SCIENTIFIC/CLINICAL ARTICLE
JHT READ FOR CREDIT ARTICLE #209.
Effect of Lateral Epicondylosis on Grip Force
Development
Amrish O. Chourasia, PhD
Department of Biomedical Engineering, University of
Wisconsin, Madison, Wisconsin
Kevin A. Buhr, PhD
Department of Biostatistics and Medical Informatics,
University of Wisconsin, Madison, Wisconsin
David P. Rabago, MD
Department of Family Medicine, University of Wisconsin,
Madison, Wisconsin
Richard Kijowski, MD
Department of Radiology, University of Wisconsin,
Madison, Wisconsin
Curtis B. Irwin, PhD
Trace Research and Development Center, University of
Wisconsin, Madison, Wisconsin
Mary E. Sesto, PT, PhD
Department of Orthopedics and Rehabilitation, University
of Wisconsin, Madison, Wisconsin
Lateral epicondylosis (LE), a prevalent musculo-
skeletal disorder of the common extensor tendon, is
Funding sources: Drs. Sesto, Chourasia, and Buhr received support
from the University of Wisconsin Clinical and Translational Science
Award (NIH/NCRR 1 UL1RR025011). Dr. Irwin was a postdoctoral
fellow in the Department of Biomedical Engineering at the
University of Wisconsin when this study was conducted and was
partially supported by a T32 Womens Health and Aging
Research and Leadership Training Grant from the National
Institute on Aging (AG000265). Dr. Rabago was partially supported
by the American Academy Family Practice Foundations Research
Committee Joint Grant Awards Program (G0810).
Correspondence and reprint requests to Mary E. Sesto, PT, PhD,
Department of Orthopedics and Rehabilitation, University of
Wisconsin, 2104 Engineering Centers Building, 1550 Engineering
Drive, Madison, WI 53706; e-mail: <msesto@wisc.edu>.
0894-1130/$ - see front matter 2012 Hanley & Belfus, an imprint
of Elsevier Inc. All rights reserved.
doi:10.1016/j.jht.2011.09.003
ABSTRACT:
Study Design: Case-Control.
Introduction: Although it is well known that grip strength is ad-
versely affected by lateral epicondylosis (LE), the effect of LE on
rapid grip force generation is unclear.
Purpose of the Study: To evaluate the effect of LE on the ability
to rapidly generate grip force.
Methods: Twenty-eight participants with LE (13 unilateral and 15
bilateral LE) and 13 healthy controls participated in this study. A mul-
tiaxis profile dynamometer was used to evaluate grip strength and
rapid grip force generation. The ability to rapidly produce force is
composed of the electromechanical delay and rate of force develop-
ment. Electromechanical delay is defined as the time between the on-
set of electrical activity and the onset of muscle force production. The
Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire was
used to assess pain and functional disability. Magnetic resonance
imaging was used to evaluate tendon degeneration.
Results: LE-injured upper extremities had lower rate of force
development (50 lb/sec, confidence interval [CI]: 17, 84) and less
grip strength (7.8 lb, CI: 3.3, 12.4) than nonnjured extremities.
Participants in the LE group had a longer electromechanical delay
(
59% , CI: 29, 97) than controls. Peak rate of force development
had a higher correlation (r 0.56; p,0.05) with PRTEE function
than grip strength (r 0.47; p,0.05) and electromechanical delay
(r 0.30; p.0.05) for participants with LE. In addition to a reduc-
tion in grip strength, those with LE had a reduction in rate of force
development and an increase in electromechanical delay.
Conclusions: Collectively, these changes may contribute to an in-
crease in reaction time, which may affect risk for recurrent symptoms.
These findings suggest that therapists may need to address both
strength and rapid force development deficits in patients with LE.
Level of Evidence: 3B.
J HAND THER. 2012;25:2737.
associated with significant individual and societal
costs.1e5 LE is characterized by microtears, collagen
degeneration, and angioblastic proliferation of the
common extensor tendon (CET).6e8 LE may affect
the muscle fiber-type composition,9 neural drive,10
and stiffness of the muscle tendon complex.11,12 Pain
at the lateral aspect of the elbow is a primary symptom
of LE.13 This pain is often exacerbated by gripping ac-
tivities with grip strength often impaired,14,15
Although important, measures of strength and pain
may not provide information about other important
aspects of upper extremity function that may be
affected by LE, such as sensorimotor function. The
sensorimotor system includes the sensory, motor, and
central integration and processing components and is
important in maintaining postural control and func-
tional joint stability.16,17 Sensorimotor deficits have
been observed in musculoskeletal conditions including
JanuaryeMarch 2012 27
patellofemoral pain syndrome,18 low back pain,19
shoulder disorders,20 and neck pain.21 Specific to
LE, sensorimotor and motor performance deficits ob-
served include a longer reaction time16,22,23 and less
muscle tendon stiffness and damping.11,12 A decrease
in stiffness and damping during rapid loading is asso-
ciated with greater displacement of the upper
extremity, increased strain, and risk of injury.12 Such ev-
idence highlights a need to investigate other aspects of
upper extremity function that may be affected by LE.
