Tyler Twist Technique for Lateral Epicondylitis
The Tyler Twist technique is an effective eccentric strengthening exercise for lateral epicondylitis that should be incorporated into a comprehensive treatment plan alongside activity modification, cryotherapy, and NSAIDs for short-term pain relief. 1
What is the Tyler Twist Technique?
The Tyler Twist is a specific eccentric strengthening exercise designed to rehabilitate the extensor tendons of the forearm in patients with lateral epicondylitis (tennis elbow). 2 The technique involves:
- Eccentric loading of the wrist extensor muscles through controlled lengthening contractions 2
- Progressive resistance training that starts with submaximal intensity and advances as tolerated 3
- Repetitive lengthening of the active musculo-tendinous unit 3
Evidence Supporting the Tyler Twist
The Tyler Twist technique demonstrates superior outcomes compared to other manual therapy approaches. 2 In a 2023 comparative study:
- Pain reduced from 5.8 to 2.0 on the numerical pain rating scale after Tyler Twist treatment 2
- Post-treatment grip strength improved to 24.13 kg with Tyler Twist versus 21.33 kg with active release technique (p=0.0001) 2
- Treatment consisted of four sessions per week for three weeks 2
Complete Treatment Protocol
Initial Conservative Management (First-Line)
Begin with activity modification to reduce repetitive wrist extension movements, as this addresses the primary causative mechanism. 1
- Avoid repetitive wrist extension against resistance, particularly in occupational and sports activities 4
- Modify gripping techniques to reduce stress on the lateral epicondyle 4
- Apply cryotherapy for acute symptom management 1
- Use NSAIDs for short-term pain relief 1
Eccentric Strengthening Program (Tyler Twist Protocol)
Initiate eccentric strengthening once acute symptoms settle, typically after initial pain control is achieved. 1
The eccentric training program should follow this progression:
- Start with submaximal contraction intensity and slow speed movements 3
- Progressively intensify over time by increasing contraction intensity and movement speed 3
- Continue for at least 6 weeks to achieve optimal results 5, 3
- Perform exercises 4 sessions per week for maximum benefit 2
Expected Outcomes and Timeline
Significant improvements occur within the first month of eccentric training. 3
- More marked reduction in pain intensity compared to non-strengthening approaches 3
- Elimination of strength deficit in forearm supinator and wrist extensor muscles 3
- Improved tendon structure on ultrasonography, with decreased thickness and recovered homogenous appearance 3
- Enhanced function during occupational, leisure, and sports activities 3
Clinical Pearls and Caveats
Eccentric strengthening does not cause symptom worsening when properly implemented. 5 However, monitor for:
- Anterior knee pain during progression (though this applies more to lower extremity protocols) 6
- Appropriate rest intervals between sessions to prevent overload 4
- Proper warm-up before activities involving wrist extension 4
The diagnosis can be made clinically in patients over 40 years old with lateral epicondyle tenderness, repetitive wrist extension activities, and dominant arm involvement, even without positive resistive testing. 1
When to Escalate Care
Consider imaging (plain radiographs initially) if symptoms persist or worsen despite conservative treatment, or if diagnostic uncertainty exists. 1
- Chronic or resistant cases may require surgical intervention as a last resort 7, 8
- Surgical options include percutaneous, arthroscopic, or open release of the extensor carpi radialis brevis tendon 8
Why This Approach Works
Eccentric training addresses the underlying tendinopathy through controlled mechanical loading that promotes tendon remodeling. 3 The mechanism involves: