Scapular Stabilization Versus Elbow Strengthening in Athletes with Lateral Epicondylitis
-
Mohammad Mahdi Ghiami
,
Hooman Minoonejad
,
Elham shirzad Araghi
,
Yousef Moghadas Tabrizi
,
Abbas Farjad Pezeshk
Abstract
Lateral elbow tendinopathy is not merely a localized elbow condition and is often associated with proximal movement impairments such as scapular dyskinesis, which may contribute to persistent pain and functional limitations in racket sport athletes.
Purpose: This study aimed to compare the effects of scapular stabilization exercises and elbow strengthening exercises on pain, disability, and functional performance in racket sport athletes with lateral elbow tendinopathy accompanied by scapular dyskinesis.
Methods: In this semi-experimental study with a pretest–posttest control group design, 49 racket sport athletes aged 18–25 years and diagnosed with lateral elbow tendinopathy and scapular dyskinesis were randomly assigned to elbow strengthening exercises, combined training (elbow strengthening plus scapular stabilization), or a control group. Interventions were conducted over eight weeks, three sessions per week. Outcome measures included pain intensity, upper limb disability, muscle strength, dynamic balance, upper limb power, and functional movement performance.
Results: Both intervention groups showed reductions in pain and disability and improvements in functional performance, with greater and clinically meaningful improvements observed in the combined training group.
Conclusion: Incorporating scapular stabilization exercises into elbow strengthening programs leads to superior clinical and functional outcomes and supports a kinetic chain–based rehabilitation approach for racket sport athletes with lateral elbow tendinopathy.
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2. Ahmed F, Hassan N, Islam W, Uddin K, Ahmed S, Islam A. Effectiveness of Physiotherapy Intervention for Elderly People with Diabetic Neuropathy: A Review Study. Journal of Modern Rehabilitation. 2024;18(2):144-51.doi:https://doi.org/10.18502/jmr.v18i2.15970
3. Landesa-Pineiro L, Leirós-Rodríguez R. Physiotherapy treatment of lateral epicondylitis: a systematic review. J Back Musculoskelet Rehabil. 2022;35(3):463-77.doi:https://doi.org/10.3233/BMR-210053
4. Day JM, Lucado AM, Dale RB, Merriman H, Marker CD, Uhl TL. The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: a pilot randomized controlled trial. J Sport Rehabil. 2021;30(5):744-53.doi:https://doi.org/10.1123/jsr.2020-0203
5. Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sports Phys Ther. 2015;45(5):414-24.doi:10.2519/jospt.2015.5290
6. Reyhani F, Meftahi N, Rojhani-Shirazi Z. Comparing shoulder proprioception, upper extremity dynamic stability, and hand grip strength in overhead athletes with and without scapular dyskinesis. J Bodyw Mov Ther. 2024;39:304-10.doi:https://doi.org/10.1016/j.jbmt.2024.03.001
7. Burn MB, McCulloch PC, Lintner DM, Liberman SR, Harris JD. Prevalence of scapular dyskinesis in overhead and nonoverhead athletes: a systematic review. Orthop J Sports Med. 2016;4(2):2325967115627608-.doi:10.1177/2325967115627608
8. Eyvazi Hezebaran A, Ghani Zadeh Hesar N, Mohammad Ali Nasab Firouzjah E, Roshani S. Effect of eight weeks scapular stabilization exercises on shoulder pain of archer men with scapular dyskinesis: a clinical trial study. J Gorgan Univ Med Sci. 2021;23(3):24-31.doi:http://goums.ac.ir/journal/article-1-3833-en.html
9. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012;20(6):364-72.doi:10.5435/JAAOS-20-06-364
10. Salamh PA, Hanney WJ, Boles T, Holmes D, McMillan A, Wagner A, et al. Is it time to normalize scapular dyskinesis? The incidence of scapular dyskinesis in those with and without symptoms: a systematic review. Int J Sports Phys Ther. 2023;18(3):558.doi:https://doi.org/10.26603/001c.74388