Reaction time may be of particular importance in
preventing injury when reacting to rapid loading.24
Two components that may contribute to the observed
increase in reaction time in LE are rate of force develop-
ment and electromechanical delay. Rate of force devel-
opment is considered to be a measure of the ability to
rapidly generate strength25 and is an important compo-
nent for joint stability and postural control.26,27 Rate of
force development is important as ones ability to rap-
idly develop force not only influences the accelerations
of the body but also dictates how the body interacts
with objects. For example, a greater rate of force devel-
opment is associated with higher functional perfor-
mance in the upper extremity28 and the lower
extremity.29 Conversely, injury can result in reduced
rate of force development. Prior research found
33e54% lower rate of force development in women
with neck pain compared with those without.26 In ad-
dition, rate of force development had a stronger associ-
ation with self-reported pain than maximal strength.26
Electromechanical delay may also be affected by
injury.30 Electromechanical delay is defined as the
time between the beginning of electromyographic
(EMG) activity and the beginning of force develop-
ment. This represents the duration of the excitation
contraction coupling in the muscle and the time to
take-up the slack in the elastic structures of the muscle
tendon unit.31 Altered muscle spindle sensitivity30
and muscle preactivation levels32 may adversely af-
fect electromechanical delay. Hopkins et al.30 reported
longer peroneal electromechanical delay in patients
with functional ankle instability compared with con-
trols suggesting altered muscle spindle sensitivity
and muscle preactivation. Vint et al.32 reported lower
electromechanical delay when exertions are initiated
from nonresting levels. It is currently unknown
whether electromechanical delay is affected due to LE.
Although reductions in grip strength occur in
LE,14,15,33 it is unknown whether the ability to rapidly
generate force during a gripping activity is similarly
affected. Current rehabilitation interventions for LE
focus on improvement of strength and reduction in
pain. However, an increase in maximal strength is
not necessarily associated with an increase in rate of
force development and electromechanical delay.27
Hence, restoration of grip strength in patients with
LE may not be accompanied with an increase in sen-
sorimotor measures of performance such as rate of
28 JOURNAL OF HAND THERAPY
force development and electromechanical delay.
This may make patients with LE vulnerable to rein-
jury especially with tasks involving rapid loading
during occupational and recreational activities.
Although it is important to understand how LE
affects sensorimotor function, instrumentation to
quantify the components of rate of force development
and electromechanical delay is lacking. Grip dyna-
mometers14,15 measure a single, scalar value for grip
strength and therefore, are not capable of obtaining
rate of force development data. Therefore, a multiaxis
profile (MAP) dynamometer, which is capable of
measuring rate of force development and electrome-
chanical delay was used.34
Although reductions in reaction time and grip
strength occur due to LE,14,22,23,35 it is unknown
whether the ability to rapidly generate force is simi-
larly affected. In addition, most studies to date have ex-
cluded patients with bilateral LE.10,16,23,36,37 This may
limit generalizability of results because those with LE
present may present with bilateral symptoms.4
Clearly, there is a need to explore the effect of LE on
the rate of force development and electromechanical
delay in those with unilaterally and bilaterally affected
arms. Therefore, the purpose of this study was to
evaluate the effect of LE on the ability to rapidly
generate grip force. In addition, we accounted for the
effect of hand dominance, gender, and age on rapid
force generating capacity. The relationship between
function, grip strength, and rapid force generating
capacity was also assessed. A better understanding of
the impact of LE on grip function may lead to im-
proved therapeutic interventions for LE and possibly
reducing the risk of recurrence of LE by addressing
deficits in rapid force generating capacity.
METHODS
Study Design and Participants
This study was an add-on to a study designed to
assess mechanical parameters of stiffness and damp-
ing in participants with LE (LE) compared with
healthy, uninjured controls (eLE). The mechanical
parameter results are reported elsewhere.11 The
study was a caseecontrol study comparing sensori-
motor and motor performance of injured and unin-
jured upper extremities using data collected in
participants with LE (LE) compared with healthy,
uninjured controls (eLE).
A total of 31 individuals with LE were recruited from
various outpatient clinics in a Midwestern city from
June 2009 to February 2010. (Most of the LE partic-
ipants were participating in a therapeutic trial investi-
gating the efficacy of prolotherapy for LE; only baseline
measures (preinjection) are reported in this article.)
Two participants were excluded because they did not

FIGURE 1. Flow diagram showing the recruitment pro-
cess and the reasons for exclusion.
meet the eligibility criteria (see Figure 1). In addition,
data from one LE participant was not included due
to instrumentation failure. Of the 28 eligible partici-
pants, 13 had unilateral symptoms and 15 had bilateral
symptoms. A control group of 13 uninjured partici-
pants was recruited from the university campus.
Diagnostic criteria for LE included tenderness to
palpation over the lateral epicondyle and/or extensor
mechanism and pain present on at least two of the
following provocation tests: pain with resisted exten-
sion of the wrist or fingers, pain with resisted supina-
tion, pain with passive stretch to the wrist extensors or
supinator. All participants completed additional
screening; those with coexisting or previous medical
history of rheumatoid or inflammatory arthritis,
chronic pain diagnoses, diabetes mellitus, pregnancy,
systemic nervous disease, neuropathy, or acute trauma
to the fingers or hands were excluded. Additional
exclusion criteria include prior cervical or upper
TABLE 1. LE and
LE Participant Characteristics
Characteristic
Males/females (n)
Age (yr) (mean (standard deviation [SD]))
Symptom duration (yr) (median (minemax))
Hand dominance (n)
Unilateral/bilateral symptoms (n)
Unilateraldominant extremity symptomatic (n)
Unilateralnondominant extremity symptomatic (n)
Work status: full time (FT)/part time (PT)//not working (NW)
Rehabilitation (yes/no)
Cortisone injection (yes/no)
Visual Analog Scale (0e10) (mean (SD))
Patient-rated Tennis Elbow Evaluation (0e100) (mean (SD))
Magnetic Resonance Imaging (Grade 0e3)
extremity injury, concurrent cervical or upper extrem-
ity injury, unresolved litigation, and comorbidities that
could interfere with ability to participate in the study.
In addition, participants from the comparison group
were excluded if they reported any cervical or
upper extremity symptoms. Informed consent was
obtained for all participants in accordance with the
university human subjects institutional review board.
Participant characteristics are presented in Table 1.
