Eccentric training programmes in the management of lateral elbow tendinopathy

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

ADSC-Based Cell Therapies for Musculoskeletal Disorders: A Review of Recent Clinical Trials

Recently published clinical trials involving the use of adipose-derived stem cells (ADSCs) indicated that approximately one-third of the studies were conducted on musculoskeletal disorders (MSD). MSD refers to a wide range of degenerative conditions of joints, bones, and muscles, and these conditions are the most common causes of chronic disability worldwide, being a major burden to the society. Conventional treatment modalities for MSD are not sufficient to correct the underlying structural abnormalities. Hence, ADSC-based cell therapies are being tested as a form of alternative, yet more effective, therapies in the management of MSDs. Therefore, in this review, MSDs subjected to the ADSC-based therapy were further categorized as arthritis, craniomaxillofacial defects, tendon/ligament related disorders, and spine disorders, and their brief characterization as well as the corresponding conventional therapeutic approaches with possible mechanisms with which ADSCs produce regenerative effects in disease-specific microenvironments were discussed to provide an overview of under which circumstances and on what bases the ADSC-based cell therapy was implemented. Providing an overview of the current status of ADSC-based cell therapy on MSDs can help to develop better and optimized strategies of ADSC-based therapeutics for MSDs as well as help to find novel clinical applications of ADSCs in the near future.

The Beneficial Effects of Eccentric Exercise in the Management of Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis

As a first-line treatment for lateral elbow tendinopathy (LET), eccentric exercise has been suggested as a conservative treatment method. This study aimed to investigate the impact of eccentric exercise on LET with regard to pain reduction, and strength and functional improvement. The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched, and studies up to May 2021 were included if (1) randomization was used for patient allocation, (2) the study comprised patients with LET, (3) the intervention was eccentric exercise, and (4) the primary outcomes included improvement in pain intensity, muscle strength, or function. The meta-analysis comprised of six studies, totaling 429 participants. Additional eccentric exercise with underlying adjuvant therapy significantly improved the visual analog scale (VAS) scores (standardized mean difference [SMD], −0.63; 95% confidence interval [CI], −0.90–−0.36) and muscle strength (SMD, 1.05; 95% CI, 0.78–1.33) compared with adjuvant therapy alone. Compared with the concentric or isotonic exercise group, the eccentric exercise group showed significantly improved VAS scores (SMD, −0.30; 95% CI, −0.58–−0.02). However, no differences in muscle strength and function were observed between the two groups. Eccentric exercise can improve pain and muscle strength in patients with LET. The limited number of included studies and heterogeneous exercise parameters are important when interpreting these findings.

Detection of effort maximality in adults performing isokinetic wrist flexion and extension

BACKGROUND: The difference between isokinetic eccentric to concentric strength ratios at high and low velocities (DEC) is a powerful tool for identifying submaximal effort in other muscle groups but its efficiency in terms of the wrist extensors (WE) and flexors (WF) isokinetic effort has hitherto not been studied. OBJECTIVE: The objective of the present study is to examine the usefulness of the DEC for identifying suboptimal wrist extensor and flexor isokinetic efforts. METHODS: Twenty healthy male volunteers aged 20–40 years (28.5 ± 3.2) were recruited. Participants were instructed to exert maximal and feigned efforts, using a range of motion of 20∘ in concentric (C) and eccentric (E) WE and WF modes at two velocities: 10 and 40∘/s. E/C ratios (E/CR) where then calculated and finally DEC by subtracting low velocity E/CR from high velocity ones. RESULTS: Feigned maximal effort DEC values were significantly higher than their maximal effort counterparts, both for WF and WE. For both actions, a DEC cutoff level to detect submaximal effort could be defined. The sensitivity of the DEC was 71.43% and 62.5% for WE ad WF respectively. The specificity was 100% in both cases. CONCLUSION: The DEC may be a valuable parameter for detecting feigned maximal WF and WE isokinetic effort in healthy adults.

Tolerance and effectiveness of eccentric vs. concentric muscle strengthening in rotator cuff partial tears and moderate to severe shoulder pain. A randomized pilot study

INTRODUCTION

Rotator cuff tears are the main cause of shoulder pain and disability. First line of treatment is conservative; there is evidence regarding the advantage of using eccentric over concentric exercises in tendinopathies, but there are no evidence-based recommendations on starting strengthening exercise during painful phases nor on the effectiveness and advantages of eccentric vs. concentric exercise in rotator cuff tears.

