Impact of Heavy Slow Resistance vs. Convectional Exercise in Lateral Epicondylitis—A Pilot Study

Authors: S. M. Divya Mary, Jibi Paul, V. Hema Suresh, P. Senthil

Abstract

Background

The extensor carpi radial muscle may become imbalanced compared to other muscles in the upper arm and can disrupt the overall muscle balance in the upper limb. This muscular imbalance may then cause inflammation or irritation in the tendon. Regular physical activity is rarely used as the only treatment for lowering limb edema. Heavy slow resistance (HSR) training is effective compared to regular exercises. HSR affects functional abilities and physical refinement differently from conventional workouts. This study evaluated the effects of HSR and conventional exercise (CE) on subjects aged 45–65 years with unilateral elbow pain on, in Chennai city.

Methods

Patient received conservative care in the Physiotherapy Department from January 2022 to April 2022. This study compares the pre‐ and posttypes. Tennis Elbow Evaluation (Patient‐Rated Tennis Elbow Evaluation, PRTEE) questionnaires, a patient‐specific functional scale, and grip strength tests were used in the study. Results from the study's treatment HSR group and treatment CE group are contrasted.

Results

After 12 weeks of therapy, investigators reassessed grip strength, PRTEE scores, and functional scale responses. In the posttest results of the Patient‐Rated Tennis Elbow Evaluation survey, there is a statistically significant difference between Group HSR and Group CE (p < 0.001). The posttest outcomes from the patient‐specific activity scoring scheme questionnaire revealed a statistically significant disparity between Groups HSR and CE (p < 0.001). The mean values for both groups exhibited a noteworthy change, with Team HSR demonstrating higher values in contrast to the control treatment.

Conclusion

HSR exercise demonstrates superior effectiveness over CEs for lateral epicondylitis (LE) management, emphasizing its significance in treatment.

Introduction

One of the most prevalent conditions affecting the arms is lateral elbow tendinopathy (LET), also known as lateral epicondylitis (LE) or lateral epicondylalgia. The LET is often described as an inflammatory‐like symptom of discomfort in the lateral epicondyle, which may be degenerative or the result of a failed tendon repair reaction. Therefore, in the absence of inflammatory cells, there may be an increase in fibroblasts, vascular hyperplasia, proteoglycans, glycosaminoglycans, and disordered, immature collagen. The most often impacted structure is the extensor carpi radialis brevis (ECRB) origin [1]. It is often a pain problem associated with sports or workplace. Most patients with LET, often referred to as tennis elbow, are between the ages of 45 and 65. There are regions known as hypovascular zones in the wounded tendon having less blood flow. Moreover, repeated motions cause the tendon to become stretched (eccentric tendon strains) and in certain cases, the region where the extensor carpi radial is brevis muscle joins to the bone has microscopic deterioration (degenerative reactions) in LET [2]. LET may cause the extensor carpi radialis unbalanced with other upper arm muscles, leading to common extensor inflammation. This imbalance is caused by the body avoiding particular muscles to avoid discomfort. This affects upper limb muscular balance and induces tendon inflammation or discomfort [3]. Pain and reduced function are the primary complaints of people with LET, often interfering with daily activities. Many studies recommend a conservative physiotherapy which aims to reduce pain and improve function, but the optimal treatment remains uncertain, necessitating further research. Moreover, patients with LET often have deficiencies in their sensory and motor systems in their non‐injured limbs. This implies that therapy that targets aspects of the motor and sensory systems on both sides may be beneficial. Research‐based approaches have been promoted and endorsed. Recent evidence supports a nonsurgical first therapy plan that includes rest or activity limitation. About 70% of difficult patients had good surgical results [4]. LE is usually diagnosed by clinical history and physical examination, however diagnostic imaging is beneficial when a differential diagnosis is suspected [5]. LE is diagnosed mostly by clinical history and physical examination. LE usually causes discomfort above the lateral humeral epicondyle and in forearm. Palpation, gripping, resisted wrist and second or third finger extension worsen this pain. Despite the idea that LE strains forearm extensor muscles, the discomfort may develop gradually without a reason [6]. Recent endorsements include a research‐based approach and supports a nonsurgical first therapy plan of rest or activity restriction. Surgery for difficult patients has a 70% success rate. Manual labor jobs include repeated arm and wrist motions, rendering workers more prone to LE, which has worse prognoses and higher treatment resistance. Office job, women, older age, smoking, and rotator cuff pathology increase LET risk. Diagnostic imaging is beneficial when a differential diagnosis is possible for LE, which is usually diagnosed by clinical history and physical examination. Clinical history and physical exam are the main LET diagnostic techniques. Pain above the lateral humeral epicondyle, typically into the forearm, is the most prevalent LE symptom. Palpating, clutching, and resisting wrist and second or third finger extension worsens this pain. LET discomfort may develop gradually without a reason, despite the notion that forearm extensor muscles are stretched [7]. An exercise regimen is among the most popular treatments for LET [8]. Traditional strength training with heavy weights or equipment mostly isolates and tires certain muscles [9]. The normal workout targets particular muscle groups like curls, presses, and rows with three to five sets and eight to twelve repetitions. Conventional strength training, like bicep curls, emphasizes contraction over extension to create muscle. Weight resistance contracts muscle, making it bigger and shorter [10, 11].

