Exercises for Tennis Elbow
Strengthening exercises are an important aspect of rehabilitation for Lateral Epicondylalgia (Tennis elbow). The aim of strengthening exercises is two-fold in this situation, addressing the local tendon changes (tendinosis) that may be present, and reversing strength deficits that are associated with decreased use of the upper limb musculature due to the pain.
Eccentric exercises – addressing local tendon changes
Eccentric contraction of a muscle is when a muscle lengthens in a controlled manner. An eccentric contraction is used to lower a load gently rather than letting it drop, or to decelerate a body part. The muscle is contracting while lengthening. An example would be performing a bicep curl; as you slowly lower the weight by straightening your arm, the bicep is lengthening while contracting, thus controlling the movement. This form of contraction places increased stress upon the muscle and attaching tendons. The increased stress is desired by our tendons, after-all their function within the body is to absorb and distribute forces. During tendinosis the structure of the tendon is changed due to, among other things, an alteration in the type of collagen that is produced. Instead of the tougher Type I collagen being present, a weaker form called Type III collagen is produced, which is also laid down in a disorganised manner. Eccentric exercises, through cellular stimulation, or mechano-transduction (Khan & Scott 2009), help to stimulate the production of the Type I variant, in an organised fashion once more.
In the case of Tennis Elbow the tendon at fault is that of one of the extensors of the wrist, the Extensor Carpi Radialis Brevis. Therefore, an eccentric exercise of this muscle involves controlling a weight as we bend, or flex, the wrist forward (as above). The program is based on studies of lower limb tendinoses, by Curwin & Stanish (1984), and Alfredson et al (1998). Curwin & Stanish suggest daily exercises using 3 sets of 10 repetitions, and progressing through speed and load, without allowing any pain. Alfredson et al suggest 3 sets of 15 repetitions twice a day, progressing with load only and allowing pain. A typical course will last 4-12 weeks.
Strengthening exercises – addressing strength and control deficits
Vicenzino et al (2003) described a lack of strength of the forearm muscles due to pain in Tennis Elbow sufferers. This included the wrist flexors and extensors, and the forearm rotators (supinators and pronators). Further studies by Alizadehkhaiyat et al (2007) and Coombes et al (2011) highlighted weaknesses of the same muscles, as well as the elbow flexors / extensors, and the shoulder rotators. In fact, in a subsequent study, Alizadehkhaiyat et al (2007) found remaining weakness of all upper limb strength measurements, bar gripping, in subjects who had had a history of Tennis Elbow, but no pain for 6 months. This can be perceived as a risk factor for the condition reoccurring.
Strengthening protocols differ depending on the type of gains that are needed. For example if maximum power is required then a program may consist of maximally heavy weights lifted for low numbers of repetitions. In the case of general strength gains for Tennis Elbow, a typical program may involve 4-6 sets of 6-12 repetitions, using increasing loads as tolerated. The contractions will involve both concentric (shortening) and eccentric (lengthening) exercises. Patients with Tennis Elbow need to be progressed through therapy onto a program of strengthening exercises for the whole of the upper limb.
Alfredson H, Pietila T, Jonsson P, Lorentzon R (1998) Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine; 26:360-366.
Alizadehkhaiyat O, Fisher A, Kemp G et al (2007) Upper limb muscle imbalance in tennis elbow: a functional and electromyographic assessment. Journal of Orthopaedic Research; 25:1651-1657.
Coombes B, Bisset L, Vicenzino B (2011) Elbow flexor and extensor muscle weakness in lateral epicondylalgia. British Journal of Sports Medicine. doi:10.1136/bjsm.2011.083949.
Curwin S, Stanish W (1984) Tendinitis: It’s etiology and treatment. Lexington: Collamore Press.
Khan K, Scott A (2009) Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine; 43(4):247-252.
Vicenzino B (2003) Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Manual Therapy; 8:66–79.