title: Clinical outcomes of the addition of eccentrics for rehabilitation of previously failed treatments of golfers elbow.
abstract: OBJECTIVE
  Eccentric training of the wrist extensors has been shown to be effective in treating chronic lateral epicondylosis. However, its efficacy in the treatment of medial epicondylosis has yet to be demonstrated. The objective of this study was to assess the effectiveness of a novel eccentric wrist flexor exercise added to standard treatment for chronic medial epicondylosis in patients who did not respond to previous therapeutic interventions for this disorder.
  20.
  
  
  METHODS
  Patients (13 men, 7 women; age 49±12 yr) with chronic medial epicondylosis who had failed previous treatment for this disorder (physical therapy 7, cortisone injection 7, PRP 1, NSAIDS 15) were prescribed isolated eccentrics in addition to wrist stretching, ultrasound, cross-friction massage, heat and ice. The specific isolated eccentric wrist flexor strengthening exercise performed by the patients involved twisting a rubber bar (Flexbar, Hygenic Corportation, Akron OH) with concentric wrist flexion of the noninvolved arm and releasing the twist by eccentrically contracting the wrist flexors of the involved arm (3 × 15 twice daily). A DASH questionnaire was recorded at baseline and again after the treatment period. Treating clinicians were blinded to baseline DASH scores. Treatment effect was assessed using paired t-test. Based on previous work it was estimated that with a sample of 20 patients there would be 80% power to detect a 13 point improvement in DASH scores (p<.05).
  
  
  RESULTS
  The pathology was in the dominant arm of 18 patients and recurrent in 10. Primary symptomatic activities were golf (14), tennis (2), basketball (1), weight lifting (1), and general activities of daily living (2). There was a significant improvement in outcomes following the addition of isolated eccentrics (Pre DASH 34.7±16.2 vs. Post DASH 7.9±11.1, p<.001). For the 18 patients involved in sports, the sports module of the DASH score improved from 73.9±28.9 to 13.2±25.0, p<.001). Physical therapy visits ranged from 1-22 with an average of 12±6 and, average treatment duration of 6.1±2.5 wks (range 1-10). Home exercise program compliance was recorded for each subject (15 full, 3 mostly, 1 occasionally, 1 none).
  
  
  CONCLUSIONS
  The outcome measure for chronic medial epicondylosis was markedly improved with the addition of an eccentric wrist flexor exercise to standard physical therapy. Given the inconsistent outcomes for patients previously treated with chronic medial epicondylosis the addition of isolated eccentrics seems warranted based on the results of this study.
  
  
  CONCLUSIONS
  This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic medial epicondylosis.
  
  
  METHODS
  2b.
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Tyler
authors.affiliation: Pro Sports Physical Therapy of Westchester Scarsdale, NY USA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Nicholas
authors.affiliation: Pro Sports Physical Therapy of Westchester Scarsdale, NY USA.
authors.forename: Brandon M
authors.initials: BM
authors.lastname: Schmitt
authors.affiliation: The Nicholas Institute of Sports Medicine and Athletic Trauma New York, NY USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Mullaney
authors.affiliation: The Nicholas Institute of Sports Medicine and Athletic Trauma New York, NY USA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Hogan
keywords: Eccentric exercise; failed treatment; medial epicondylosis