The initial suggestion for a supervised exercise program for treating LET came from Stasinopoulos and Stasinopoulos [12]. For LET patients, exercise programs may be divided into two those that are done at home and those that are done in a clinical environment. For patients with tendinopathies in LET, a home exercise regimen is often recommended since it can be done at any time of day without professional supervision, and the patient may contact the therapist once or twice a week for further guidance. The patient who participates in the clinic's fitness program comes in each day to work out under the guidance of the therapist. As a result, exercise regimens implemented in a clinical context are known as supervised exercise regimens [13]. As far as we are aware, no research has been done to investigate how well a slow resistance training regimen works for LET patients. Thus, the current research was to compare the outcomes in patients with LET before and after they began a modest resistance exercise regimen.

HSR, which allows for a controlled pace of loading while still providing an appropriate load, has gained popularity as a management technique in the early stages of the condition, with consistent effects reported regardless of the type of muscle contraction [14].

This study compares the pre‐ and posttypes using PRTEE (Patient‐Rated Tennis Elbow Evaluation) questionnaires, which provide a patient‐specific functional scale (PSFS), and grip strength tests were also used in the study. The participants' questionnaires were distributed at the ACS Medical College and Hospital campus's outpatient physiotherapy department. Results from the study's treatment group HSR and Conventional Exercise (CE) group were compared and tabulated.

Materials and Methods

Research Method

In our study, 24 patients with single‐side Tennis elbow received conservative care in the physiotherapy department from January 2022 to April 2022.

Research Duration

Following the selection of the relevant samples, the appropriate exercise was conducted which lasted 12 weeks, with the intervention taking place 3 days a week for 30 min each. The institution's review panel at the ACS Medical College and Hospital gave its approval for conducting the study.

Recruitment of Study Participants

Participants for the study were selected based on specific inclusion criteria. Individuals aged between 45 and 65 years with unilateral LE were randomly assigned to either HSR Group or CE Group. Eligible participants tested positive on both the Cozen's and Mill's tests and had a clinical diagnosis of LE. The condition affected either the dominant or nondominant elbow and had persisted for more than 12 months. Participants will not be recruited in the study if they have any of the following a bleeding disorder, are taking anticoagulants, have a history of thrombosis or thrombophlebitis, have any condition that weakens the skin, have a systemic illness, have had any injections, have a history of elbow surgery or diffuse pain syndrome, or have undergone physical therapy intervention in the past 6 months.

Sample Selection

From the early published report, it was estimated that 15 patients for each group were sufficient to detect a 40% difference in effect of exercise and its score improvement between the pre‐ and post‐groups at p < 0.05 with 80% power. Moreover, in another reported studies of chronic lateral epicondylosis with 15 patients 20% difference in VAS (Visual Analog Scale) pain score was able to detect between pre‐ and post‐groups at p < 0.05 with 80% power in sample size calculation. But we have used 24 patients sample size which were more than sufficient. The sample size was also calculated using the formula. Using the sample size formula provided earlier, we calculated the power associated with a sample size of 24 n=2σ2(Zα/2+Zβ)2/Δ2 and found a power of 0.80, which is typically considered sufficient for detecting meaningful effects in our study between two groups. Therefore, this sample size provides adequate power for our study [15, 16].

The method of simple random sampling was used to choose 24 samples. Consent was given voluntarily by all participants. Twelve of the participants were allotted to each two Group HSR and Group CE.

Demography Characteristics

Among the participants (Table 1 and Figure 1), 45‐year‐old man and a 65‐year‐old woman were the youngest and oldest patients, respectively. 38% of the patients were seen when they were between the ages of 50 and 55. 53 years old was the typical incidence age. 60% of the participants were female, and the majority of them were in the 50–59 age range.

Study Design

Randomized controlled trial; Level of evidence, 1 [15].

Dependent Variable: (1) Improvement in grip strength; (2) Movement preservation; (3) Normality of function.

Independent Variable: (1) HSRT and (2) CE.

Data Collection

PRTEE questionnaires, the patient‐specific functional scale (PSFS) was utilized to gather information on the quality of life of patients with unilateral LE and the pain‐free grip test (PFGT) using a hand‐held dynamometer [16]. These tests were followed by the HSRT and CEs. The PFGT is used to gauge pain‐free grip. Since gripping is a typical pain‐producing functional activity related to LET, which is more clinically effective than maximum grip testing. Using a portable dynamometer, measurements are taken and recorded. The best of the three results were recorded after the test is administered three times with a maximum 1‐min break in between [17]. The PSFS is a self‐report outcome function measure that are applied to patients with varied levels of independence [18, 19]. The purpose of PSFS is to offer the researcher a valid, reliable, responsive, and effective outcome measure that would be simple to use and adaptable to a wide range of clinical presentations [20]. A 15‐item questionnaire called the PRTEE, formerly known as the Patient‐Rated Forearm Evaluation Questionnaire (PRFEQ), is used to assess forearm pain and functional limitations in people with LE in patients [21, 22].

With the PRTEE, patients can rate their tennis elbow discomfort and disability on a range of 0–10, and it has two subscales [23]:

(1) Pain subscale – 5 items (0 = no pain, 10 = worst imaginable); (2) Function subscale (0 = no difficulty, 10 = unable to do); (3) Specific activities – 6 items; (4) Usual activities – 4 items.

Once the PRTEE form has been filled by the patients, an automatic computation known as the PRTEE Evaluation is carried out [24].

Exercise Protocol

Group HSR workout regimen includes HSR Training (HSRT): The tendon needs to undergo stress at a sufficient level to induce strain, leading to changes in its mechanical properties [25]. To achieve this, a loading strategy involving higher intensities, typically expressed as a percentage of one repetition maximum (1RM, the maximum weight lifted once, ranging from 70% to 80% of RM), serves as a suitable alternative. Bohm et al.'s comprehensive study revealed that an intensity threshold of 70% of the maximum weight consistently induced changes in the mechanical, material, and potentially morphological aspects of the tendon, irrespective of the contraction type [26].

In HSRT, substantial stresses on the tendon, such as 70%–85% of 1RM, are applied [27]. This involves significant loading on the tendon, as it represents the maximum weight an individual can lift in one repetition. The recommended program suggests initiating with a manageable load, such as 15RM, but with a higher repetition of 3 × 15, gradually increasing the weight and reducing repetitions weekly. This approach allows for fewer repetitions and higher loading volumes on the tendon, increasing time spent under tension and enhancing tendon adaptability. The morphological changes observed in fibrils (components of muscle fibers) and the generation of new fibrils are believed to result from HSRT, steering the tendon toward a more normal morphology [28].

