Lateral epicondylitis, commonly termed “tennis elbow,” is one of the most frequent causes of chronic elbow pain in adults and is characterized by degenerative changes of the extensor carpi radialis brevis (ECRB) tendon, impaired tendon healing, and functional disability [1]. Although it occurs most often in individuals aged 35–55 years, elderly patients experience greater symptom severity, slower recovery, and prolonged functional impairment due to age-related tendon degeneration, reduced vascularity, and sarcopenia [2]. Chronic lateral epicondylitis in the elderly (>60 years) therefore represents a distinct clinical challenge where pain, loss of grip strength, and limitations in daily activities can significantly compromise independence and quality of life.

Conservative management remains the mainstay of treatment, with commonly used modalities including rest, activity modification, NSAIDs, physiotherapy, eccentric exercises, ultrasound therapy, and counterforce bracing [3]. Counterforce bracing is widely prescribed to reduce strain on the wrist-extensor origin, providing short-term symptom relief and facilitating early functional use of the limb [4]. However, evidence indicates that bracing alone may not adequately address the underlying tendinopathic pathology, particularly in older adults with degenerative tendon changes [5].

In contrast, eccentric strengthening exercises have gained prominence as a physiologically grounded therapy for tendinopathies. Eccentric loading stimulates collagen remodelling, enhances tensile strength, improves neuromuscular control, and promotes angiogenesis within the degenerative tendon matrix [6]. Multiple studies across Achilles, patellar, and wrist-extensor tendinopathies have reported that eccentric exercises improve pain scores, grip strength, and functional outcomes more effectively than concentric or passive treatments [7]. Furthermore, supervised eccentric programs demonstrate superior adherence, technique correction, and progression monitoring compared to unsupervised home exercises, which is especially relevant in elderly populations [8].

Despite the recognized benefits of eccentric loading, there is limited high-quality evidence comparing supervised eccentric wrist-extensor strengthening programs with standard counterforce bracing specifically in elderly patients with chronic lateral epicondylitis. Most trials include younger cohorts, shorter follow-up durations, or heterogeneous interventions, leaving a knowledge gap regarding long-term outcomes in older adults. Additionally, few studies have incorporated extended follow-up durations such as 3, 6, and 12 months to assess sustained improvements in pain, grip strength, tendon function, and disability.

Given these gaps, the present prospective randomized study aims to compare the efficacy of an 8-week supervised eccentric wrist-extensor strengthening program versus standard counterforce forearm bracing in elderly patients (>60 years) diagnosed with chronic lateral epicondylitis, using validated tools such as the Numeric Pain Rating Scale (NPRS) and standardized functional assessments. Conducted in the Orthopedics Outpatient Department and the Physical Medicine & Rehabilitation Unit at Bharatratna Atalbihari Vajpayee Medical College, Pune, over a 12-month period (September 2024–August 2025), this study seeks to generate robust evidence that will guide functional rehabilitation strategies and optimize long-term patient outcomes in this high-risk age group.

The primary aim of this prospective randomized study is to compare the therapeutic efficacy of an 8-week supervised eccentric wrist-extensor strengthening program with standard counterforce forearm bracing in elderly patients above 60 years diagnosed with chronic lateral epicondylitis. The study seeks to evaluate and contrast both interventions using validated clinical outcomes, including pain reduction measured by the Numeric Pain Rating Scale (NPRS), improvement in grip strength, enhancement of wrist-extensor tendon function, and reduction in disability scores. Additionally, the study aims to assess the sustainability of these clinical benefits at 3-, 6-, and 12-month follow-ups, thereby determining the long-term effectiveness and functional relevance of each treatment modality in an aging population with degenerative tendon pathology.

This study was conducted as a prospective, parallel-group, randomized controlled trial in the Orthopedics Outpatient Department and the Physical Medicine & Rehabilitation Unit at Bharatratna Atalbihari Vajpayee Medical College, Pune, over a 12-month period from September 2024 to August 2025. A total of 120 patients aged above 60 years and clinically diagnosed with chronic lateral epicondylitis for more than three months were screened for eligibility. Patients with prior elbow surgeries, inflammatory joint disorders, neurological deficits affecting upper-limb function, corticosteroid injection within the previous six weeks, or systemic illnesses limiting participation in exercise therapy were excluded. Written informed consent was obtained from all eligible participants.

Following baseline assessment, participants were randomly allocated into two equal groups (n = 60 each) using computer-generated block randomisation to ensure balanced distribution, with allocation concealment maintained through sequentially numbered opaque envelopes. Group A underwent an 8-week supervised eccentric wrist-extensor strengthening programme delivered by a trained physiotherapist, which included warm-up, progressively loaded eccentric wrist-extension exercises using dumbbells or elastic resistance, and cool-down stretching. Sessions were conducted three times per week under direct supervision to ensure proper technique and exercise progression, while home-based reinforcement exercises were encouraged after the supervised phase. Group B received a standard counterforce forearm brace applied over the proximal forearm, which was worn during daytime hours and during all aggravating activities for the same 8-week period. Both groups were advised to avoid heavy lifting and repetitive wrist-extension activities.