11. Sciascia A, Kibler WB. Current views of scapular dyskinesis and its possible clinical relevance. International journal of sports physical therapy. 2022;17(2):117.doi:https://doi.org/10.26603/001c.31727
12. Hogan C, Corbett J-A, Ashton S, Perraton L, Frame R, Dakic J. Scapular dyskinesis is not an isolated risk factor for shoulder injury in athletes: a systematic review and meta-analysis. Am J Sports Med. 2021;49(10):2843-53.doi:https://doi.org/10.1177/0363546520968508
13. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. Br J Sports Med. 2019;53(12):705-12.doi:10.1136/bjsports-2018-099784
14. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 2014;48(8):692-7.doi:https://doi.org/10.1136/bjsports-2013-092148
15. Lee JH, Kim TH, Lim KB. Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. J Phys Ther Sci. 2018;30(4):590-4.doi:https://doi.org/10.1589/jpts.30.590
16. Kirithika G, Kamalakannan M, Ramana K, Anitha A. Efficacy of scapular strengthening exercise and eccentric forearm exercise on functional recovery in subjects with lateral epicondylitis. Indian J Physiother Occup Ther. 2024;18.doi:10.37506/v1zm1714
17. Vidyashree K A. Integrating scapular strengthening exercises into rehabilitation of lateral epicondylitis: a narrative review. Indian J Physiother Occup Ther. 2025;19 (Vol. 19 No. Conf 1 (2025): Conference Proceedings Of Mithracon 2025).doi:https://doi.org/10.37506/2bjdrt82
18. Alireza Z, Hashem P, Razieh H, Amir Reza S, Amir Reza Ghareh K. Comparison of Functional Movement Screen Scores and Performance Between Male and Female Soccer Players. Journal of Modern Rehabilitation. 2025;0(-)
19. Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based approach. British Journal of Sports Medicine. 2015;49(5):327-37.doi:10.1136/bjsports-2014-093559
20. Hotta GH, de Assis Couto AG, Cools AM, McQuade KJ, de Oliveira AS. Effects of adding scapular stabilization exercises to a periscapular strengthening exercise program in patients with subacromial pain syndrome: a randomized controlled trial. Musculoskelet Sci Pract. 2020;49:102171.doi:https://doi.org/10.1016/j.msksp.2020.102171
21. Tang L, Chen K, Ma Y, Huang L, Liang J, Ma Y. Scapular stabilization exercise based on the type of scapular dyskinesis versus traditional rehabilitation training in the treatment of periarthritis of the shoulder: study protocol for a randomized controlled trial. Trials. 2021;22(1):713.doi:https://doi.org/10.1186/s13063-021-05654-2
22. Rasool MJ, Akram S, Jamil A, Tauseef M, Ilyas A. Effects of Power Ball exercises in addition to routine physical therapy on pain, grip strength and functional disability in patients with carpal tunnel syndrome. Healer J Physiother Rehabil Sci. 2023;3(4):451-60.doi:https://doi.org/10.55735/hjprs.v3i4.139
23. Babaei Mobarakeh M, Letafatkar A, Barati AH. Effect of eight weeks of Powerball-mediated resistance training on strength, proprioception, and upper extremity performance in volleyball players with tennis elbow. Sci J Rehabil Med. 2018;7(3):141-56.doi:https://doi.org/10.22037/jrm.2017.110996.1683
24. Mirhassan Zadeh Kuhkamar M, Hadadnezhad M, Khaleghi Tazji M. The effect of 8 weeks' scapular focused training on pain, proprioception, scapular kinematics and upper extremity performance in male volleyball players with shoulder impingement syndrome. Medical Journal of Tabriz University of Medical Sciences and Health Services. 2020;42(4):466-75.doi:10.34172/mj.2020.069
25. Jones IA, Togashi R, Heckmann N, Vangsness Jr CT. Minimal clinically important difference for patient-reported shoulder outcomes. J Shoulder Elbow Surg. 2020;29(7):1484-92.doi:https://doi.org/10.1016/j.jse.2019.12.033
26. Gagnier JJ, Mullins M, Huang H. Minimal clinically important difference for patient-reported outcomes in musculoskeletal disorders. Journal of Clinical Epidemiology. 2018;102:1-12.doi:10.1016/j.jclinepi.2018.06.010