Group CE workout regimen includes traditional exercise and hand

(1) Rotation: In a right angle, the elbow is bent. Turn the hand and forearm slowly until the palm was pointing downward while extended the hand forth with the palm up. Kept the posture for 5 s. Repeated 9 more times. Performed two additional sets of 10 repetitions [29].

(2) Rotation With Weight: The wrist rotation with weight is another alternative that is comparable to the wrist rotation mentioned before. On the other hand, this has the individual holding a little weight in their hands, such a food can or a small dumbbell [30].

(3) Lifts: With the elbow flexed at a straight angle, the hand stretched outward with the palm facing up, and the wrist flexed inward toward the body, the person holds a light weight in their hands, such as a small dumbbell or food can for 5 s, and then gradually let go of the weight [31]. (4) Bends: Maintain the stance for 15–30 s. Standing up straight and bend one arm gradually upward until the hand contacts the shoulder. The exercise is repeated nine times.

Group CE workout regimen also includes hand

(1) Extensors: The palm of the arm is made to point down when it is raised straight in front of the body. The stretched hand is brought back toward the body gently with the other hand. After 15–30 s, this position is held and then straighten the wrist [32, 33, 34].

(2) Flexors: The patient was made to raise their arm straight in front while slowly bending their wrist up such that the palm faced downward. The patient pulled the fingers back toward their body with the other hand. For 15–30 s, the patient maintained this posture. The patient regained wrist erectness and this is repeated nine times [35, 36].

(3) Squeeze Activity: Roll a towel, sock, or tennis ball are made to hold in fist for 20 s and relaxed, and this is repeated nine times [37, 38].

(4) Twist Activity: With one hand on each end of the loosely wrapped towel, patient is made to hold at its ends, lengthwise and asked to maintain shoulder relaxation. The patient turned the towel counter clockwise with their hands, as if wringing out water. They repeated this nine more times. After that, the patient turned the towel ten more times in the other direction [39, 40].

Statistical Analysis

The data underwent statistical collection and analysis. The effects before and after training in the HSRT group were statistically compared with those in the Traditional exercises group.

Values were presented as means ± SD. The pain scores (VAS) and questionnaire results were analyzed using analysis of variance (ANOVA), with multiple comparisons conducted using the Newman–Keuls test. Differences within groups between pre‐test and posttest treatment were examined using a paired t‐test. A significance level of 5% (p < 0.05) was adopted for all statistical tests. The analysis was performed using SPSS version 11.5.

Results

On comparing the mean values of the HSR group and the CE group for unilateral LE, significant increases were observed in the posttest mean values. The HSR group was found to be more effective than the CE group with a significance level of p ≤ 0.005. Additionally, when comparing the pre‐ and posttest values within the HSR group and CE group separately, the HSR group exhibited a highly significant difference in mean values at P ≤ 0.005.

The outcomes of the PRTEE survey for Groups HSR and CE. The statistics tools include the paired t‐test, and unpaired t‐test. No significant distinction is observed in the pre‐test results for Groups HSR and CE ( p > 0.005) [41]. However, in the posttest results of the PRTEE survey, there is a statistically significant difference between Group HSR and Group CE (p < 0.005) [42]. The PRTEE survey indicates a substantial disparity in posttest results for both groups. On the comparison of the responses from Groups HSR and CE to the Patient‐specific activity scoring scheme questionnaire, encompassing both pre‐ and posttest assessments, along with corresponding t‐test [43]. The posttest outcomes from the Patient‐specific activity scoring scheme questionnaire reveal a statistically significant disparity between Groups HSR and CE (****p *= 0.005) [44, 45].

