Manual Therapy 15 (2010) 6673

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Manual Therapy
journal homepage: www.elsevier.com/math

Original Article

Exercise-induced mechanical hypoalgesia in musculotendinous tissues

of the lateral elbow
Helen Slater a, *, Eric Theriault a, Bent Ove Ronningen a, Richard Clark a, Kazunori Nosaka b
a
b

School of Physiotherapy, Curtin University of Technology, GPO Box U1987, Perth 6845, Australia
School of Exercise, Biomedical and Health Sciences, Edith Cowan University, Joondalup, Australia

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 24 December 2008
Received in revised form
25 June 2009
Accepted 10 July 2009

The aim of this study was to investigate mechanical sensitivity responses at the lateral elbow to repeated
weekly bouts of low load exercise in healthy subjects. Thirteen young men (n 6) and women participated in 4 weeks of exercise. Arms were randomly allocated to an eccentric-only exercise protocol (ECC:
5 sets of 20 contractions) or to a concentriceccentric protocol (CON-ECC: 5 sets of 10 eccentric/10
concentric contractions) performed at 30% maximal wrist extension force. Arms were exercised
consecutively within each supervised weekly session. Quantitative measures of pressure pain threshold
(PPT) recorded at three sites and maximal force for grip and wrist extension were assessed at baseline,
and immediately pre/post exercise at each session. Muscle endurance during 100 maximal grip
contractions force was assessed at baseline and one week following the nal exercise session. Results
showed that regardless of protocol, repeated low load exercise resulted in a time-dependent increase in
PPT at all sites post exercise Weeks 3 and 4 and persisting at follow up Week 5 (P < 0.02). No signicant
difference between protocols was evident for any measure. Muscle force and endurance were not
signicantly augmented compared with baseline. In conclusion mechanical hypoalgesia is induced by
repeated low load exercises regardless of exercise mode, and this may prove benecial if replicated
clinically.
2009 Elsevier Ltd. All rights reserved.

Keywords:
Pressure pain threshold
Wrist extensors
Grip strength
Eccentric
Concentric

1. Introduction
Changes in mechanical sensitivity can occur in response to acute
resistance exercises in healthy subjects (Koltyn and Arbogast, 1998;
Kosek and Lundberg, 2003; Marqueste et al., 2004; Slater et al.,
2005; Staud et al., 2005). Acute exercise typically results in an
immediate exercise-induced hypoalgesia at sites local to the exercised muscles (OLeary et al., 2007) or at sites both local and remote
from the exercised muscles (Staud et al., 2005). Mechanical deep
tissue sensitivity changes following acute exercise probably involve
multiple interacting peripheral and central pain-modulatory
mechanisms (Koltyn and Arbogast, 1998; Kosek and Lundberg,
2003; Marqueste et al., 2004; Staud et al., 2005; Gibson et al., 2006).
Whether persistent changes in mechanical deep tissue sensitivity
occur in response to repeated bouts of exercise loading is unclear,
although mechanical tissue adaptations do occur with resultant net
collagen synthesis, decreased stress-susceptibility and improved
load-resistance of musculotendinous units (Kjaer et al., 2006). Both

* Corresponding author. Tel.: 61 89266 3099; fax: 61 89266 3699.

E-mail address: h.slater@curtin.edu.au (H. Slater).
1356-689X/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2009.07.002

the degree of load and frequency appear important factors with

greater susceptibility to tendinopathies with repeated microtrauma
(Wang, 2006) or if tendons are stress-shielded against functional
cyclical repeat loading (Arnoczky et al., 2007) or subject to repeated
high loads (Langberg et al., 1999).
Mechanical loading using exercise is clinically recommended for
musculoskeletal health and recovery from tendinopathies.
Currently both eccentric and concentric loading is advocated,
although systematic review concludes insufcient evidence in
favour of eccentric over concentric in lateral elbow rehabilitation
(Woodley et al., 2007). Eccentric loading has been recommended
specically in the rehabilitation of tendinopathies (Alfredson et al.,
1998; Ohberg et al., 2004; Knobloch et al., 2007) including lateral
elbow tendinopathy (Svernlov and Adolfsson, 2001) and combined
concentriceccentric exercise has also been described (MartinezSilvestrini et al., 2005), both protocols associated with reduced
levels of pain (Stasinopoulos and Stasinopoulos, 2004). One
potentially benecial effect of performing unaccustomed eccentric
exercise compared with concentric or isometric exercises, is
attenuation of induced muscle stiffness, soreness and force loss
when the same eccentric exercise is repeated (Clarkson et al., 1992).
This adaptive or protective effect conferred by a single bout of