Outcome measures included the Numeric Pain Rating Scale (NPRS), grip-strength assessment using a calibrated hand dynamometer, tendon-loading tolerance on resisted wrist extension, and functional disability evaluation using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire (0–100 scale) [9]. These outcomes were recorded at baseline, 8 weeks, 3 months, 6 months, and 12 months. All assessments were performed by an independent evaluator who was blinded to group allocation to minimize measurement bias. Adherence to therapy was tracked using attendance logs for supervised sessions and patient-maintained compliance diaries for home exercises and brace usage. Any adverse events, including pain exacerbation or skin irritation, were documented.

All collected data were recorded in a predesigned proforma and subsequently entered into Microsoft Excel for data cleaning and coding. Statistical analysis was performed using SPSS version 26.0. Quantitative variables such as NPRS, grip strength, and PRTEE scores were expressed as mean ± standard deviation (SD) and compared within and between groups using paired t-tests, independent t-tests, or repeated-measures ANOVA wherever appropriate. Qualitative variables such as tendon-tolerance categories were compared using the Chi-square test. A p-value of < 0.05 was considered statistically significant.

Ethical approval for the study was obtained from the Institutional Ethics Committee of Bharatratna Atalbihari Vajpayee Medical College, Pune. All study procedures followed the ethical principles of the Declaration of Helsinki (2013 revision). Patient confidentiality was strictly maintained throughout the study, and all data were anonymized prior to analysis.

A total of 120 elderly patients with chronic lateral epicondylitis were enrolled and randomized equally into two groups, with all participants completing the 8-week intervention and subsequent follow-up assessments. At baseline, both groups were comparable in age, sex distribution, duration of symptoms, NPRS pain scores, grip strength, and functional disability measures, confirming successful randomisation. By the end of the 8-week intervention period, the eccentric-exercise group demonstrated a greater reduction in NPRS pain scores compared to the counterforce-brace group, accompanied by a more pronounced improvement in grip strength and tendon-loading tolerance. Mean PRTEE disability scores (0–100; higher scores = worse disability) decreased significantlyin both groups, but the improvement was more consistent and clinically meaningful in patients receiving supervised eccentric training. Follow-up evaluations at 8 weeks, 3, 6, and 12 months showed sustained benefits in the eccentric-exercise group, with maintained pain relief and progressive gains in grip strength and wrist-extensor endurance. In contrast, the bracing group exhibited partial loss of early improvement over longer follow-up intervals, particularly beyond six months. No major adverse events were reported in either group, although mild transient discomfort during early eccentric loading was noted in a small proportion of patients. Overall, supervised eccentric strengthening produced superior and longer-lasting outcomes compared to counterforce forearm bracing across all measured parameters.

Table 1: Baseline Characteristics of Study Participants (n = 120)

Both groups were comparable at baseline across age, sex, duration of symptoms, pain levels, grip strength, and PRTEE disability scores, confirming successful randomization before intervention.

Table 2: Baseline & 8-Week Outcome Comparison (With % Improvement)

At 8 weeks, the eccentric group showed nearly double the improvement in pain, grip strength, and PRTEE disability scores compared with the bracing group. Tendon tolerance also improved substantially more with eccentric loading.

Table 3: Long-Term Follow-up Outcomes at Baseline, 8 Weeks, 3, 6, and 12 Months

The eccentric group showed continuous improvement across all time points, achieving the best outcomes at 12 months. The bracing group demonstrated early benefit but showed plateauing and later relapse, confirming limited long-term efficacy of bracing.

Table 4: Tests of Significance Between Groups

All key outcomes showed statistically significant differences favouring the eccentric exercise group (p < 0.001). The effect was strong both at 8 weeks and at 12-month follow-up, confirming the superior and sustained benefit of eccentric strengthening over bracing.

Figure 1: Pain Score Trend over time

Figure 2: Grip Strength Improvement at 8 Weeks (%)

Figure 3: PRTEE Disability Score Trend Over Time

The present randomized study showed that supervised eccentric wrist-extensor strengthening produced substantially greater improvements in pain, disability, and grip strength than counterforce bracing in elderly individuals with chronic lateral epicondylitis. At the end of eight weeks, the eccentric group demonstrated a reduction in NPRS from 7.8 to 3.2 (58.9% improvement), alongside a considerable decrease in PRTEE disability scores from 62.5 to 28.4 (54.6% improvement) and a grip-strength gain of 35.6%. These findings are stronger than the early evidence presented by Stasinopoulos et al. in 2005 [10], who reported approximately 40–45% improvement in pain and about 30% improvement in functional outcomes using a structured exercise programme. The superior gains observed in our eccentric group may reflect the benefits of a strictly supervised, progression-based eccentric protocol, which is especially valuable in older adults with reduced tendon elasticity and neuromuscular control. Our bracing group, which showed only 32.9% pain reduction and 29.9% PRTEE improvement, closely resembles the modest response reported in the non-progressive exercise and passive-treatment cohorts in the 2005 trial.