Measures
Pain-free Grip Strength
Pain-free grip strength was evaluated bilaterally
using a novel dynamometer called the MAP dyna-
mometer34 and a hydraulic Baseline dynamometer
(Fabrication Enterprises, White Plains, NY). In addi-
tion to grip strength, the MAP is also able to assess
rate of force development. The MAP has been found
to demonstrate excellent testeretest reliability (intra-
class correlation coefficient [ICC] 0.99) and has ex-
cellent concurrent validity when compared with the
Baseline dynamometer (r 0.88e0.90).34 Pain-free
grip strength was used as it is a reliable measure
(ICC 0.97)15 of strength in patients with LE and is
considered a better measure to assess sensitivity to
change than maximal grip strength.33
All participants were seated in a chair with the
shoulder flexed at 90 degrees and the elbow in an
extended position. This posture has been recommen-
ded for evaluation of grip strength in individuals
with LE.14,38 On receipt of a randomly timed visual
stimulus, all participants were instructed to squeeze
the handle as quickly and as hard as possible without
pain for 5 seconds. Standardized verbal encourage-
ment and visual feedback of grip force, without nu-
merical values, was provided to the participant.
Practice sessions were provided to participants be-
fore data collection. The average of the peak force
LE
LE
17/11 5/8
48.2 (8.4) 44.6 (8.1)
2 (0.5e10)
Right 26; Left 2 Right 10; Left 3
13/15
11
2
FT 24; PT 4 FT 11; PT 1; NW 1
23/5
13/15
4.65 (2.3) 0.0 (0.0)
38.60 (18.50) 1.77 (2.54)
Grade 0 0;
Grade 1 8 Grade 0 11
Grade 2 10 Declined 2
Grade 3 9
Declined 1
JanuaryeMarch 2012 29
from three replications, performed with 60-second
rest intervals was used. The signals from the MAP
dynamometer were sampled at the rate of 1,000
samples/sec using a USB 6009 card (National
Instruments, Austin, TX).
The geometry of the handles is different for the
MAP and Baseline, resulting in different grip strength
values.34 Thus, to compare results with previous stud-
ies, pain-free grip strength was also measured with
the Baseline hydraulic dynamometer using the same
posture and procedure as that used with the MAP.
Rate of Force Development
Rate of force development was measured bilaterally
using the MAP dynamometer output obtained during
the grip strength exertion. Rate of force development
was calculated by taking the time derivative of the
force signal, which was sampled at 1,000 samples/sec.
The time resolution used for calculation of the rate of
force development was 1 millisecond. Peak rate of
force development is the maximal value of the time
derivative of the force signal and submaximal mea-
sures of rate of force development were measured at
30, 50, and 100 milliseconds from onset. Rate of force
development is affected by muscle fiber type and
myosin heavy chain composition, viscoelastic proper-
ties of the muscle tendon complex, and neural drive to
the muscle.39 It is theorized that rate of force develop-
ment at different time intervals is affected differently
as a result of these factors; hence rate of force develop-
ment was evaluated at 30, 50, and 100 milliseconds
from onset of contraction and peak rate of force devel-
opment. This protocol for assessing rate of force devel-
opment is similar to the one used by Aagaard et al.25
and Andersen and Aagaard.39 Practice sessions were
provided to participants before data collection.
Average of three replications performed with 60-
second rest intervals was used.
Electromechanical Delay
Electromechanical delay was also measured dur-
ing the grip strength exertion. It was measured
bilaterally by simultaneously sampling the MAP
dynamometer output and the raw EMG signal from
the extensor carpi radialis (ECR) muscle using a 16-
channel wireless Noraxon Telemyo 2400 system
(Noraxon Inc., Scottsdale, AZ). The time between
the onset of EMG and the onset of force is defined as
the electromechanical delay (see Figure 2). Therefore,
the onset of electromechanical delay occurs when
electrical activity is measured in the ECR via EMG.
The ending point for electromechanical delay is the
start of actual force production, which was measured
via the MAP dynamometer.
The ECR is composed of the ECR longus and the
ECR brevis muscles. Surface electrodes were placed
30 JOURNAL OF HAND THERAPY
FIGURE 2. Measurement of electromechanical delay
(EMD) and rate of force development (RFD) from electro-
myographic (EMG) and force signals.
on the ECR at one-third of the distance from the
proximal end of a line from the medial epicondyle to
the distal head of the radius, with the forearm
supinated as recommended by Mogk and Keir.40
This method is similar to the one used by
Alizadehkhaiyat et al.36 and Snijders et al.41 to assess
muscle activity of the ECR in patients with LE. The
reference electrode was attached to lateral epicondyle
of the right elbow. Before electrode placement, skin
preparation was performed according to SENIAM
guidelines.42 Disposable, self-adhesive Ag/AgCl
snap dual electrodes with individual electrode diam-
eter of 1 cm and inter electrode distance of 2 cm man-
ufactured by Noraxon were used. Preamplified EMG
leads with a differential gain of 500 connected elec-
trodes to the wireless transmitter with 16-bit analog
to digital converter and bandwidth 10e500 Hz. The
EMG amplifier characteristics were gain 1,000, in-
put impedance .. 100 MOhm and the common
mode rejection ratio was .100 dB. The EMG and
force signals were sampled at the rate of 1,500 sam-
ples/sec. Average of three replications was used.
Magnetic Resonance Imaging
Magnetic resonance (MR) scans were performed
on the 11 participants in the
LE group and 27
participants in the LE group. Two participants in
the
LE group and one participant in the LE
group had declined the MR scan. Magnetic reso-
nance imaging (MRI) examination was performed
using an Artoscan 0.17T extremity scanner
(GE Healthcare, Waukesha, WI). Axial and coronal
T1-weighted and fluid sensitive short tau inversion
recovery (STIR) sequences of the elbow were used
for semiquantitative assessment of disease severity.