H. Slater et al. / Manual Therapy 15 (2010) 6673

eccentric exercise is often referred to as the repeated bout effect

(Clarkson et al., 1992) and occurs even at low load (Lavender and
Nosaka, 2006). Whether the attenuated responses described above
are also associated with a persistent reduction in mechanical deep
tissue sensitivity is unknown, however such a protective effect
might be clinically important, as increasing mechanical load too
rapidly in musculotendinous conditions such as tendinopathies can
result in increased pain and reduced function.
Therefore, the aim of this study using healthy subjects was to
compare the effects on deep tissue sensitivity and muscle function
in the wrist extensors of two types of repeated low load eccentric
exercise. Given that both protocols involved an eccentric exercise
component, it was hypothesised that mechanical deep tissue
sensitivity and specic muscle function responses to repeated low
load exercise would be similar and that both repeated low load
exercise protocols would alter deep tissue sensitivity at the lateral
elbow but not muscle function.
2. Methods
2.1. Subjects
A within-group repeated-measures experimental design was
used with thirteen healthy subjects (six men, seven women) aged
1835 (mean  SD 27.1 1.4) years. The number of subjects was
determined by a difference of 15% for pressure pain thresholds
(PPT) and muscle function parameters for interventions with
means and standard deviations drawn from a previous study using
similar measures following eccentric exercise of wrist extensors
(Slater et al., 2005). For this within-group design, a sample size of
12 was required to achieve power of 0.80 with alpha at 0.05. Mean
(SD) height and weight were 169.6 (2.3) cm and 67.7 (3.3) kg,
respectively. Eleven subjects were right hand dominant. Exclusion
criteria included a history of upper limb fractures, surgery of the
upper limb, musculoskeletal disorders of the shoulder, wrist or
hands, any neurological or muscle disorders, use of any form of
medication at present or on an ongoing basis and prior training of
the forearm muscles. Participants were instructed to continue their
daily routine but avoid any form of upper extremity resistance
training. This study was approved by Curtin University of Technology Human Research Ethics Committee. Written informed
consent was gained from subjects prior to participation in the
study.
2.2. Study design
Both arms were exercised, with subjects arms randomly
assigned into the eccentric protocol (ECC) or the combined
concentric-eccentric (CON-ECC) exercise protocol. Subjects participated in six sessions over six weeks. Reliability of a gripping
fatigue test was established at Week 0 and 7 days later at Week 1
prior to commencement of the exercise bouts. At Week 1, immediately following the fatigue test, subjects commenced the rst of
four bouts of weekly low load ECC or CON-ECC exercise. At Week 5,
repeat testing of all Week 1 pre-fatigue measures was undertaken
(no ECC or CON-ECC exercise) (Fig. 1). Baseline was dened as
Week 1, pre-fatigue testing.
2.3. Exercise
Subjects performed two different exercise protocols, one on
each arm in a counterbalanced fashion. Subjects were required to
perform both ECC and CON-ECC exercise at the same session each
week and the parameters for each protocol are fully detailed in
Fig. 1 (legend). The exercise mode allocated to each arm remained