27. MacDermid JC, Silbernagel KG. Outcome evaluation in tendinopathy: foundations of assessment and a summary of selected measures. J Orthop Sports Phys Ther. 2015;45(11):950-64.doi:10.2519/jospt.2015.6054
28. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the DASH in patients with shoulder pain. Journal of Orthopaedic & Sports Physical Therapy. 2009;39(8):584-95.doi:10.2519/jospt.2009.2901
29. Cacchio A, Necozione S, MacDermid JC, Rompe JD, Maffulli N, Di Orio F, et al. Cross-cultural adaptation and measurement properties of the Italian version of the Patient-Rated Tennis Elbow Evaluation questionnaire. 2012;92(8):1036-45.doi:https://doi.org/10.2522/ptj.20110398
30. Lowdon H, Chong HH, Dhingra M, Gomaa A-R, Teece L, Booth S, et al. Comparison of interventions for lateral elbow tendinopathy: a systematic review and network meta-analysis for patient-rated tennis elbow evaluation pain outcome. J Hand Surg Am. 2024;49(7):639-48.doi:https://doi.org/10.1016/j.jhsa.2024.03.007
31. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13-9.doi:10.1016/j.jht.2016.09.001
32. Mostafaee N, Divandari A, Negahban H, Kachooei AR, Moradi A, Ebrahimzadeh MH, et al. Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice. 2022;38(9):1153-64.doi:https://doi.org/10.1080/09593985.2020.1821417
33. Lucado AM, Kolber MJ, Cheng MS. Scapular muscle performance in individuals with lateral elbow tendinopathy. J Shoulder Elbow Surg. 2019;28(10):1960-7.doi:10.1016/j.jse.2019.03.033
34. Ludewig PM, Lawrence RL, Braman JP. What is the role of the scapula in shoulder pain? Br J Sports Med. 2022;56(15):834-42.doi:10.1136/bjsports-2021-104567
35. Ludewig PM, Lawrence RL, Braman JP. What is the role of the scapula in shoulder pain? British Journal of Sports Medicine. 2022;56(15):834-42.doi:10.1136/bjsports-2021-104567
36. Salamh P, Lewis J. The role of proximal control in elbow and wrist disorders. Physical Therapy in Sport. 2021;50:45-52.doi:10.1016/j.ptsp.2021.04.003
37. Bohannon RW. Minimal clinically important difference for grip strength: a systematic review. J Phys Ther Sci. 2019;31(1):75-8.doi:https://doi.org/10.1589/jpts.31.75
38. Mendez-Rebolledo G, Araya-Quintanilla F, Guzmán-Muñoz E, Salazar-Mendez J, Cruz-Montecinos C, Berckmans KR, et al. Comparative electromyographic study of scapular stabilizing muscles during five main rehabilitation exercises. Am J Phys Med Rehabil. 2024;103(6):502-9.doi:10.1097/PHM.0000000000002394
39. Horlings CG, Küng U, Van Engelen B, Voermans N, Hengstman G, Van Der Kooi A, et al. Balance control in patients with distal versus proximal muscle weakness. Neuroscience. 2009;164(4):1876-86.doi:https://doi.org/10.1016/j.neuroscience.2009.09.063
2. Ahmed F, Hassan N, Islam W, Uddin K, Ahmed S, Islam A. Effectiveness of Physiotherapy Intervention for Elderly People with Diabetic Neuropathy: A Review Study. Journal of Modern Rehabilitation. 2024;18(2):144-51.doi:https://doi.org/10.18502/jmr.v18i2.15970
3. Landesa-Pineiro L, Leirós-Rodríguez R. Physiotherapy treatment of lateral epicondylitis: a systematic review. J Back Musculoskelet Rehabil. 2022;35(3):463-77.doi:https://doi.org/10.3233/BMR-210053
4. Day JM, Lucado AM, Dale RB, Merriman H, Marker CD, Uhl TL. The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: a pilot randomized controlled trial. J Sport Rehabil. 2021;30(5):744-53.doi:https://doi.org/10.1123/jsr.2020-0203
5. Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sports Phys Ther. 2015;45(5):414-24.doi:10.2519/jospt.2015.5290
6. Reyhani F, Meftahi N, Rojhani-Shirazi Z. Comparing shoulder proprioception, upper extremity dynamic stability, and hand grip strength in overhead athletes with and without scapular dyskinesis. J Bodyw Mov Ther. 2024;39:304-10.doi:https://doi.org/10.1016/j.jbmt.2024.03.001
7. Burn MB, McCulloch PC, Lintner DM, Liberman SR, Harris JD. Prevalence of scapular dyskinesis in overhead and nonoverhead athletes: a systematic review. Orthop J Sports Med. 2016;4(2):2325967115627608-.doi:10.1177/2325967115627608
