differences between the groups regarding function or quality of life measures.Conclusion:Eccentric graded exercise reduced pain and increased muscle strength in chronic tennis elbow more effectively than concentric graded exercise.

Quotes from study:
In conclusion , an exercise programme for chronic tennis elbow should be designed to gradually put load on the affected painful tissue, and stress the eccentric work phase, but need not exclude the concentric work phase.”

My Comments:
This is a great study, not because I need another blog on tendinopathy, but because it refutes some earlier tendinopathy research that found concentric exercise to be either worthless or aggravating. These researchers found both concentric (lifting a weight) and eccentric (lowering a weight) contractions to be beneficial, with eccentric exercises only being only about 10% better. This backs up my own physical therapy protocols where I make use of regular progressive resistance exercise (combining concentric and eccentric contractions). It also helps to explain why some more recent studies were heavy slow lifting with regular concentric and eccentric contractions are more effective than eccentric only contractions for the treatment of tendinopathy. The big downside of eccentric only contractions is not that they aren’t effective (as this and almost all studies show they are) but that they are tedious to both coach and perform as the patient has to lift the weight with their good arm and lower it with their bad arm.  Also, by using normal combined lifts in physical therapy, patients are learning an effective exercise they can continue indefinitely as part of their fitness program. By contrast, eccentric only exercises are more of a “specialty therapy exercise” that patients rarely would nor should wish to continue after their pain resolves.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

2 thoughts on “Tennis Elbow: Both Concentric and Eccentric Exercise Helps

    • Thanks! You know, I just read that paper and you can’t tell from the abstract but they weren’t even lifting weights. It was just active and passive wrist extension/flexion for 30 seconds per rep. I have to think without any resistance treatment wouldn’t have been any better than a placebo control. In the paper they said they couldn’t think of a placebo control and I’m thinking, how about dry needling, low level laser, microcurrent, kinesiotape, even a sugar pill? The group that added isometric wrist extension had a better result. I expect because at least holding the wrist in full extension there would be some resistance. Sometimes I wonder what researchers are thinking.

      I’m glad you liked my coracoidopathy blog! I feel like it’s the best one I’ve done. I would love to hear your experience working with it going forward!

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