67

the same throughout testing, while the order of arms exercised was
alternated at each session. Based on pilot data, 30% maximal
voluntary contraction (MVC) isometric wrist extension, measured
at 20 wrist extension was chosen for the physiologic load. Low
load was predicted to avoid the tissue sensitizing effects associated
with induced muscle soreness following eccentric exercise (Slater
et al., 2005). Pilot data was consistent with no induced muscle
damage. Exercise was performed using a free weight with the
weight kept constant throughout the exercise period. For standardisation purposes, subjects were positioned in sitting with the
elbow exed (30 ) and the forearm pronated and stabilised on an
adjustable forearm rest.
2.4. Deep tissue sensitivity
Pressure pain thresholds (PPTs) have been established as a reliable measure of deep tissue sensitivity (Rolke et al., 2005) and have
been extensively documented in tennis elbow studies (Vicenzino
et al., 2001; Slater et al., 2003; Bisset et al., 2006). PPTs were
recorded using an electronic algometer (Somedic AB, Sweden) with
a stimulation area of 1.0 cm2 and application rate of 50 kPa/s until
the subject detected the pain threshold. PPT was dened as the
point at which the sensation of pressure changed to a sensation of
pain. The PPT was measured at three sites: the common extensor
origin at the lateral epicondyle (CEO), the musculo-tendinous
junction of extensor carpi radialis brevis (ECRB) muscle and the
radial head laterally which acted as a control site as previously
described (Slater et al., 2005). Three measures were taken at each
site, with a thirty seconds interval between measures. The mean of
the three trials was recorded as the PPT.
2.5. Pain and muscle soreness
Subjects maintained a self-report diary to record any muscle
soreness experienced in the exercised arms for 72 h following each
exercise session. Measures of at-rest and movement-related pain
were assessed using a visual analogue scale (VAS), consisting of
a 10 cm line marked at one end as no pain and at the other as
worst pain imaginable. For muscle soreness, subjects completed
a modied Likert scale of muscle soreness (Slater et al., 2003) for
the upper limb, with 0 dening no soreness and 6 indicating
a severe degree of muscle soreness.
2.6. Maximal grip force (MGF)
MGF was measured with an electronic digital dynamometer
(MIE Medical Research Ltd., Leeds, UK). Subjects were positioned in
supine with the arm supported in elbow extension and forearm
pronation. Subjects were asked to exert maximal isometric grip
force (kg), which was recorded as the mean of three trials with an
interval of 5 s between trials (Slater et al., 2005).
2.7. Maximal wrist extension force (MWEF)
MWEF was recorded via a force gauge (AFG, range 0500 N,
Mecmesin Ltd., England). The force gauge was mounted on
a specially designed platform, positioned on a table beside the
plinth. The height of the hand attachment and force transducer was
kept constant for each subject but could be varied to accommodate
various hand sizes. Subjects were positioned in supine with the arm
supported in elbow extension, forearm pronation and approximately 20 wrist extension. MWEF (kg) was recorded as the mean
of three repeated measures with a 5 s interval (Slater et al., 2003).

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H. Slater et al. / Manual Therapy 15 (2010) 6673

Fig. 1. The experimental design is shown. Subjects performed 4 bouts of exercise for the wrist extensors, one session per week for 4 weeks (7 days between sessions), and a fatigue
test (100 maximal gripping contractions) at Weeks 0 and 7 days later at Week 1 prior to the commencement of the exercise period and at Week 5, 7 days after completion of the
exercise bouts. For the eccentric protocol (ECC), subjects completed 5 sets of 20 repetitions with a 2 minutes rest between sets. Subjects were instructed to lower the weight in
a controlled fashion from 50 wrist extension to 70 wrist exion, at a speed of approximately 30 /s, as controlled by a metronome. Each cycle of eccentric contraction involved 4
seconds of contraction/4 seconds of passive recovery. During the passive recovery periods, an examiner supported the exercise bar and brought it back to the starting position. For
the combined concentric-eccentric protocol (CON-ECC), subjects lowered the wrist into 70 exion in 4 seconds using a controlled eccentric contraction followed by a concentric
action to generate wrist extension to 50 in 4 seconds at a speed of approximately 30 /s in both directions. A 4 second recovery was taken between each eccentric and concentric
repetition. The CON-ECC protocol involved 5 sets of 10 repetitions (10 eccentric and 10 concentric) with 2 minutes rest between sets. The number of repetitions differed between
protocols to ensure an equivalent number of movements were completed. Dot indicates the battery of quantitative test measures taken at each bout and consisting of pressure pain
threshold at three sites, maximal grip and wrist extensor force, and muscle soreness.