8. Eyvazi Hezebaran A, Ghani Zadeh Hesar N, Mohammad Ali Nasab Firouzjah E, Roshani S. Effect of eight weeks scapular stabilization exercises on shoulder pain of archer men with scapular dyskinesis: a clinical trial study. J Gorgan Univ Med Sci. 2021;23(3):24-31.doi:http://goums.ac.ir/journal/article-1-3833-en.html
9. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012;20(6):364-72.doi:10.5435/JAAOS-20-06-364
10. Salamh PA, Hanney WJ, Boles T, Holmes D, McMillan A, Wagner A, et al. Is it time to normalize scapular dyskinesis? The incidence of scapular dyskinesis in those with and without symptoms: a systematic review. Int J Sports Phys Ther. 2023;18(3):558.doi:https://doi.org/10.26603/001c.74388
11. Sciascia A, Kibler WB. Current views of scapular dyskinesis and its possible clinical relevance. International journal of sports physical therapy. 2022;17(2):117.doi:https://doi.org/10.26603/001c.31727
12. Hogan C, Corbett J-A, Ashton S, Perraton L, Frame R, Dakic J. Scapular dyskinesis is not an isolated risk factor for shoulder injury in athletes: a systematic review and meta-analysis. Am J Sports Med. 2021;49(10):2843-53.doi:https://doi.org/10.1177/0363546520968508
13. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. Br J Sports Med. 2019;53(12):705-12.doi:10.1136/bjsports-2018-099784
14. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 2014;48(8):692-7.doi:https://doi.org/10.1136/bjsports-2013-092148
15. Lee JH, Kim TH, Lim KB. Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. J Phys Ther Sci. 2018;30(4):590-4.doi:https://doi.org/10.1589/jpts.30.590
16. Kirithika G, Kamalakannan M, Ramana K, Anitha A. Efficacy of scapular strengthening exercise and eccentric forearm exercise on functional recovery in subjects with lateral epicondylitis. Indian J Physiother Occup Ther. 2024;18.doi:10.37506/v1zm1714
17. Vidyashree K A. Integrating scapular strengthening exercises into rehabilitation of lateral epicondylitis: a narrative review. Indian J Physiother Occup Ther. 2025;19 (Vol. 19 No. Conf 1 (2025): Conference Proceedings Of Mithracon 2025).doi:https://doi.org/10.37506/2bjdrt82
18. Alireza Z, Hashem P, Razieh H, Amir Reza S, Amir Reza Ghareh K. Comparison of Functional Movement Screen Scores and Performance Between Male and Female Soccer Players. Journal of Modern Rehabilitation. 2025;0(-)
19. Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based approach. British Journal of Sports Medicine. 2015;49(5):327-37.doi:10.1136/bjsports-2014-093559
20. Hotta GH, de Assis Couto AG, Cools AM, McQuade KJ, de Oliveira AS. Effects of adding scapular stabilization exercises to a periscapular strengthening exercise program in patients with subacromial pain syndrome: a randomized controlled trial. Musculoskelet Sci Pract. 2020;49:102171.doi:https://doi.org/10.1016/j.msksp.2020.102171
21. Tang L, Chen K, Ma Y, Huang L, Liang J, Ma Y. Scapular stabilization exercise based on the type of scapular dyskinesis versus traditional rehabilitation training in the treatment of periarthritis of the shoulder: study protocol for a randomized controlled trial. Trials. 2021;22(1):713.doi:https://doi.org/10.1186/s13063-021-05654-2
22. Rasool MJ, Akram S, Jamil A, Tauseef M, Ilyas A. Effects of Power Ball exercises in addition to routine physical therapy on pain, grip strength and functional disability in patients with carpal tunnel syndrome. Healer J Physiother Rehabil Sci. 2023;3(4):451-60.doi:https://doi.org/10.55735/hjprs.v3i4.139
23. Babaei Mobarakeh M, Letafatkar A, Barati AH. Effect of eight weeks of Powerball-mediated resistance training on strength, proprioception, and upper extremity performance in volleyball players with tennis elbow. Sci J Rehabil Med. 2018;7(3):141-56.doi:https://doi.org/10.22037/jrm.2017.110996.1683
