Some issues in physical therapy just seem counterintuitive upon first glance. An emerging treatment method used in the management of tendonopathy is eccentric training. While eccentric training has obviously been around for years, researchers are beginning to see its utility in managing chronic tendon disease.Adding mechanical stress to a tissue that is already mechanically stressed didn't match my intuition early in my career. Fortunately for many of my patients, I still had a lot to learn. We are now learning that many cases of chronic tendonopathy bear little resemblance to the inflammatory process of tendonitis. In fact, some histochemical studies of chronic tendonopathies have revealed no evidence of inflammatory tissue.
With a more sophisticated understanding of the pathophysiology of tendon disease, researchers have begun to explore treatment options that fall out of the typical inflammation-based treatment paradigms. Another (perhaps even more significant) driving force behind these investigations is that our current methods are meeting with mixed results. An emerging treatment option is the use of eccentric training in the management of chronic tendon disease.
Today's article published in the British Journal of Sports Medicine provides a framework for using exercise to manage lateral elbow pain (LEP). While not a clinical trial, the article provides a solid framework for utilizing supervised eccentric training coupled with static stretching to treat recalcitrant LEP. The authors acknowledge that more work needs to be done in this are to determine the optimal mechanical load for the lateral elbow that would elicit positive adaptations without exceeding the tissue tolerance of the musculotendinous complex.
Although I wasn't bowled over by the caliber of this report, I think it does indicate that we are moving into a more sophisticated and precise way of handing tendonopathy. The use of eccentric training reflects a deeper understanding of the pathophysiology of chronic tendon disorders. Upon first glance, it certainly doesn't fit the paradigm of a how we traditionally handled these types of problems. Good thing we are giving these issues a second glance.
Stasinopoulos, D. (2005). An exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine, 39(12), 944-947. DOI: 10.1136/bjsm.2005.019836
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Just surfing through, great blog. Thanks!
ReplyDeleteRod,
ReplyDeleteHave you implemented this in your practice? And if so, how are the outcomes compared to "standard care" (stretching, rest, antiimflams, etc)?
I always seem to get bilateral epicondylitis or medial and lateral epicondylitis, which gives me a different pt population then used in this study, so have been hesitant to go with eccentrics.
Jason
What's up Jason? I don't get tons and tons of lateral elbow pain. The last four or five cases I've had have responded very well to a gradual eccentric protocol inconjunction with the standard care as you mentioned.
ReplyDeleteI still have them stretch and perform many of the anti-inflammatory rx (hard to completely let go of that), but I've seen folks doing really well with it, particularly if they have failed conservative treatment via the inflammatory route.
There is typically a 24-48 period where symptoms aren't too hot after the first few sessions, but grip strength, pain, and function have been imroving much more quickly than in the past with my cases.
It probably isn't appropriate for everyone, but the chronic cases seem to be doing well with it at our clinic. Thanks as always for checking out the blog.
hey rod,
ReplyDeletehow do you decide how much is too much with the eccentrics, like it said in the blog "determine the optimal mechanical load for the lateral elbow that would elicit positive adaptations without exceeding the tissue tolerance of the musculotendinous complex"
thanks
gueorgui
I've done eccentric exercise for patellar tendinitis (knee) and it has been very helpful.
ReplyDeleteHi, recently i've been reading a lot about eccentric exercise, and it seems like it would be a very good method for curing my medial elbow pain. However I can't find a precise description of the exercise involved, how they are performed best, etc. Any tips about this?
ReplyDelete