In addition to statistical significance, effect sizes were calculated to determine the magnitude of the differences between the HSR and CE groups for each outcome measure. Cohen's d was used to calculate the effect size for the PRTEE, Patient‐Specific Activity Scale (PSAS), and grip strength measurements. The interpretation of Cohen's d followed standard small (0.2), medium (0.5), and large (0.8) effects. PRTEE: The effect size (Cohen's d) for the posttest results between the HSR group and the CE group was calculated to be −1.49. This indicates a large effect, suggesting that HSR exercises were substantially more effective in reducing symptoms of LE compared to CEs. PSAS: The posttest effect size (Cohen's d) between the two groups was −0.11, demonstrating a small effect in favor of the HSR group. This suggests that HSR improved patient‐specific functional activities only slightly more than CEs. Grip Strength: The effect size (Cohen's d) was 0.33, showing a small‐to‐medium improvement in grip strength for the HSR group compared to the CE group.

Number Needed to Treat (NNT) was calculated to assess the clinical relevance of the results. NNT represents the number of patients who need to undergo HSR therapy for one additional patient to benefit compared to CE. Based on the improvement in PRTEE scores, the NNT was found to be 5, indicating that for every 5 patients treated with HSR, one additional patient would experience significant clinical improvement compared to CE.

Detailed Comparison of HSR and Traditional Exercises: Exercise Intensity and Load

(1) HSR Exercises:

Focus on high resistance with slow, controlled movements. Typically, patients lift heavier weights at lower repetitions, often following a 3–4 sets of 6–8 repetitions format. The exercises are designed to create high tension in the affected tendons, which can stimulate tendon remodeling and repair. Resistance is progressively increased as the patient builds strength, ensuring that the load continually challenges the muscles and tendons.

(2) CEs:

Typically involve lighter weights with higher repetitions (e.g., 10–15 repetitions per set). These exercises focus more on endurance than strength. Often involve dynamic, quicker movements with less emphasis on controlling the speed of the exercise, making the loading on the tendon less intense. Load progression is usually slower, and the exercises may not provide the same level of tendon stimulation as HSR exercises.

Detailed Comparison of HSR and Traditional Exercises: Movement Patterns and Tempo

(1) HSR Exercises:

Movements are deliberately performed at a slow tempo (e.g., 3 s for concentric phase, 3 s for eccentric phase). This slow tempo increases the time under tension for the tendon, a key factor in tendon healing. The slow movement helps minimize compensatory movements, ensuring that the target muscle group (typically the extensor tendons in the elbow) is isolated and activated effectively. Exercises in HSR for LE often include eccentric strengthening, such as slow wrist extensions with weights, where the patient lowers the wrist in a controlled manner, emphasizing tendon elongation.

(2) CEs:

The tempo is faster, with more focus on completing the movement rather than on controlled, slow contractions. Movements are often less focused on eccentric loading. The quick movement patterns can limit the amount of time the tendon is under stress, which may reduce the effectiveness of the exercise for tendon repair.

Detailed Comparison of HSR and Traditional Exercises: Tendon Adaptation and Remodeling

(1) HSR Exercises:

HSR is specifically designed to promote tendon adaptation and remodeling. By using high loads and slow movements, HSR induces a response in the tendon that encourages collagen realignment and strengthening. Studies suggest that the mechanical loading provided by HSR helps to increase tendon stiffness, making the tendon more resilient and less prone to irritation.

(2) CEs:

CEs tend to focus more on muscular endurance rather than direct tendon loading, which may limit their effectiveness in inducing significant tendon adaptation. While they can help improve overall function and reduce pain through increased blood flow and muscle activation, the lower intensity may not promote the same level of tendon repair or strengthening as HSR exercises.

Detailed Comparison of HSR and Traditional Exercises: Pain Reduction and Functional Improvement

(1) HSR Exercises:

Clinical studies have shown that HSR exercises are superior in reducing pain and improving functional outcomes for patients with LE. In the study, for instance, HSR exercises led to significantly better outcomes in terms of PRTEE scores and grip strength, with a large effect size of −1.49 for PRTEE scores, indicating substantial symptom reduction. The targeted, controlled nature of HSR seems to offer greater improvements in strength and daily functional abilities, such as lifting or gripping objects.