24. Mirhassan Zadeh Kuhkamar M, Hadadnezhad M, Khaleghi Tazji M. The effect of 8 weeks' scapular focused training on pain, proprioception, scapular kinematics and upper extremity performance in male volleyball players with shoulder impingement syndrome. Medical Journal of Tabriz University of Medical Sciences and Health Services. 2020;42(4):466-75.doi:10.34172/mj.2020.069
25. Jones IA, Togashi R, Heckmann N, Vangsness Jr CT. Minimal clinically important difference for patient-reported shoulder outcomes. J Shoulder Elbow Surg. 2020;29(7):1484-92.doi:https://doi.org/10.1016/j.jse.2019.12.033
26. Gagnier JJ, Mullins M, Huang H. Minimal clinically important difference for patient-reported outcomes in musculoskeletal disorders. Journal of Clinical Epidemiology. 2018;102:1-12.doi:10.1016/j.jclinepi.2018.06.010
27. MacDermid JC, Silbernagel KG. Outcome evaluation in tendinopathy: foundations of assessment and a summary of selected measures. J Orthop Sports Phys Ther. 2015;45(11):950-64.doi:10.2519/jospt.2015.6054
28. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the DASH in patients with shoulder pain. Journal of Orthopaedic & Sports Physical Therapy. 2009;39(8):584-95.doi:10.2519/jospt.2009.2901
29. Cacchio A, Necozione S, MacDermid JC, Rompe JD, Maffulli N, Di Orio F, et al. Cross-cultural adaptation and measurement properties of the Italian version of the Patient-Rated Tennis Elbow Evaluation questionnaire. 2012;92(8):1036-45.doi:https://doi.org/10.2522/ptj.20110398
30. Lowdon H, Chong HH, Dhingra M, Gomaa A-R, Teece L, Booth S, et al. Comparison of interventions for lateral elbow tendinopathy: a systematic review and network meta-analysis for patient-rated tennis elbow evaluation pain outcome. J Hand Surg Am. 2024;49(7):639-48.doi:https://doi.org/10.1016/j.jhsa.2024.03.007
31. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13-9.doi:10.1016/j.jht.2016.09.001
32. Mostafaee N, Divandari A, Negahban H, Kachooei AR, Moradi A, Ebrahimzadeh MH, et al. Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice. 2022;38(9):1153-64.doi:https://doi.org/10.1080/09593985.2020.1821417
33. Lucado AM, Kolber MJ, Cheng MS. Scapular muscle performance in individuals with lateral elbow tendinopathy. J Shoulder Elbow Surg. 2019;28(10):1960-7.doi:10.1016/j.jse.2019.03.033
34. Ludewig PM, Lawrence RL, Braman JP. What is the role of the scapula in shoulder pain? Br J Sports Med. 2022;56(15):834-42.doi:10.1136/bjsports-2021-104567
35. Ludewig PM, Lawrence RL, Braman JP. What is the role of the scapula in shoulder pain? British Journal of Sports Medicine. 2022;56(15):834-42.doi:10.1136/bjsports-2021-104567
36. Salamh P, Lewis J. The role of proximal control in elbow and wrist disorders. Physical Therapy in Sport. 2021;50:45-52.doi:10.1016/j.ptsp.2021.04.003
37. Bohannon RW. Minimal clinically important difference for grip strength: a systematic review. J Phys Ther Sci. 2019;31(1):75-8.doi:https://doi.org/10.1589/jpts.31.75
38. Mendez-Rebolledo G, Araya-Quintanilla F, Guzmán-Muñoz E, Salazar-Mendez J, Cruz-Montecinos C, Berckmans KR, et al. Comparative electromyographic study of scapular stabilizing muscles during five main rehabilitation exercises. Am J Phys Med Rehabil. 2024;103(6):502-9.doi:10.1097/PHM.0000000000002394
39. Horlings CG, Küng U, Van Engelen B, Voermans N, Hengstman G, Van Der Kooi A, et al. Balance control in patients with distal versus proximal muscle weakness. Neuroscience. 2009;164(4):1876-86.doi:https://doi.org/10.1016/j.neuroscience.2009.09.063
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| Lateral elbow tendinopathy; Scapular dyskinesis; Scapular stabilization; Exercise therapy; Athletic performance | ||
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How to Cite
1.
Ghiami MM, Minoonejad H, shirzad Araghi E, Moghadas Tabrizi Y, Farjad Pezeshk A. Scapular Stabilization Versus Elbow Strengthening in Athletes with Lateral Epicondylitis. jmr. 2026;(-).