2.8. Muscle endurance

A fatigue test for the wrist extensors was modied from a study
in which knee extensor fatigue was investigated (Mouraux et al.,
2000). The modied fatigue test comprised 100 maximal isometric
gripping actions of 3 s duration (10 sets of 10 maximal grips with
a 30 s rest interval between sets) using the same equipment and
testing position as used in the assessment of MGF (kg). A metronome was used to time the procedure. To demonstrate the reliability of the fatigue test, all subjects performed the fatigue test at
Week 0 and 7 days later at Week 1 on both arms. Muscle fatigue
was calculated using the following fatigue index formula:
100  (last 5 repetitions/rst 5 repetitions)  100) (Mouraux et al.,
2000).

measures ANOVA was used, followed by Student NewmanKeuls

(SNK) post-hoc tests when signicant. To establish the acute effects
of low load exercise within each exercise bout at Weeks 24,
pairwise t-tests were conducted with the signicance level
adjusted to P-value < 0.025. For fatigue data, protocol (2 levels:
ECC; CON-ECC) by time (2 levels: rst fatigue test  last fatigue test)
repeated measures ANOVA was performed. Signicance was
accepted at P < 0.05.

3. Results
3.1. Baseline comparisons
There were no signicant baseline pre-fatigue Week 1 differences between arms in any of the quantitative measures (Table 2).

2.9. Statistical analysis

Data was analysed using SPSS 17.00 software package. To
establish reliability of test measures, subjects undertook repeat
measures of all variables for both arms at Week 0 (fatigue test only,
no ECC or CON-ECC exercise) and at Week 1 (Fig. 1). Measures of
PPT, MGF, MWEF and fatigue were found to have high reliability by
ICC3,k (Table 1). Baseline (dened as pre fatigue testing at Week 1)
values for all quantitative measures were compared between arms
by a paired t-test. Mean and standard error (SE) values are given in
the text, tables and gures.
A majority of measurements associated with PPT, VAS and
motor parameters data met the requirements of a normal distribution as determined by the ShapiroWilk normality test. For
analysis of chronic effects of repeated ECC and CON-ECC exercise on
PPTs, MGF and MWEF a protocol (2 levels: ECC; CON-ECC) by time
(Week 1 immediately pre-fatigue test, immediately post exercise at
Weeks 14 and immediately pre-fatigue at Week 5) repeated

Table 1
Intraclass Correlation Coefcients (ICC) and 95% condence intervals established by
repeating measurements at Week 0 and at Week 1 pre-exercise (baseline) for
pressure pain thresholds (PPT) at three sites (CEO Common extensor origin;
ECRB Extensor carpi radialis brevis; RH Radial head), maximal grip force (MGF),
maximal wrist extensor force (MWEF), and fatigue index. High levels of reliability
were demonstrated for all variables as indicated by the ICC values close to 1, variance
ratios (expressed by the F statistic) and signicant P-values.
Variables

PPT (kPa)
CEO
ECRB
RH
MGF (kg)
MWEF (kg)
Fatigue index

ICC (3, k)

0.84
0.73
0.81
0.93
0.96
0.75

95 % Condence Interval
Lower bound

Upper bound

0.63
0.40
0.58
0.85
0.92
0.35

0.93
0.88
0.92
0.97
0.98
0.92

Sig.

6.09
3.72
5.28
14.94
27.99
3.93

0.001
0.001
0.001
0.001
0.001
0.002

H. Slater et al. / Manual Therapy 15 (2010) 6673

Table 2
Baseline mean ( SE; n 13) values for pressure pain thresholds (PPT) at three sites
(CEO Common extensor origin; ECRB Extensor carpi radialis brevis; RH Radial
head), maximal grip force (MGF) and maximal wrist extensor force (MWEF) for the
eccentrically trained arm (ECC) and concentric-eccentric trained arm (CON-ECC).
The results of the comparison between ECC and CON-ECC arms demonstrate no
signicant baseline differences between arms as indicated by the non-signicant
P-values.
Variables