(2) CEs:

While CEs can also lead to pain reduction, the improvements tend to be less dramatic compared to HSR exercises. The effect size for PRTEE in the study was smaller, showing less reduction in symptoms and functional limitations. CEs may still be useful for general strengthening and endurance but are not as effective for tendon rehabilitation and pain management.

Detailed Comparison of HSR and Traditional Exercises: Clinical Relevance (NNT)

(1) HSR Exercises:

Based on the study's results, the NNT for HSR therapy was calculated to be 5, meaning that for every 5 patients treated with HSR, one additional patient would experience significant clinical improvement in comparison to CE. This shows that HSR has a strong practical impact and is likely to lead to meaningful improvements for many patients.

(2) CEs:

Although CEs provide benefits, they tend to be less efficient in achieving clinically significant outcomes, as demonstrated by the lower effect sizes and less pronounced grip strength improvements in the study.

Detailed Comparison of HSR and Traditional Exercises: Long‐Term Outcomes

(1) HSR Exercises:

Tendon remodeling and strengthening through HSR exercises offer the potential for more durable, long‐term pain relief and functional recovery. The emphasis on tendon loading makes it more likely that the underlying cause of LE—tendon degeneration—will be addressed effectively. HSR has also been shown in other studies to reduce recurrence rates due to its focus on strengthening the tendon and muscle unit.

(2) CEs:

While CEs can help in the short term, they may not provide the same level of tendon healing, which could lead to higher recurrence rates of symptoms over time. These exercises tend to be better suited for general maintenance or for patients who may not tolerate higher loads, but they may not resolve the underlying tendon degeneration as effectively as HSR.

Discussion

To evaluate the study's hypothesis, “Effect of Heavy Slow Resistance training, stretch shortening cycle over traditional exercises in chronic LE of elbow” statistical analysis was used to compare the significance of the experimental HSR and control CE groups. This is the first study that compares typical exercise with HSR training across a wide age range (45–65 years) [45]. Studying the elbow motion of people with unilateral LE of the elbow has been beneficial to our understanding of how joint mechanics contribute to the development and progression of the condition. Exertion‐related discomfort is linked to those who have restricted wrist flexion, limited elbow extension, and high elbow extension forces. Much less is known about the associated features of muscle function and the deficiencies that impact movement patterns. Elbow mobility is correlated with weak muscles at any given activity. Increased tension on the elbow may result in a considerable reduction in wrist flexibility. This could be the case for those who routinely display symptoms such as soreness around the tendon, limited range of motion in the elbow and wrist, and discomfort while exerting themselves [46].

This method involves performing exercises with heavy weights at a slow, controlled pace, typically 3 s for both concentric and eccentric phases. HSR's objective is to enhance tendon strength and functionality by stimulating collagen production and facilitating tendon restructuring. Essential exercises include of wrist extensors, forearm supination, and grip strengthening [47]. Incremental advancement in resistance and unwavering regularity in training are important for optimal efficacy. HSR exercise has shown favorable benefits in alleviating pain and improving grip strength, hence leading to improved long‐term results for those suffering from LE. Utilizing a slow training approach is a very efficient strategy for middle‐aged and older individuals to enhance their muscular strength. While more research is required to investigate the effects of resistance training on vulnerable groups, it is important to take into account the pace of repetition when prescribing such exercise.