OBJECTIVE

To evaluate the tolerance of a resistance strengthening program and to compare eccentric vs. concentric programs.

DESIGN

A pilot, experimental, randomized controlled study.

SETTING

Outpatient Rehabilitation Center.

PATIENTS

Twenty-six patients with a diagnosis of partial rotator cuff tear were randomly assigned to: the experimental group (eccentric, n = 12) and the control (concentric, n = 14).

INTERVENTION

The experimental group performed muscle strengthening with eccentric technique directed to shoulder and scapular girdle muscles, while the control group performed the concentric technique.

MAIN OUTCOME MEASURES

Visual Analogue Scale (VAS), Constant Scale, Strength, Structure (Ultrasound report).

RESULTS

The tolerance rate was 96% in both groups. Median age (experimental vs. control) was 54.5 vs. 54 years (p = 0.69). Results at baseline, and at months 1, 3, and 12 (median) were as follows: for VAS (mm), experimental: 55, 30, 30, and 10, p < 0.001 (intra-group); control: 50, 30, 30, and 5, p = 0.01; Constant scale (points): experimental 58.5, 88, 93, and 85, p < 0.001; control 50.62, 80, and 91.5, p = 0.038; normalized strength (Kg); experimental: 0.23, 0.29, 0.73, and 0.72, p = 0.001, and control: 0.24, 0.21, 0.54, and 0.66, p = 0.01. We found inter-group differences in the Constant scale at 1 and 3 months (p < 0.05), and in strength at months 1 and 3 (p < 0.05). We observed structural differences in tendon (healing) between groups at 3 and 12 months.

CONCLUSIONS

Eccentric and concentric strengthening were well tolerated; both show early improvement in pain, functionality and tendon structure. Eccentric training appears to be more effective than concentric in the early improvement of functionality, strength and tendon healing.

Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines

Objective

To systematically review all randomised clinical trials to determine the efficacy of local strengthening exercises compared with other forms of conservative management for adults with posterior tibial tendon dysfunction.

Design

Systematic review.

Data sources

Four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched up to June 2018.

Eligibility criteria for selecting studies

The study included randomised clinical trials investigating individuals with posterior tibial tendon dysfunction where local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. Standardised mean differences (SMDs) were used to compare change scores between groups and descriptors of exercise prescription assessed according to the Template for Intervention Description and Replication and the Toigo and Boutellier recommendations.

Results

3 studies (n=93) were eligible for inclusion in the review. Varying strengthening exercises were compared with stretching and foot orthoses (n=2) or no intervention (n=1). Moderate effects (SMD 0.6-1.2) were found for reducing pain and disability with eccentric strengthening in conjunction with stretching and orthoses compared with concentric exercises, stretching and orthoses combined, and stretching and orthoses alone. Evaluation of exercise prescription parameters demonstrated minimal reporting, with the only consistent parameters being the number of sets and repetitions of the exercises, and the duration of the experimental period.

Conclusion

This review demonstrates the paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction, and highlights the lack of exercise prescription parameters reported in clinical trials.

Trial registration number

CRD42017076156.

Management of Chronic Lateral Epicondylitis With Manual Therapy and Local Cryostimulation: A Pilot Study

Objective

The purpose of this pilot study was to evaluate the feasibility and efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis.

Methods

The control group (n = 19) was treated with manual therapy consisting of soft-tissue therapy and radial head mobilizations. The experimental group (n = 18) received cryostimulation in addition to manual therapy care similar to that for the control group. Both protocols consisted of 8 treatments over a 4-week period. Outcome measures included pain intensity (visual analog scale), pain-free grip strength (handheld dynamometer), and functional index (Patient-Rated Tennis Elbow Evaluation questionnaire). Assessments were performed at baseline, postintervention, and 3-month follow-up. Adherence and dropout rates were also considered.

Results

Both groups exhibited significant improvements in pain intensity and functional index at postintervention assessments, which were maintained at follow-up. All participants attended the prescribed number of treatments, but 27% were lost at follow-up. Minor adverse events were reported after cryostimulation in 4 cases.