ECC

PPT-CEO (kPa)
PPT-ECRB (kPa)
PPT-RH (kPa)
MGF (kg)
MWEF (kg)
Fatigue index

563.9
558.9
559.7
28.2
12.6
30.6

(40.1)
(54.5)
(48.0)
(2.3)
(1.5)
(3.3)

CON-ECC

P-value

520.0
537.9
548.6
28.8
13.5
26.8

0.84
0.17
0.95
0.50
0.44
0.32

(46.7)
(47.9)
(56.3)
(2.5)
(1.9)
(4.5)

3.2. Deep tissue sensitivity (PPT)

In regard to the chronic temporal effects of exercise on deep
tissue sensitivity, no signicant difference in PPTs between protocols was demonstrated at CEO (F (5, 60) 0.74; P 0.60), at ECRB
(F (5, 60) 0.31; P 0.90) or at RH (F (5, 60) 0.94; P 0.46) from
Week 1 pre-fatigue to post exercise Weeks 14 and pre-fatigue
Week 5 (Fig. 2). For both protocols, PPT increased signicantly
across the four-week exercise period at CEO (F (5, 60) 7.30;
P < 0.001), at ECRB (F (5, 60) 8.75; P < 0.001) and at RH (F (5,
60) 3.61; P < 0.006). In comparison with pre-fatigue testing at
Week 1, PPTs were signicantly higher post exercise at ECRB Weeks
1 (SNK: P < 0.04), 3 and 4 and at pre-fatigue testing Week 5 exercise
(SNK: P < 0.001), at CEO Weeks 3 and 4 and at pre-fatigue testing
Week 5 (SNK: P < 0.02), at RH Week 2 to Week 4 inclusive and at
Week 5 pre-fatigue testing (SNK: P < 0.02).
Acute temporal effects of exercise on PPTs were similar regardless
of protocol. Compared with pre-exercise, PPTs were signicantly
higher post exercise for both protocols at ECRB Week 3 (t (25) 3.97,
P < 0.001) and at Week 4 for both ECRB (t (25) 2.85, P < 0.008) and

69

RH (t (25) 2.42, P < 0.02) (Fig. 3). No signicant acute changes in

PPT were found at CEO within each exercise bout at Weeks 2, 3 and 4
(P > 0.05) (Table 3 shows absolute mean PPT data at all times)
3.3. Muscle soreness and pain
No subjects reported muscle soreness, movement-related pain
or at-rest pain following any exercise session for either exercise
protocol at any time point (data not shown).
3.4. Maximal grip force and maximal wrist extension force
In regard to the chronic effects of exercise, an interaction
between protocols and time was demonstrated for MGF (F (5, 60)
2.65; P < 0.03) (Fig. 4), although there were no signicant main
effects (protocol: F (1, 12) 0.03; P < 0.87; time: F (5, 60) 1.11;
P < 0.37). For MWEF, no signicant chronic temporal effects were
demonstrated between protocols from pre-fatigue testing at week
1, across all post exercise times Weeks 14 to pre-fatigue at week 5
(F (5, 60) 0.1.184; P 0.328) and no signicant main effects were
demonstrated (protocol: F (1, 12) 0.12; P < 0.73; time: F (5, 60)
1.56; P < 0.19).
Acute temporal effects of exercise on force were similar
regardless of protocol: MGF decreased signicantly at Week 2 post
exercise compared with pre (t (25) 2.80, P < 0.01) (Fig. 5) but not at
Weeks 3 and 4 (t (25) 2.80, P < 0.34). Neither protocol demonstrated any signicant acute pre-post exercise changes in MWEF at
Weeks 2, 3 or 4 (t (25) 2.80, P < 0.55) (Table 3 shows mean absolute force data at all times).
3.5. Muscle endurance
Muscle fatigue was not signicantly different between protocols
at Week 5 compared with baseline at Week 1 (F (1, 12) 3.34;
P 0.09) (Fig. 6). Muscle fatigue was not reduced at Week 5

Fig. 2. Changes in mean (SE) pressure pain thresholds (PPT) at (a) the extensor carpi radialis brevis, (b) the common extensor origin and (c) the radial head for the eccentrically
exercised arm (ECC) and the concentricallyeccentrically exercised arm (CON-ECC) from Week 1 (before fatigue test: pre), Weeks 14 (after exercise: post), and Week 5 (before
fatigue test). *Signicantly (P < 0.05) higher PPT compared with baseline (pre-fatigue Week 1) PPT.