It is critical that the exercises be difficult enough to cause the tendon fibers to sustain the appropriate degree of damage in a regulated manner. The body's natural healing mechanisms are stimulated by this strain, which ultimately results in the production of collagen and the rebuilding of tendons. Consequently, the tendon becomes more resilient, more flexible, and better able to withstand the forces that will be placed on it in the future [48]. This HSR is necessary for enhancing the health and function of the tendon, which will eventually result in a reduction in discomfort and the prevention of future damage. When designing an exercise intervention, it is important to take into account proper regeneration times and slower adaption rates of tendon in comparison to muscle [48]. This is done to prevent periods of excessive tendon strain and stress [48]. This may lead to maladaptation and tendon injury. Repetitive strains, on the other hand, may generate tendon micro‐injuries and, as a consequence, tendon inflammation, both of which can play a role in the development of tendon degeneration, even if they are below the threshold at which the tendon experiences failure.

Upon closer examination, the mean values for both groups exhibited a notable change, with Team HSR demonstrating integer standard deviation values in contrast to the control treatment. These observed alterations can be attributed to the impact of HSR [49]. To optimize muscle strength and reduce discomfort, exercises should be performed with the elbow extended, the forearm in a pronated position, and the wrist elevated as much as possible. It is crucial to expose the tendon to stress at a level that induces sufficient strain to bring about alterations in the mechanical properties of the tendon.

From the descriptive statistics (Table 2), this survey shows the prevalence of LE in the age group with a minimum of 45 years and a maximum of 65 years, with a mean value of 53.27 and a standard deviation of 5.98. From the frequency table, the gender distribution is 35.21% for males and 45.05% for females, with a cumulative percentage of 100%. For the place distribution at ACS Medical College, Chennai, the percentages are 50.7% and 49.3%, with a cumulative percentage of 100%. For X‐rays and surgery, the cumulative percentage is also 100%. Fortunately, most instances are self‐limiting and effectively treated with generic analgesics, with 90% of sufferers recovering over time. For patients with severe or persistent symptoms, more conventional intervention choices, such as surgery, may be beneficial. Bohm et al. concluded that the intensity threshold of 70% of maximum was likely to cause changes in the mechanical, material, and possibly morphological aspects of a tendon, regardless of the kind of contraction. A rise in posttest HSR indicates that all of these factors have improved the patients' overall quality of life. HSR has the potential to both reverse the course of LE and reduce its incidence.

In our study, rigorous measures were implemented across various aspects of study design. Participants were randomly assigned to groups to minimize bias, and blinding procedures were in place to ensure unbiased assessment of outcomes. We adhered to standardized, published protocols for the exercise intervention to maintain consistency and replicability. Data collection was conducted meticulously by trained personnel to uphold the accuracy of our findings. Ethical compliance was strictly followed, with approval from the institutional ethics committee and informed consent obtained from all participants. These steps collectively contribute to the robustness and reliability of our study. Our study presented results transparently, including significant and nonsignificant findings. We discussed clinical implications, addressing study limitations. This comprehensive approach enhances the credibility and applicability of our findings in physiotherapy practice.

The study aimed to compare the immediate effects of HSR and CE on LE over a 12‐week period, which was deemed sufficient to assess initial effectiveness. It focused on short‐term improvements in grip strength, PRTEE scores, and functional scales, avoiding long‐term follow‐up due to participant burden and resource limitations. As a pilot study, its goal was to gather preliminary data to support larger‐scale research. The findings aimed to provide actionable insights for clinical practice, enabling clinicians to make immediate treatment decisions without relying on long‐term follow‐up data. Extending the study required more resources, which were limited. Self‐reported measures (PRTEE questionnaires, PSFS) may have some inherent subjectivity, potentially impacting the study's objectivity. Mention that the study was conducted at a single institution, which may limit the generalizability of the findings to a broader population.

Conclusion

This study made a detailed comparison of the effects of HSR exercises and CEs in individuals with unilateral external epicondylitis residing in Chennai and community selection of 24 participants aged 45–65 years, random assignment to groups HSR and CEs, and use of grip strength measures, PRTEE questionnaires, and PSFSs ensured the evaluation of the interventions thoroughly analyzed data analyzes including the PRTEE questionnaire, PSFSs, and grip strength scores after 12 weeks showed that HSR and CE – two showed comparable improvements in patient outcomes.