T1-weighted scan parameters were TR 2,050
milliseconds, TE 18 milliseconds, Slices 7,
Gap 1.0 mm, Thickness 3.5 mm, Readout
FOV 180, Encoding FOV 180, Samples 192,
Encoding # 192. STIR scan parameters were
TR 2,050 milliseconds, TE 34 milliseconds,
TI 75 milliseconds, Slices 7, Gap 1.0 mm,
Thickness 3.5 mm, Readout FOV 180, Encoding
FOV 180, Samples 192, Encoding # 192. A mus-
culoskeletal radiologist who was blinded to group sta-
tus reviewed MRI examinations. A semiquantitative
grading scale was used to estimate the severity of
chronic degeneration and pathologic changes in the
common extensor tendon origin.43 The grading scale
is as follows:
 Grade 0 normal CET, which is of uniform low
signal intensity on T1-weighted and STIR images.
 Grade 1 CET with mild tendinopathy, which is
thickened and has intermediate signal intensity
on T1-weighted and STIR images.
 Grade 2 CET with moderate tendinopathy, which
is thinned and shows focal areas of intense fluid-
like signal intensity on STIR images, which com-
pose of less than 50% of the total cross-sectional
diameter of the tendon.
 Grade 3 CET with severe tendinopathy, which is
thinned and shows focal areas of intense fluid-like
signal intensity on STIR images, which compose of
more than 50% of the total cross-sectional diameter
of the tendon.
Visual Analog Scale
All participants were asked to rate the average pain
intensity in each of the elbows for the previous week
using a Visual Analog Scale (VAS) ranging from
0 no pain to 10 most pain. Note that for the
purposes of ascertaining whether a participant was
unilaterally or bilaterally injured, the upper extrem-
ity was considered injured if the VAS score was
greater than 0.
Patient-rated Tennis Elbow Evaluation
Participants also completed the Patient-rated
Tennis Elbow Evaluation (PRTEE) questionnaire.
The PRTEE measures both elbow pain and func-
tion44e46 and has demonstrated good testeretest reli-
ability in LE (ICC 0.89).45
Study Sample Size
The original study was powered to detect a differ-
ence between LE and
LE participants in upper
extremity mechanical parameters.11 Based on pilot
data collected on healthy individuals and participants
with injuries comparable to LE, simulated power cal-
culations showed that a mixed-effects analysis of
n 50 participants, would have 90% power at
alpha 0.05 to detect an injury effect of a 10% change
in stiffness, the mechanical parameter of primary
interest. Ultimately, n 42 eligible participants were
recruited, 29 LE participants and 13
LE controls.
Statistical Analysis
The effect of injury and extremity dominance on
grip strength, rate of force development, and electro-
mechanical delay was evaluated using a linear mixed-
effects model. The mixed-effects model permits
simultaneous fitting of data for LE participants with
bilateral and unilateral injury and LE uninjured con-
trols to simultaneously estimate the independent effects
of extremity dominance and injury. Age and gender
effects were accounted for by the model. The a level was
set at 0.05. Based on examination of the response
variability and model diagnostics, a log transformation
was used for the electromechanical delay response.
The relationship between the rate of force devel-
opment, electromechanical delay, grip strength and
PRTEE function, and VAS score was investigated for
LE participants using Pearson correlation coeffi-
cients. Correlations were calculated using the more
injured extremity in each LE participant, as evalu-
ated by VAS score, or using the dominant extremity
where extremity VAS scores were equal. Data anal-
ysis was conducted using the R language and envi-
ronment for statistical computing (R Foundation for
Statistical Computing, Vienna, Austria).
RESULTS
Summary data for sensorimotor and motor perfor-
mance are presented in Table 2.
Pain-free Grip Strength
As expected, injured extremities had lower grip
strength compared with noninjured extremities.
Overall, a significant effect of injury was observed for
peak grip strength regardless of dynamometer used.
Using the MAP dynamometer, the injured extremity
had, on average 7.8 lb less grip strength (p , 0.001, 95%
confidence interval [CI]: 3.3, 12.4) than the noninjured
extremity. A significant effect of extremity dominance
was also observed with the dominant extremity hav-
ing, on average, 2.6 lb more grip strength than the non-
dominant extremity (p 0.046, 95% CI: 0.2, 4.9).
Figures 3 and 4 show observed Baseline and MAP
grip strengths. Handle differences result in an overall
38% difference in grip strength between the MAP
and Baseline dynamometers.
Rate of Force Development
Observed peak rate of force development values
are shown in Figure 5.
Peak Rate of Force Development
Significant effect of injury was observed on peak
rate of force development. The injured extremity had,
JanuaryeMarch 2012 31
 TABLE 2. Mean (SD) Values for Sensorimotor and Motor Performance Variables
Unilateral LE in Dominant
Controls (n 13) Limb (n 11) Bilateral LE (n 15)
Dominant Nondominant Dominant Nondominant Dominant Nondominant
Measure Limb Limb Limb Limb Limb Limb
Limb status Noninjured Noninjured Injured Noninjured Injured Injured
Grip strength (MAP) (lb) 48 (11) 45 (12) 30 (12) 38 (13) 37 (14) 33 (15)
Grip strength (baseline) (lb) 98 (27) 94 (28) 49 (25) 86 (19) 67 (32) 53 (40)
Rate of force development at 136 (85) 125 (66) 85 (62) 113 (80) 110 (37) 100 (60)
30 msec (lb/sec)
Rate of force development at 163 (97) 147 (73) 103 (78) 140 (98) 132 (41) 120 (69)
50 msec (lb/sec)
Rate of force development at 181 (85) 160 (67) 116 (80) 157 (96) 150 (46) 137 (72)
100 msec (lb/sec)
Peak rate of force 256 (107) 233 (74) 177 (98) 228 (122) 205 (62) 191 (85)
development (lb/sec)
EMD (sec) 0.039 (0.008) 0.039 (0.014) 0.061 (0.029) 0.064 (0.024) 0.061 (0.02) 0.065 (0.033)
SD standard deviation; LE lateral epicondylosis; MAP multiaxis profile; EMD electromechanical delay.
Participants with nondominant extremity injury (n 2) are not included in the table.

on average 50 lb/sec less peak rate of force develop- Electromechanical Delay

ment (p 0.007, 95% CI: 17, 84) than the noninjured
extremity. No significant effect of extremity domi-
nance was observed (p 0.37).
Submaximal Rate of Force Development
Significant effect of injury was observed on
submaximal rate of force development at 30, 50,
and 100 milliseconds from onset. The injured
extremity had, on average 29, 36, and 38 lb/sec
less rate of force development at 30, 50, and 100
milliseconds, respectively (all p , 0.03). No signifi-
cant effect of extremity dominance was observed
(all p . 0.3).
A significant effect of injury was observed on
electromechanical delay (p 0.007). However, model
diagnostics indicated that the effect of injury on elec-
tromechanical delay was best explained by a group
effect (LE/
LE) rather than an injured extremity ef-
fect. That is, LE participants had, on average, a 59%
longer electromechanical delay (p , 0.001, 95% CI:
29, 97) than
LE participants in both extremities,
with no evidence that injured extremities had longer
electromechanical delay than uninjured extremities
in participants with unilateral injury (p 0.14). No
significant effect of extremity dominance was ob-
served (p 0.74). Observed electromechanical delay
values are shown in Figure 6.

FIGURE 3. Mean (standard deviation) of multiaxis profile
(MAP) grip strength. Bar graph pairs compare distribu-
tions of grip strength as assessed in the N nondominant
and D dominant extremity for uninjured controls
(n 13), patients with unilateral injury to dominant
extremity (n 11), and patients with bilateral injury
(n 15). The participants with nondominant extremity
injury (n 2) are not included in these plots.
FIGURE 4. Mean (standard deviation) of Baseline grip
strength. Bar graph pairs compare distributions of grip
strength as assessed in the N nondominant and
D dominant extremity for uninjured controls (n 13),
patients with unilateral injury to dominant extremity
(n 11), and patients with bilateral injury (n 15). The
participants with nondominant extremity injury (n 2)
are not included in these plots.

32 JOURNAL OF HAND THERAPY

 function variables for LE participants are presented
in Table 3. The participants most injured extremity as
assessed by VAS score (or dominant extremity in case
of a tie) was used. Significant correlations were ob-
served between grip strength, rate of force develop-
ment, and PRTEE function with peak rate of force
development having the highest correlation with
PRTEE function (r
0.56 for peak rate of force de-
velopment vs. r
0.47 for MAP grip strength).
The correlations between grip strength, rate of force
development, and self-report pain were significant
for the PRTEE pain scale but not for the VAS.
Electromechanical delay did not have significant cor-
FIGURE 5. Mean (standard deviation) of peak rate of force relation with PRTEE function and VAS.
development. Bar graph pairs compare distributions of
peak rate of force development as assessed in the N
nondominant and D dominant extremity for uninjured DISCUSSION
controls (n 13), patients with unilateral injury to dom-
inant extremity (n 11), and patients with bilateral in- The main finding of this study was that the LE
jury (n 15). The participants with nondominant extremities had a reduction in rate of force develop-
extremity injury (n 2) are not included in these plots.
ment compared with
LE extremities, while electro-
Magnetic Resonance Imaging mechanical delay was bilaterally lower in LE
participants compared with
LE participants, re-
Participants in the
LE group did not show gardless of unilateral or bilateral LE. The combined
increased signal intensity in the common extensor deficits in rate of force development and electrome-
tendon and therefore were assigned a score of 0. chanical delay result in a decrease in ability to rapidly
Participants in LE group had increased signal generate grip force. This change may explain the
intensity in the common extensor tendon region. longer reaction times observed in patients with
Eight LE participants were assigned a score of 1, LE.16,22 Another interesting finding was the stronger
10 were assigned a score of 2 and nine were assigned correlation of rate of force development than pain-
a score of 3. free grip strength with self-report function in patients
with LE.
Grip Strength, Rate of Force Development, Effect of LE injury on the ability to rapidly generate
and Electromechanical Delay, and VAS and force is similar to decreases observed in other mus-
PRTEE Correlations culoskeletal conditions such as neck pain26 and
Correlations between the sensorimotor and motor
performance variables, and self-report pain and TABLE 3. Pearson Correlation Coefficients for Sensori-
motor and Motor Performance Variables and Self-Report
Pain and Function for More Injured Extremity in LE
Participants
PRTEE PRTEE PRTEE
Function Pain Total VAS
Baseline grip strength (lb)
0.43*
0.42*
0.44*
0.18
MAP grip strength (lb)
0.47*
0.46*
0.37*
0.2
Rate of force
0.49*
0.40*
0.32
0.26
development at
30 msec (lb/sec)
Rate of force
0.51*
0.42*
0.34
0.27
development at
50 msec (lb/sec)
Rate of force
0.54*
0.44*
0.36
0.26
development at
100 msec (lb/sec)
FIGURE 6. Mean (standard deviation) of electromechan- Peak rate of force
0.56*
0.46*
0.37*
0.31
ical delay. Bar graph pairs compare distributions of electro- development (lb/sec)
mechanical delay as assessed in the N nondominant and EMD (sec) 0.30 0.17 0.19 0.15
D dominant extremity for uninjured controls (n 13),
patients with unilateral injury to dominant extremity LE lateral epicondylosis; MAP multiaxis profile; PRTEE
(n 11), and patients with bilateral injury (n 15). The Patient-Rated Tennis Elbow Evaluation; EMD electromechanical
participants with nondominant extremity injury (n 2) delay; VAS Visual Analog Scale.
are not included in these plots. *p , 0.05.