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H. Slater et al. / Manual Therapy 15 (2010) 6673

Fig. 3. Acute changes in mean (SE) pressure pain thresholds (PPT) from pre to post exercise at Weeks 2, 3 and 4 at (a) the extensor carpi radialis brevis, (b) the common extensor
origin and (c) the radial head for the eccentrically exercised arm (ECC) and the concentricallyeccentrically exercised arm (CON-ECC). *Signicantly (P < 0.05) higher PPT post
exercise compared with pre-exercise PPT.

Fig. 4. Changes in mean (SE) maximal grip force (a) and maximal wrist extension
force (b) for the eccentrically exercised arm (ECC) and the concentrically-eccentrically
exercised arm (CON-ECC) from Week 1 (before fatigue test: pre), Weeks 14 (after
exercise: post), and Week 5 (before fatigue test). # A signicant interaction (P < 0.032;
protocol  time) was demonstrated for MGF, however no main effects were evident.

Fig. 5. Acute changes in mean (SE) maximal grip force (a) and maximal wrist
extension force (b) from pre to post exercise at Weeks 2, 3 and 4 for the eccentrically
exercised arm (ECC) and the concentricallyeccentrically exercised arm (CON-ECC).
*Signicantly (P < 0.05) reduced maximal grip force compared with pre-exercise.

H. Slater et al. / Manual Therapy 15 (2010) 6673

compared with Week 1 for either protocol (F

P 0.15).

(1, 12) 2.331;

4. Discussion
This study was novel in investigating the effect of repeated
bouts of low load exercise on mechanical sensitivity at the lateral
elbow and associated muscle force and fatigue parameters and
comparing these responses between two exercise protocols.
Following the four weeks of exercise, both repeated low load
exercise protocols resulted in localised mechanical hypoalgesia at
all three lateral elbow sites and this effect persisted at one week
post exercise. Delayed onset muscle soreness was not induced for
either protocol and neither protocol augmented any force parameter. No selective benet for either exercise mode on mechanical
sensitivity or muscle function was demonstrated. These results
support the study hypothesis.
4.1. Deep tissue sensitivity response to repeated bout of low load
exercise
Repeated low load ECC and CON-ECC exercise resulted in a timedependent increase in PPT at all sites post exercise Weeks 3 and 4
and persisting at pre-fatigue testing Week 5. This increase in PPTs is
consistent with reduced mechanical sensitivity of deep tissues as
a response to repeated low load exercise. In regard to persistent
changes in deep tissue sensitivity, the temporal pattern post exercise was different across PPT sites with mechanical hypoalgesia
evident at ECRB initially Week 1 post exercise and at RH Week 2
post exercise but not until Week 3 at CEO. These data may reect
chronic mechanical adaptations to low load exercise that are
mediated via tissue-specic (osseotendinous and musculotendinous) mechanotransduction processes occurring at differential rates (Kjaer et al., 2006) and differentially mediated at
cellular, molecular and tissue levels (Wang, 2006). Additionally, as
both protocols involved eccentric exercise the chronic decrease in
deep tissue sensitivity implies a gradual adaptation of lateral elbow
tissues to repeated loading, consistent with the repeated bout
effect. This adaptive response can occur even with low load
eccentric exercise (Lavender and Nosaka, 2008) as performed in the
current study and is characterised by attenuated sensory-motor
responses to a subsequent bout of eccentric exercise (Clarkson
et al., 1992). The mechanisms underlying this protective effect are
thought to involve a number of complex interacting neural mechanisms and mechanical and molecular processes (McHugh, 2003).