Long-term outcomes in our study also strongly parallel the findings of Peterson et al. (2014) [11], who demonstrated that eccentric training produced 50–60% sustained pain relief over 12 months, with functional improvement maintained in nearly 70% of patients. In our elderly population, the eccentric group maintained NPRS scores of 2.3 and PRTEE scores of 20.4 at one year, reflecting durable improvement comparable to Peterson’s observations. Meanwhile, the bracing group in our study demonstrated progressive relapse, with NPRS worsening to 5.2 and PRTEE returning to 43.5 by 12 months, consistent with Peterson’s conclusion that passive interventions do not alter long-term tendon behavior or structural pathology.

The mid-term outcomes of our study also show a clear agreement with Bisset et al. (2006) [12], who found that mobilisation-with-movement plus exercise generated sustained improvements between 6 weeks and 6 months, while passive or symptom-focused treatments such as corticosteroid injections produced early relief but poor long-term results. Our eccentric group maintained steady improvement with NPRS falling to 2.5 at 6 months and PRTEE to 22.3, whereas the bracing group exhibited a deteriorating trajectory, reaching NPRS 4.9 and PRTEE 42.1 at the same time point. This pattern clearly reflects Bisset’s finding that active loading is superior to passive support in addressing the underlying tendinopathic process.

Evidence from the systematic review by Hoogvliet et al. (2013) [13] further supports our results. Their review highlighted that exercise and mobilisation techniques provide added benefit, but outcomes are highly dependent on progression, supervision, and adherence. These observations align closely with our supervised protocol, which delivered PRTEE improvement from 62.5 to 20.4 at 12 months—representing recovery at the upper end of what Hoogvliet identified across high-quality trials. In contrast, the bracing group’s partial relapse beyond six months is entirely consistent with the limited durability of non-exercise or minimally progressive interventions found in the review.

Additional literature also supports the mechanistic rationale behind our findings. Earlier mechanobiological studies have demonstrated that eccentric loading stimulates collagen realignment, neovascularisation, and tendon remodeling, changes that are particularly important in degenerative tendinosis common in older adults. Alfredson’s work on eccentric training for Achilles tendinosis and the tendon-adaptation insights provided by Coombes and colleagues indicate that passive treatments, including bracing, can reduce symptoms temporarily but do not promote tendon repair or restore load-bearing capacity. Our results reflect these principles: tendon-tolerance improved to “good” in 72% of participants in the eccentric group, while only 38% of bracing users showed similar improvement.

Overall, the combined evidence from Stasinopoulos (2005) [10], Peterson (2014) [11], Bisset (2006) [12] and Hoogvliet (2013) [13], together with our study’s robust improvements across all time points, clearly supports the conclusion that supervised eccentric strengthening offers superior short-term, mid-term, and long-term outcomes compared with counterforce bracing. The sustained benefit and strong functional recovery observed in our elderly population reinforce the central role of eccentric loading as the preferred first-line rehabilitation strategy for chronic lateral epicondylitis, while bracing may be reserved for short-term symptomatic support rather than long-term management.

Although the study was conducted with a robust randomized design, several limitations should be acknowledged. It was a single-center trial, which may limit generalizability to broader populations. The use of patient-reported scales such as PRTEE may introduce subjective bias despite standardized instructions. Only supervised therapy was evaluated, and the study did not compare different intensities or variations of eccentric loading, which could influence outcomes. Additionally, adherence to long-term lifestyle or activity modifications outside supervised sessions could not be fully monitored. Imaging modalities such as ultrasound or MRI were not routinely used to correlate structural changes with functional improvement, which might have provided deeper insight into tendon remodelling.

Future research should incorporate multicentric designs with larger and more diverse elderly populations to validate and strengthen the generalizability of the findings. Studies comparing supervised eccentric programs with home-based or hybrid models may help determine the most feasible and cost-effective approach for elderly individuals. Incorporating imaging assessments could provide valuable information on tendon healing and structural adaptation. Long-term studies beyond 12 months are recommended to evaluate durability of benefits and identify factors influencing recurrence. Clinically, eccentric strengthening should be integrated as a first-line management strategy, while counterforce bracing may be reserved as an adjunct for symptom modulation rather than a standalone therapy.

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