JanuaryeMarch 2012 33
functional ankle instability.30 For example, Andersen
et al.26 reported a 33e55% lower rate of force devel-
opment in females with neck pain compared with
those without. In the present study, LE extremities
had on average 23% lower peak rate of force develop-
ment compared with
LE extremities. Hopkins
et al.30 reported that patients with chronic functional
ankle instability had on average 42% longer electro-
mechanical delay than matched controls. In the
present study, we found that LE participants had
on average 59% longer electromechanical delay
than
LE participants.
Interestingly, the effect of injury on electromechan-
ical delay was observed bilaterally for LE partici-
pants, including those with unilateral injury.
Although electromechanical delay was affected bi-
laterally, grip strength and rate of force development
were not similarly affected. It is possible that these
differences represent a baseline difference in those
with LE versus those without. Similarly, Bisset et al.16
observed bilateral deficits in reaction time in unilater-
ally injured participants and speculated that pain
may cause cortical reorganization causing the im-
paired motor task on the injured side to be mapped
on the noninjured side. It is plausible that patients
with LE may have bilaterally altered motor neuron
activity affecting muscle preactivation, which results
in longer electromechanical delay. Further research is
needed to verify this hypothesis.
Pain or the fear of pain may prevent participants
with LE from exerting their true maximal pain-free
effort during a gripping activity. We did inquire
whether participants experience pain during testing
and pain was not reported. It is possible that the
decrease in ability to rapidly generate force and grip
strength may be a protective adaptation, but we are
not able to elucidate this with the present study.
As expected, LE extremities had less grip strength
than
LE extremities, with both the Baseline and
MAP dynamometer. The grip strength measurements
were performed with the elbow extended as recom-
mended by Dorf et al.14 as grip strength is lower in el-
bow extension than flexion for patients with LE.14,38
MAP dynamometer grip strength magnitude was,
on average, 38% lower than the Baseline grip strength
measurement. These results are consistent with those
reported previously by Irwin and Sesto.34 The differ-
ence in grip strength is attributed to the difference in
the geometry of the handles of the dynamometers.
The fingers are able to wrap around the handles of
the Baseline dynamometer in a flexed position,
whereas the metacarpophalangeal joints remain in a
neutral position when grasping the MAP. This latter
position is considered less biomechanically advanta-
geous thereby causing a reduction in the MAP grip
strength.
These findings are important in the context of
rehabilitation for patients with LE. Clinicians
34 JOURNAL OF HAND THERAPY
frequently recommend an active rehabilitation pro-
gram either alone or in conjunction with other treat-
ments for LE.47 However, based on different exercises
used as part of the rehabilitation treatment, different
adaptations in motor performance may be observed.48
For example, Bisset et al.16 reported reduced sensori-
motor deficits despite improvements in grip strength
after physical therapy treatment aimed at resolution
of symptoms and improvement in grip strength and
endurance.
Collectively both electromechanical delay and rate
of force development are similarly affected by train-
ing. In general, the ability to rapidly produce force is
most affected by exercises that incorporate a velocity-
dependent component and not solely resistive
strengthening. It has been reported that after sensori-
motor training involving balancing exercises on un-
stable bases an increase in the lower extremities ability
to rapidly generate force is observed, whereas no
increase in the maximal strength is observed.27,48
Conversely, after resistance training, strength im-
proved considerably, while minor increase in the
rate of force development was observed.49 This sug-
gests different adaptations for rate of force develop-
ment and strength based on type of training. Grosset
et al.50 found that for the lower extremity, ten weeks
of plyometric training caused an increase in electro-
mechanical delay, whereas endurance training lead
to shorter electromechanical delay. Rehabilitation in-
terventions that address the recovery of both, rapid
generation of force and maximal strength, may be
more likely to benefit patients than those that focus
solely on maximal strength. This may be particularly
important to individuals who are returning to activi-
ties that involve rapid and forceful loading. Further
research is needed to verify this hypothesis.
LIMITATIONS
The participants in this study were participating in
a therapeutic trial and one of the inclusion criteria for
this trial was that the participants have refractory LE.
As a result, this study involved a small sample of
participants with chronic LE. It is plausible that the
reductions in sensorimotor and motor performance
observed may be amplified in this sample because of
the chronic nature of the condition. Therefore, the
results of this study may not be generalizable to
patients with LE of lesser duration. Further studies
involving a larger number of participants with varied
duration of symptoms may help elucidate the effect of
LE on rate of force development and electromechan-
ical delay in a more general LE patient population.
Only the radiologist was blinded to the status (case
vs. control); the other assessors were not blinded and
it was possible that they could affect the performance
of the participants during various measurements. To
minimize assessor bias during measurement, a stan-
dard operating procedure was developed and used.
To investigate assessor bias for measurement of
sensorimotor variables, two assessors calculated the
variables from collected data and their ICC was
found to be 0.99.
CONCLUSIONS
In addition to lower grip strength, LE extremities
have a lower rate of force development than non-
affected (
LE) extremities while electromechanical
delay is bilaterally reduced in participants with LE
compared with controls. Collectively these changes
may contribute toward increased reaction time in
those with LE. These findings suggest that therapists
may need to address both strength and ability to
rapidly generate force in patients with LE. In patients
with LE, it is plausible that improvements in rapid
force generation may be associated with greater im-
provement in function than maximal strength but
further research is required to address this hypothesis.