71

It is unclear however if a persistent decrease in deep tissue

mechanical sensitivity parallels this attenuated response as to our
knowledge no studies have investigated this specic psychophysical response following repeated sessions of low load exercise.
Whether such persistent deep tissue sensitivity changes also occur
in response to single exercise modes (i.e. concentric, isometric)
requires further investigation.
As mechanical hypoalgesia did not occur immediately after
every single exercise bout, it is unlikely that acute activation of
endogenous pain-modulatory systems as described following
a single bout of exercise (Koltyn and Umeda, 2007) was a dominant mechanism underlying the cumulative exercise-induced
mechanical hypoalgesia. In contrast, the further acute decrease in
PPT post exercise and post fatigue testing at ECRB (Weeks 3 and
4) and at RH (Weeks 4), does suggest activation of endogenous
pain modulatory systems in addition to chronic tissue adaptations
outlined above. These PPT data are in accordance with the ndings of immediate exercise-induced mechanical hypoalgesia
demonstrated in healthy subjects following a single bout of
exercise (Koltyn et al., 2001; Staud et al., 2005) with load
parameters similar to those described in the current study. The
acute post exercise mechanical hypoalgesia elicited at Weeks 3
and 4 is unlikely to be explained by the exercise stimulus, as the
protocol parameters did not change across the four weeks.
Although speculative, it is plausible that following repeated low
load exercise, the potential to more effectively recruit segmental
inhibitory or plurisegmental pain modulatory mechanisms is
enhanced. In the current study, given the absence of induced
tissue damage (i.e., self report indicated no induced pain or
muscle soreness following any bout of exercise) the balance
between pro-nociceptive and anti-nociceptive mechanisms may
shift in favour of pain inhibition. The acute exercise-induced
mechanical hypoalgesia may also reect the different innervation
densities that exist between muscle and tendon (Mense and
Simons, 2001). In comparison with tendon (CEO), as exercising
muscles including ECRB and the extensor muscles overlying RH
activate Ab afferents (Mense and Simons, 2001), these muscles
may more efciently recruit endogenous pain modulatory
systems. This may explain the more pronounced increase in PPT
of ECRB and RH following exercise. It is also possible that in
response to ECC and CON-ECC low load exercise muscle, tendon
and bone adaptations including deep tissue mechanical sensitivity
may not occur at the same rates or to the same degree (Wang,
2006). Future studies will incorporate a more distant PPT site as
a control to implicate segmental or plurisegmental pain modulatory system activation. Additionally, the possibility that repeated
isometric contractions may also generate persistent deep tissue
sensitivity changes cannot be excluded. Further investigation is
required to establish any additional persistent effect on deep
tissue sensitivity of the two pre-exercise fatigue tests, as conducted in the current study.
4.2. Muscle strength response to repeated bouts of low load exercise

Fig. 6. Change (mean  SE) in fatigue index from Week 1 to Week 5 for the eccentrically exercised arm (ECC) and the concentrically-eccentrically exercised arm (CONECC).

Within each successive bout no muscle damage appeared to be

induced after either protocol, since no delayed onset muscle soreness or signicant decreases in force were evident following exercise. Where demonstrated, the modest decrease in force
immediately after exercise is most likely due to muscle fatigue
rather than damage. As the load was deliberately not increased at
each session, no signicant increase in grip and wrist extensor force
was predicted following the 4 week repeated low load exercise
period. Maximal grip force did vary between protocols, however
given there were no main effects combined with an inconsistent
temporal interaction pattern and the modest force difference (less

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H. Slater et al. / Manual Therapy 15 (2010) 6673

Table 3
Mean ( SD; N 13) values for all variables for the eccentrically trained arm (ECC) and concentriceccentric trained arm (CON-ECC) Weeks 15.
Week

Week 1

Variables

Pre fatigue

PPT-CEO (kPa)
ECC Con 563.9
CON-Ecc 520.0
PPT-ECRB (kPa)
ECC Con 558.9
CON-Ecc 537.9
PPT-RH (kPa)
ECC Con 559.7
CON-Ecc 548.6
MGF (kg)
ECC Con
28.2
CON-Ecc
28.8
MWEF (kg)
ECC Con
12.6
CON-Ecc
13.5

