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BJSM Online First, published on September 19, 2017 as 10.1136/bjsports-2017-098093
1
School of Health, Medical
and Applied Sciences, Central
Queensland University,
Rockhampton, Queensland,
Australia
2 Category of the mobile application
School of Biomedical Sciences,
University of Queensland,
Brisbane, Queensland, Australia
3
Appleton Institute for
Behavioural Science, Central
Queensland University, Adelaide,
South Australia, Australia
4
School of Health and
Rehabilitation Sciences,
University of Queensland,
Brisbane, Queensland, Australia
Correspondence to
DrLuke JHeales, Department
of Exercise and Health Science,
School of Health, Medical
and Applied Sciences, Central
Queensland University,
Rockhampton, Queensland,
Australia; l.heales@c qu.edu.au
Accepted 8 August 2017
To cite: HealesLJ, LastellaM,
CoombesBK, etal.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-098093
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
Mobile app user guides
Stretching the evidence behind tennis elbow: mobile
app userguide
Luke J Heales,1,2 Michele Lastella,3 Brooke K Coombes,2 Bill Vicenzino4
Name of the mobile application
Tennis Elbow.
Health and fitness.
Platform
iOS V.6.0 or later; Android V.2.3 or later.
Cost
iPhone $A5.99; Android $A5.99.
About the app
Tennis elbow (TE), formally known as lateral
epicondylalgia, is a musculoskeletal condition asso-
ciated with pain over the lateral elbow and histo-
logical changes of the common extensor tendon.1
Numerous treatments are advocated for this condi-
tion, with recent developments in the use of mobile
technology now added to the list.
The application titled Tennis Elbow is one of
the few user-friendly applications incorporating
education, a stretching programme, and a diary for
recording symptoms and exercises undertaken. The
rationale provided for the aetiology of TE is muscle
shortening from overuse, and The magic formula
is now called stretch the flexors! (figure1). The
application recommends five stretching exercises,
targeting muscles of the trunk and upper limb (eg, Figure 1 Screenshot of the proposed tightening of the
finger flexors, wrist extensors). It allows users to flexor muscles.
track the number of exercises performed and their
pain intensity using a user-friendly, colour-coded
rating scale (figure2). This information, along with Use in clinical practice
a timer to count the duration of exercise, may assist Evidence from a randomised controlled trial suggests
the user to monitor their progress and compliance that strengthening is more effective at reducing
with stretching. pain and improving grip strength than stretching,
A notable concern with this application is the lack although both groups improved.3 Given the lack of
of scientific evidence. The applications rationale for evidence for muscle shortening in TE and stretching
the intervention is that TE is secondary to muscle as a treatment, it is difficult to endorse stretching as
shortening from overuse; however, there is currently an isolated treatment using the prescribed exercises
no published evidence of muscle shortening in TE. or doses provided within this application.
Although stretching has been shown to reduce pain Due to heterogeneity in the pathophysiology
in a variety of musculoskeletal conditions,2 this treat- and clinical presentation of TE, one treatment is
ment does not address the primary impairment of unlikely to be effective in all cases.1 Using a recently
weakness during gripping, the key feature of TE. On published algorithm for the management of TE,1
the contrary, the recommended stretches may cause a this application might benefit a low-risk subgroup
reduction in strength2 and an altered neuromuscular of individuals who have relatively mild pain and
control.2 The application collects data on pain inten- disability, without additional risk factors for poorer
sity to generate an automated and predetermined prognosis (eg, concurrent neck/shoulder pain). For
number of repetitions that should be performed the such individuals, it is recommend a health prac-
following day, with greater symptoms indicating titioner provide an individualised intervention.
that more exercise is necessary (figure2). However, Overall this user-friendly application may provide
the rationale that greater symptoms be treated with a reasonable framework for assisting some individ-
more stretching should be approached with caution. uals in managing and monitoring their condition.
HealesLJ, etal. Br J Sports Med 2017;0:1. doi:10.1136/bjsports-2017-098093 1
 Downloaded from http://bjsm.bmj.com/ on September 20, 2017 - Published by group.bmj.com
Mobile app user guides
Figure 2 Screenshot of an individual tracking the intensity of their
complaint (ie, pain intensity) using the colour-coded rating scale, which
is used to recommend the number of exercises. The user can also track
the number of exercises performed.
Pros
The application provides exercises to individuals with TE
and encourages reflection on causative factors and advice
to remain active but avoid excessive exertion, which is
consistent with guidelines.
Users can track their pain intensity on a daily basis.
2 HealesLJ, etal. Br J Sports Med 2017;0:1. doi:10.1136/bjsports-2017-098093
The application acknowledges that stress may lead to
increased muscle tension and symptoms of TE, offering
suggestions for stressrelief.
In the Terms and Conditions section, the app provides infor-
mation withregard to ceasing the stretching exercises and
seeking medical advice should there be ongoing symptoms,
deterioration of symptoms or new complaints of any kind,
which is consistent with guidelines.
Cons
Cost
The application provides limited and unsubstantiated infor-
mation about the condition, which is not supported by the
literature (eg, stating muscle shortening is the cause of TE).
The application only prescribes stretching exercises and does
not include active strengthening, which is not consistent
with guidelines.
The application uses inaccurate terminology (eg, strecker
muscles) and contains several grammatical errors, which
limits the clarity of information provided.
It is unclear whether the recommended number of exercises
is for all five stretches (eg, six recommended exercises all
five stretches=total of 30 stretches).
The stretching exercises are unmodifiable and the number
of prescribedrepetitions is automaticallydetermined from
the individualsreported pain intensity with greater reported
pain indicating thatgreater stretching is required.
Contributors LJH and ML contributed to the concept, design and write-up of the
manuscript. BKC and BTV contributed to the editing and review of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
References
1 Coombes BK, Bisset L, Vicenzino B. Management of Lateral Elbow Tendinopathy: One
Size Does Not Fit All. J Orthop Sports Phys Ther 2015;45:93849.
2 Page P. Current concepts in muscle stretching for exercise and rehabilitation. Int J
Sports Phys Ther 2012;7:10919.
3 Svernlv B, Adolfsson L. Non-operative treatment regime including eccentric training
for lateral humeral epicondylalgia. Scand J Med Sci Sports 2001;11:32834.
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Stretching the evidence behind tennis elbow:

mobile app user guide
Luke J Heales, Michele Lastella, Brooke K Coombes and Bill Vicenzino

Br J Sports Med published online September 19, 2017

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http://bjsm.bmj.com/content/early/2017/09/19/bjsports-2017-098093

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