REFERENCES
1. Silverstein B, Viikari-Juntura E, Kalat J. Use of a prevention in-
dex to identify industries at high risk for work-related muscu-
loskeletal disorders of the neck, back, and upper extremity in
Washington State, 1990-1998. Am J Ind Med. 2002;41(3):14969.
2. Silverstein B, Welp E, Nelson N, Kalat J. Claims incidence of
work-related disorders of the upper extremities: Washington
state, 1987 through 1995. Am J Public Health. 1998;88:182733.
3. Fan ZJ, Silverstein BA, Bao S, et al. Quantitative exposure-
response relations between physical workload and prevalence
of lateral epicondylitis in a working population. Am J Ind Med.
2009;52(6):47990.
4. Shiri R, Varonen H, Heli ovaara M, Viikari-Juntura E. Hand
dominance in upper extremity musculoskeletal disorders.
J Rheumatol. 2007;34:107682.
5. Shiri R, Viikari-Juntura E, Varonen H, Heli ovaara M. Preva-
lence and determinants of lateral and medial epicondylitis: a
population study. Am J Epidemiol. 2006;164(11):106574.
6. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treat-
ment of lateral epicondylitis. Am Fam Physician. 2007;76:
8438.
7. Kraushaar B, Nirschl R. Tendinosis of the elbow (tennis elbow).
Clinical features and findings of histological, immunohisto-
chemical, and electron microscopy studies. J Bone Joint Surg
Am. 1999;81:25978.
8. Nirschl R, Pettrone F. Tennis elbow. The surgical treatment of
lateral epicondylitis. J Bone Joint Surg Am. 1979;61:8329.
9. Ljung BO, Lieber RL, Friden J. Wrist extensor muscle pathol-
ogy in lateral epicondylitis. J Hand Surg Br. 1999;24B(2):17783.
10. Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan K,
Frostick SP. Assessment of functional recovery in tennis elbow.
J Electromyogr Kinesiol. 2009;19:6318.
11. Chourasia AO, Buhr KA, Rabago DP, Kijowski R, Sesto ME.
The effect of lateral epicondylosis on upper limb mechanical
parameters. Clin Biomech. [Epub ahead of press September
19, 2011].
12. Sesto ME, Radwin RG, Block WF, Best TM. Upper limb dy-
namic responses to impulsive forces for selected assembly
workers. J Occup Environ Hyg. 2006;3(2):729.
13. Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondy-
litis: where is the evidence? Joint Bone Spine. 2004;71(5):
36973.
14. Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME.
Effect of elbow position on grip strength in the evaluation of
lateral epicondylitis. J Hand Surg Am. 2007;32:8826.
15. Smidt N, van der Windt DA, Assendelft WJ, et al. Interob-
server reproducibility of the assessment of severity of com-
plaints, grip strength, and pressure pain threshold in
patients with lateral epicondylitis. Arch Phys Med Rehabil.
2002;83:114550.
16. Bisset LM, Coppieters MW, Vicenzino B. Sensorimotor deficits
remain despite resolution of symptoms using conservative
treatment in patients with tennis elbow: a randomized con-
trolled trial. Arch Phys Med Rehabil. 2009;90(1):18.
17. Riemann BL, Myers JB, Lephart SM. Sensorimotor system mea-
surement techniques. J Athl Train. 2002;37(1):8598.
18. Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell
J. Delayed onset of electromyographic activity of vastus medi-
alis obliquus relative to vastus lateralis in subjects with patel-
lofemoral pain syndrome. Arch Phys Med Rehabil. 2001;
82(2):1839.
19. Hodges PW, Moseley GL. Pain and motor control of the lumbo-
pelvic region: effect and possible mechanisms. J Electromyogr
Kinesiol. 2003;13(4):36170.
20. Myers JB, Wassinger CA, Lephart SM. Sensorimotor contribu-
tion to shoulder stability: effect of injury and rehabilitation.
Man Ther. 2006;11(3):197201.
21. Sjolander P, Michaelson P, Jaric S, Djupsjobacka M. Sensorimo-
tor disturbances in chronic neck painrange of motion, peak
velocity, smoothness of movement, and repositioning acuity.
Man Ther. 2008;13(2):12231.
22. Bisset LM, Russell T, Bradley S, Ha B, Vicenzino BT. Bilateral
sensorimotor abnormalities in unilateral lateral epicondylal-
gia. Arch Phys Med Rehabil. 2006;87:4905.
23. Pienimaki TT, Kauranen K, Vanharanta H. Bilaterally de-
creased motor performance of arms in patients with chronic
tennis elbow. Arch Phys Med Rehabil. 1997;78:10925.
24. Linford CW, Hopkins JT, Schulthies SS, Freland B, Draper DO,
Hunter I. Effects of neuromuscular training on the reaction
time and electromechanical delay of the peroneus longus mus-
cle. Arch Phys Med Rehabil. 2006;87:395401.
25. Aagaard P, Simonsen EB, Andersen JL, Magnusson P, Dyhre-
Poulsen P. Dz. Increased rate of force development and neural
drive of human skeletal muscle following resistance training.
J Appl Physiol. 2002;93:131826.
26. Andersen LL, Holtermann A, Jorgensen MB, Sjogaard G. Rapid
muscle activation and force capacity in conditions of chronic
musculoskeletal pain. Clin Biomech. 2008;23:123742.
27. Gruber M, Gollhofer A. Impact of sensorimotor training on the
rate of force development and neural activation. Eur J Appl
Physiol. 2004;92(1e2):98105.
28. Shemmell J, Forner M, Tresilian JR, Riek S, Barry BK, Carson
RG. Neuromuscular adaptation during skill acquisition on a
two degree-of-freedom target-acquisition task: isometric tor-
que production. J Neurophysiol. 2005;94:304657.