Conclusions

This study indicated that it is feasible to complete a clinical trial evaluating the efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. On the basis of these preliminary data, the combination of cryostimulation and manual therapy care did not provide any additional benefits in both the short term and the long term. Manual myofascial point treatment and mobilization techniques yielded positive outcomes in chronic lateral epicondylitis. Further studies should focus on the sole therapeutic effect of cryostimulation in both patients with acute and those with chronic conditions.

A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis

Introduction

Lateral elbow tendinosis is a condition that is well known to cause difficult challenges for hand therapists due to its long-term recovery and morbidity. Elastic therapeutic tape is commonly used as a treatment modality, despite limited evidence.

Methods

A randomized controlled trial was conducted to evaluate the effectiveness of elastic therapeutic tape, in conjunction with eccentric exercises, in the treatment of lateral elbow tendinosis. Forty participants with this condition (12 men, 28 women) were randomly allocated to three groups: (i) elastic therapeutic tape and eccentric exercises, (ii) sham tape and eccentric exercises, and (iii) eccentric exercises alone. All groups received education on activity modification techniques. Interventions were undertaken over a 12-week period (four weekly sessions and four fortnightly sessions) and outcome measures were recorded at baseline, three months and six months post randomisation.

Results

At three and six months, improvements were made in all three groups as assessed with the Patient-Rated Tennis Elbow Evaluation, the Short Form 36, pain-free grip strength, and the Occupational Self Assessment. However, there were no statistically significant differences between groups in any of these measures. There were no significant side effects or symptom exacerbation with using the elastic therapeutic tape.

Conclusions

Whilst all groups improved on key outcomes, it is possible that exercise alone and/or natural recovery were responsible for improvements. It is positive to note that the use of elastic therapeutic tape was well tolerated by participants and not associated with any significant side effects or symptom exacerbation.

The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series

Introduction

‘Lateral elbow tendinosis’ or ‘lateral elbow tendinopathy’ have been suggested to be more appropriate diagnostic terms instead of ‘lateral epicondylitis’ as the condition is degenerative rather than inflammatory. For this reason, it is important that interventions target this degeneration at the common extensor tendon.

Methods

A descriptive, retrospective review of a series of four patients with lateral elbow tendinosis was conducted to examine functional outcomes with the use of elastic therapeutic tape, eccentric exercises and activity modification techniques.

Results

All patients recorded improved changes in pain and grip strength within three months of treatment using elastic therapeutic tape, eccentric exercises and activity modification techniques.

Conclusions

There may be clinical benefit in the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for the treatment of lateral elbow tendinosis. More rigorous and comprehensive studies are recommended to further investigate this intervention.

Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results

BACKGROUND

Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle.

OBJECTIVE

To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time.

METHODS

A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4-6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients' perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates.

RESULTS

All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as 'successful' at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a 'successful' outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks.

CONCLUSIONS

Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02085928.

Lateral epicondylitis

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.

Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review

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.

Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review

BACKGROUND

Previous reviews have highlighted the benefit of loaded therapeutic exercise in the treatment of tendinopathy. Changes in observable structural outcomes have been suggested as a possible explanation for this response to therapeutic exercise. However, the mechanism for the efficacy of therapeutic exercise remains unclear.

OBJECTIVE

To systematically review the relationship between the observable structural change and clinical outcomes following therapeutic exercise.

DATA SOURCES

An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to June 2012.

STUDY ELIGIBILITY CRITERIA

Any study design that incorporated observable structural outcomes and clinical outcomes when assessing the effect of therapeutic exercise on participants with tendinopathy.

STUDY APPRAISAL AND SYNTHESIS METHODS

Included studies were appraised for risk of bias using the tool developed by the Cochrane Back Review Group. Due to heterogeneity of studies, a qualitative synthesis was undertaken.

RESULTS

Twenty articles describing 625 patients were included. Overall, there is a strong evidence to refute any observable structural change as an explanation for the response to therapeutic exercise when treated by eccentric exercise training. Moderate evidence does exist to support the response of heavy-slow resistance training (HSR).

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The available literature does not support observable structural change as an explanation for the response of therapeutic exercise except for some support from HSR. Future research should focus on indentifying other explanations including neural, biochemical and myogenic changes.

REGISTRATION NUMBER

Registered with PROSPERO, registration number CRD42011001638.

Tendinopathy in sport

CONTEXT

Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.

EVIDENCE ACQUISITION

The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.

RESULTS

Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.

CONCLUSIONS

Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.