Week 2

Week 3

Week 4

Week 5

Post-exercise

Pre-exercise

Post-exercise

Pre-exercise

Post-exercise

Pre-exercise

Post-exercise

Pre-fatigue

Post exercise

(144.6)
(168.3)

561.4 (166.1)
559.3 (181.9)

552.7 (144.9)
577.7 (171.0)

574.8 (147.9)
546.6 (161.6)

616.5 (157.5)
584.6 (223.1)

657.0 (183.4)
589.2 (165.3)

652.6 (170.1)
612.7 (214.5)

641.9 (179.1)
658.8 (161.0)

674.5 (157.9)
651.6 (178.2)

706.8 (180.7)
719.1 (213.0)

(196.4)
(172.9)

634.0 (311.1)
586.0 (218.8)

609.6 (242.2)
559.1 (184.4)

623.6 (245.7)
559.6 (192.0)

598.8 (178.1)
576.0 (188.6)

704.4 (243.4)
672.8 (259.2)

653.0 (201.0)
656.9 (185.6)

715.4 (231.0)
717.3 (216.9)

667.9 (185.1)
670.6 (193.8)

758.2 (263.1)
702.4 (187.4)

(173.2)
(202.9)

641.2 (310.1)
603.4 (259.4)

608.1 (252.5)
624.6 (258.4)

662.8 (275.6)
663.3 (307.7)

660.8 (232.1)
619.8 (240.0)

691.3 (295.7)
674.2 (284.4)

649.5 (245.4)
670.4 (230.9)

675.3 (250.1)
720.1 (235.6)

692.8 (224.6)
666.0 (220.9)

760.7 (286.6)
735.4 (251.3)

(8.4)
(9.0)

28.9 (8.1)
27.6 (8.3)

30.3 (8.6)
31.1 (11.4)

27.8 (6.5)
28.9 (9.0)

30.7 (11.0)
30.3 (11.8)

29.8 (8.5)
28.1 (8.1)

29.9 (9.2)
30.0 (10.6)

29.7 (9.8)
29.0 (10.8)

30.0 (10.0)
30.9 (11.5)

25.5 (7.3)
24.2 (7.2)

(5.5)
(7.0)

12.6 (5.6)
11.9 (5.5)

13.5 (6.1)
13.9 (6.2)

13.7 (4.6)
13.1 (4.9)

13.6 (5.2)
13.5 (5.2)

13.2 (4.3)
12.8 (4.5)

13.1 (5.2)
13.1 (5.7)

12.7 (4.7)
12.1 (5.2)

13.7 (5.0)
13.6 (5.5)

13.3 (4.5)
13.7 (6.4)

PPT pressure pain thresholds; CEO Common extensor origin; ECRB Extensor carpi radialis brevis; RH Radial head; MGF maximal grip force; MWEF maximal wrist
extensor force.

than 2 kg), these data suggest a clinically insignicant nding. The

lack of increase in endurance following the exercise period was
most likely due to an insufcient exercise stimulus to induce
changes or might indicate resilience to fatigue of the wrist extensors (Finsen et al., 2005).
For the current protocols, 30% maximal isometric wrist extension was chosen for the exercise load as this exceeds many of the
demands of the wrist extensor muscle group during activities of
daily living (Finsen et al., 2005) and our pilot data indicated this
load did not provoke muscle soreness. The frequency of exercise at
weekly intervals was also chosen to avoid the potential tissue
sensitizing effects and force attenuation commonly associated with
provoked muscle damage following unaccustomed eccentric exercise (Cleak and Eston, 1992).
5. Conclusion
Repeated low load exercise incorporating an eccentric component is associated with mechanical hypoalgesia of lateral elbow
musculotendinous tissues. In healthy subjects, the current study
suggests no signicant difference between exercises consisting of
eccentric contractions only and of combined concentric and
eccentric contractions for exercising the wrist extensors to induce
mechanical hypoalgesia. Using low load exercise to generate
localised mechanical hypoalgesia may prove benecial if replicated
in patients with lateral elbow tendinopathy.
Acknowledgements
The authors would like to thank Mr. Glen Brabham for his
assistance with statistical analyses.
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