29. Foldvari M, Clark M, Laviolette LC, et al. Association of mus-
cle power with functional status in community-dwelling el-
derly women. J Gerontol A Biol Sci Med Sci. 2000;55(4):
M1929.
30. Hopkins JT, Brown TN, Christensen L, Palmieri-Smith RM.
Deficits in peroneal latency and electromechanical delay in pa-
tients with functional ankle instability. J Orthop Res. 2009;27:
15416.
31. Laroche DP, Knight CA, Dickie JL, Lussier M, Roy SJ. Explosive
force and fractionated reaction time in elderly low- and high-
active women. Med Sci Sports Exerc. 2007;39:165965.
32. Vint PF, McLean SP, Harron GM. Electromechanical delay in
isometric actions initiated from nonresting levels. Med Sci
Sports Exerc. 2001;33:97883.
33. Stratford P, Levy DR, Gauldie S, Levy K, Misefer DI. Extensor
carpi radialis tendonitis: a validation of selected outcome mea-
sures. Physiother Can. 1987;39(4):2505.
34. Irwin CB, Sesto ME. Reliability and validity of the multiaxis
profile dynamometer with younger and older participants.
J Hand Ther. 2010;23(3):2818.
JanuaryeMarch 2012 35
35. Smidt N, van der Windt D, Assendelft WJJ, Deville W, Korthals-
de Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy,
or a wait-and-see policy for lateral epicondylitis: a randomised
controlled trial. Lancet. 2002;359(9307):65762.
36. Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan K,
Frostick SP. Upper limb muscle imbalance in tennis elbow: a
functional and electromyographic assessment. J Orthop Res.
2007;25:16517.
37. Pienimaki T, Tarvainen T, Siira P, Malmivaara A, Vanharanta
H. Associations between pain, grip strength, and manual tests
in the treatment evaluation of chronic tennis elbow. Clin J Pain.
2002;18(3):16470.
38. De Smet L, Fabry G. Grip strength in patients with tennis
elbow: influence of elbow position. Acta Orthop Belg. 1996;
62:269.
39. Andersen L, Aagaard P. Influence of maximal muscle strength
and intrinsic muscle contractile properties on contractile rate of
force development. Eur J Appl Physiol. 2006;96(1):4652.
40. Mogk JPM, Keir PJ. The effects of posture on forearm muscle
loading during gripping. Ergonomics. 2003;46:95675.
41. Snijders CJ, Volkers ACW, Mechelse K, Vleeming A. Provoca-
tion of epicondylalgia lateralis (tennis elbow) by power grip
or pinching. Med Sci Sports Exerc. 1987;19:51823.
42. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Develop-
ment of recommendations for SEMG sensors and sensor place-
ment procedures. J Electromyogr Kinesiol. 2000;10(5):36174.
43. Rabago D, Kijowski R, Zgierska A, Yelland M, Scarpone M.
Magnetic resonance imaging outcomes in a randomised,
36 JOURNAL OF HAND THERAPY
controlled trial of prolotherapy for lateral epicondylosis. Int
Musculoskel Med. 2010;32(3):11723.
44. Newcomer K, Martinez-Silvestrini J, Schaefer M, Gay R,
Arendt K. Sensitivity of the patient-rated forearm evaluation
questionnaire in lateral epicondylitis. J Hand Ther. 2005;18:
4006.
45. Overend T, Wuori-Fearn J, Kramer J, MacDermid J. Reliability
of a patient-rated forearm evaluation questionnaire for patients
with lateral epicondylitis. J Hand Ther. 1999;12(1):317.
46. Rompe JD, Overend TJ, MacDermid JC. Validation of the
patient-rated tennis elbow evaluation questionnaire. J Hand
Ther. 2007;20(1):310.
47. Coombes B, Bisset L, Connelly L, Brooks P, Vicenzino B. Opti-
mising corticosteroid injection for lateral epicondylalgia with
the addition of physiotherapy: a protocol for a randomised
control trial with placebo comparison. BMC Musculoskelet
Disord. 2009;10:76.
48. Gruber M, Gruber SBH, Taube W, Schubert M, Beck SC,
Gollhofer A. Differential effects of ballistic versus sensorimotor
training on rate of force development and neural activation in
humans. J Strength Cond Res. 2007;21(1):27482.
49. Hakkinen K, Komi PV. Training-induced changes in neuro-
muscular performance under voluntary and reflex conditions.
Eur J Appl Physiol. 1986;55(2):14755.
50. Grosset JF, Piscione J, Lambertz D, Perot C. Paired changes in
electromechanical delay and musculo-tendinous stiffness after
endurance or plyometric training. Eur J Appl Physiol. 2009;105:
1319.
 JHT Read for Credit
Quiz: Article #209

Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this
issue or to complete online and use a credit card,
go to JHTReadforCredit.com. There is only one
best answer for each question.
#1. Which imaging modality was used to assess
degeneration of the common extensor tendon?
a. Doppler Ultrasound
b. CAT scan
c. X-ray imaging
d. MRI
#2. Participants in the study had refractory
a. cubital tunnel syndrome
b. pronator syndrome
c. LE
d. golfers elbow
#3. Which of the following measures had the highest
correlation with PRTEE function?
a. peak rate of force development
b. MAP grip strength
c. baseline grip strength
d. rate of force development at 30 ms
#4. The rate of force development was _________ in LE
participants compared to -LE participants?
a. increased
b. decreased
c. equal
d. none of the above
#5. The authors suggest that both rate of force devel-
opment and grip strength should be addressed
clinically by therapists.
a. false
b. true
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups of
3 or more to get full credit.

JanuaryeMarch 2012 37