Statistical analysis revealed significant increases in practice and elbow and forearm function in people with LE, which subsequently increased overall well‐being in both groups. Our findings suggest that HSR is more effective than CEs in managing the complications of unilateral LE. These results provide valuable insights in physical therapy, providing clinicians and researchers with an evidence‐based perspective to select appropriate exercise programs according to the specific needs of individuals with this condition here.

HSR exercises offer superior benefits over CE for the management of LE. HSR's focus on high‐load, slow, controlled movements allows for more effective tendon remodeling, leading to greater pain reduction, functional improvement, and long‐term recovery. The clinical relevance of HSR is highlighted by a significant NNT of 5, meaning that a greater proportion of patients experience meaningful benefits compared to those undergoing conventional therapy. Conversely, CE provides some pain relief and functional benefits, but the effect is generally smaller, and the exercises are less targeted at tendon repair.

Long‐Term Follow‐Up

Suggests conducting further research with a longer follow‐up period to observe the sustainability of the improvements and potential differences between the two exercise approaches over time. Diversify Recommends including participants from various demographics to enhance the external validity of the study. Multicenter Conducting multicenter studies to validate and generalize the findings across different settings and populations.

Objective Measures

Suggest incorporating objective measures in addition to self‐reported data to provide a more comprehensive assessment of treatment outcomes. Consideration of Other Interventions: Future research to investigate the efficacy of combining HSR and CEs or to compare it with other interventions to determine the optimal treatment regimen.

Clinical Implications

The comparable efficacy of both HSR and CEs highlights the versatility in designing rehabilitation programs for individuals with unilateral LE. Clinicians can choose between these interventions based on patient preferences, available resources, and specific clinical considerations.

Patient‐Centric Approach

The utilization of PSFSs and PRTEE questionnaires emphasizes the importance of incorporating patients' perspectives into the assessment of treatment outcomes. This patient‐centric approach enhances the relevance and applicability of the findings to real‐world rehabilitation scenarios.

Long‐Term Considerations

Although the study evaluated outcomes after 12 weeks, future research could explore the sustainability of improvements over a more extended period. Long‐term follow‐up assessments would provide valuable insights into the lasting effects of HSR and CE interventions and guide recommendations for ongoing management.

Diverse Demographics

While the current study focused on individuals aged 45–65 in the Chennai region, future research could explore the generalizability of these findings to a broader demographic, including different age groups, geographical locations, and cultural backgrounds.

Combination Therapies

Considering the positive outcomes observed with both HSR and CEs, future investigations could explore the potential benefits of combining these approaches. A multimodal treatment strategy might provide synergistic effects, offering a more comprehensive and tailored approach to address the multifaceted nature of LE.

Further Biomechanical Analysis

Understanding the underlying biomechanical mechanisms contributing to the observed improvements could enhance the specificity of exercise prescription. Investigating the impact of HSR and CEs on muscle activation patterns, joint mechanics, and tissue healing processes could provide a deeper understanding of their therapeutic effects.

Author Contributions

S. M. Divya Mary: conceptualization (lead), formal analysis (lead), methodology (lead), writing – original draft (lead), writing – review and editing (lead). Jibi Paul: conceptualization (supporting), writing – original draft (supporting). V. Hema Suresh: writing – review and editing (equal). P. Senthil: methodology (equal), writing – review and editing (equal).

Ethics Statement

Ethical approval for this study was obtained from the Institutional Ethics Committee (Approval Number: 547/2022/IEC/ACSMCH Dt: 21/06/2022). All procedures performed in this study involving human participants were following the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent

All participants provided written informed consent before their inclusion in the study. They were informed about the study objectives, procedures, potential risks, benefits, and their right to withdraw at any time without consequences. Confidentiality of personal information was maintained throughout the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Permission to Reproduce Material From Other Sources

We acknowledge that necessary permissions have been obtained to reproduce material from other sources in this manuscript. Proper attribution has been provided in accordance with the guidelines of the respective copyright holders.