2. Methods
A randomized clinical trial was conducted between March 2011 and September 2011 in an outpatient department,Physiotherapy and Rehabilitation centre, Alleppey, Kerala,India. Patients were referred by orthopaedic consultant,health care providers, and also self-referral to the centre.Patients were included if they were between 30 to 45 years
of age and had been diagnosed with tennis elbow, and the duration of symptoms was between 8 and 10 weeks.
2.1. Inclusion Criteria
(1) Pain with gripping.
(2) Pain with resisted wrist extension.
(3) Pain with passive wrist flexion with the elbow extension.
(4) Tenderness on palpation over the lateral epicondyle of humerus.
2.2. Exclusion Criteria
(1) Cardiovascular diseases.
(2) Neurological impairments.
(3) Aversion to manual contact.
(4) Neuromuscular diseases.
(5) Previous trauma to the elbow region.
(6) Elbow pain.
(7) Previous surgery to the elbow region.
(8) Peripheral nerve entrapment.
(9) Cervical radiculopathy.
(10) Corticosteroid injection within 6 months.
(11) Previous therapy for elbow joint (minimizing expectation bias).
All patients signed the written consent form prior to participation. The recruited patients had also completed a standard health questionnaire which encompassed details relating to patient demographics, duration of symptoms, any previous treatment ีundertaken, and job status.
2.3. Treatment. Patients assigned to Group A received supervised therapeutic exercise program which included static stretching of the Extensor Carpi Radialis Brevis followed
by eccentric strengthening of the wrist extensors. Static stretching was performed in the seated position with elbow extension, forearm pronation, and wrist flexion with ulnar
deviation. According to the patient tolerance stretch force was applied. This stretch position was held for duration of 30–45 seconds and was performed 3 times before and 3 times after the eccentric exercise portion of the treatment for a total of 6 repetitions [14]. There was a 30-second rest interval between each bouts of stretching.Eccentric strengthening exercise was performed in the seated position with full elbow extension, forearm pronation,and maximum wrist extension. From this position, the patient slowly lowered wrist into flexion for a count of 30,using the contralateral hand to return the wrist to maximum extension. Patients were instructed to continue the exercise even when they experience mild discomfort and to stop the exercise if the pain worsens and becomes disabling. For whom the eccentric exercise could be performed without minor discomfort or pain, the load was increased using free weights based on the patients 10 RM (Repetition Maximum).Three sets of ten repetitions were performed during each treatment, with a one-minute rest interval between each set.Patients were also provided with education manual regarding ergonomics and activity modification technique to avoid aggravation of symptoms.