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ORIGINAL ARTICLE

Acta Orthop Traumatol Turc 2015;49(5):465–470


doi: 10.3944/AOTT.2015.14.0215

Comparison of extracorporeal shock wave therapy


in acute and chronic lateral epicondylitis
İsmet Köksal1, Olcay Güler2, Mahir Mahİroğulları2, Serhat Mutlu3,
Selami Çakmak4, Ertuğrul Akşahİn5

Yenimahalle State Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey


1

Medipol University Faculty of Medicine, Department of Orthopedics and Traumatology, İstanbul, Turkey
2

3
Kanuni Sultan Süleyman Training and Research Hospital, Department of Orthopedics and Traumatology, İstanbul, Turkey
4
Gülhane Military Medical Academy Haydarpaşa Training and Research Hospital,
Department of Orthopedics and Traumatology, İstanbul, Turkey
5
Numune Training and Research Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey

Objective: The aim of this study is to evaluate and compare the results of extracorporeal shock wave
therapy (ESWT) in the treatment of acute (<3 months) lateral epicondylitis (LE) and chronic (>6
months) LE groups.
Methods: Fifty-four patients who were diagnosed with LE and treated with BTL-5000 SWT Power
(BTL Türkiye Medikal Cihazlar, Ankara, Turkey) ESWT were included in the study. Twenty-four
patients who had symptoms for <3 months were defined as the acute LE group (Group A), and 30
patients who had symptoms for >6 months were defined as the chronic LE group (Group B). All cases
were evaluated pretherapy and at Weeks 2, 12, and 24 posttherapy according to pain while resting,
pain while stretching, pain when pressed, pain while lifting chair, pain while working, nighttime pain
on LE zone.
Results: Almost all values in both Group A and Group B were significantly improved at Weeks 2, 12,
and 24 compared to the baseline values.
Conclusion: ESWT is equally effective in the treatment of acute LE and chronic LE. In addition, the
current data suggest the progression of LE cases from acute phase to chronic phase may be prevented
by treatment with ESWT.
Keywords: Epicondylitis; extracorporeal shock wave therapy; tennis elbow.
Level of Evidence: Level III Therapeutic Study

Lateral epicondylitis (LE) is a pathology caused by ex- 40–50 years. Its incidence is equal in men and women.[1]
cessive use of the limbs, especially during sports and pro- While acute onset is common in young athletes, chronic
fessional activities. It is characterized by pain originating phase is more common in the elderly.
from the lateral epicondyle and extending to the humer- LE is described as acute if symptoms are <3 months
us and forearm, as determined during physical examina- and chronic if symptoms are >6 months.[2] There are
tion. It is generally observed in patients aged between many treatment methods for LE in the existing litera-

Correspondence: Mahir Mahiroğulları, MD. Medipol Üniversitesi Tıp Fakültesi, Ortopedi ve


Travmatoloji Anabilim Dalı, Atatürk Bulvarı, No: 27, 34830 Fatih, İstanbul, Turkey.
Tel: +90 – 444 85 44 e-mail: mahirogullari@yahoo.com Available online at
www.aott.org.tr
Submitted: June 16, 2014 Accepted: October 08, 2014 doi: 10.3944/AOTT.2015.14.0215
©2015 Turkish Association of Orthopaedics and Traumatology QR (Quick Response) Code
466 Acta Orthop Traumatol Turc

ture. In conservative therapy, nonsteroid anti-inflamma- ESWT application was performed without the use
tory medicine (NSAI), brace, forearm bandage, ultraso- of local anesthesia. A shock wave with an impulse of
nography, steroid application, low dose laser application, 2.000, frequency of 5 Hz, and pressure of 2.5 bars was
extracorporeal shock wave therapy (ESWT), and other applied to each elbow. One session lasted 5 minutes,
methods are suggested. Surgical therapy methods are re- with an interval of 3 days between sessions. Three ses-
served for patients who cannot benefit from conservative sions were applied to each patient, and a second round
treatment. Numerous studies show that ESWT is effec- of ESWT was not applied to any patient.
tive in treatment of chronic persistent LE.[3–5] Further- All cases were evaluated at Weeks 2, 12, and 24 pre-
more, it is believed that ESWT is effective in preventing and posttherapy according to pre- and posttreatment
progression to the chronic phase when applied in the scores. Evaluation was performed to determine pain
acute phase. scores. Visual analog scoring system (VAS) was used
The objective of this study is to evaluate the efficien- for pain scoring. The VAS scoring system was used to
cy of ESWT application in the treatment of acute (<3 assess pre- and posttreatment degree of pain, which
months) LE and chronic (>6 months) LE, as well as to was scored from 0 (no pain) to 10 (extremely severe).
compare outcomes in both groups. Pain scores were evaluated as pain while resting, pain
while stretching (defined as full flexion of the wrist),
Patients and methods pain while lifting chair,[6,7] and pain when pressed (de-
Patients who came to the physical therapy center with a fined as tenderness while palpation), nighttime pain
diagnosis of LE and were treated with BTL-5000 SWT (defined as pain caused awaking), pain while work-
Power (BTL Türkiye Medikal Cihazlar, Ankara, Turkey) ing (defined as pain that reduces the working perfor-
ESWT between 2008–2009 were included in the study. mance). Pain while lifting chair was defined as the pain
Twenty-four patients who had symptoms for <3 months that occurred when a chair weighing 3.5 kg was lifted
and had not been treated previously were defined as the using the affected extremity while the shoulder was at
acute LE group (Group A). Thirty patients who had a 60° anteflexion position and the elbow was extended.
symptoms for >6 months and had not benefitted from In this study, Statistical Package for Social Sciences
therapies such as NSAI, brace, forearm bandage, and for Windows 15.0 (SPSS Inc., Chicago, Illinois, USA)
physical therapy were defined as the chronic LE group was used for conversion and analysis of raw data ob-
(Group B). Patients who had local infection, were <18 tained from surveys.
years, were pregnant, had a bleeding disorder, or had been Data obtained as a result of the study were compared
diagnosed with arthritis were excluded from the study. in terms of temporal change using Wilcoxon signed-

Table 1. Data from Group A and Group B pre- and post-ESWT.

Pain while Pain while Pain when Pain while Pain while Nighttime
resting stretching pressed lifting chair working pain

Group A
Pretherapy 5.79±1.91 7.25±1.29 8.5±0.98 6.63±1.21 6.38±1.01 7.04±1.2
2 weeks posttherapy 5.08±1.14 6.67±1.31 8.17±1.13 6.33±0.92 6.08±0.97 6.04±1.37
12 weeks posttherapy 4.71±1.46 6.13±1.7 7.71±1.49 5.96±1.16 5.46±1.28 4.83±1.49
24 weeks posttherapy 3.67±1.63 4.71±1.83 5.88±1.9 4.58±1.61 4.63±1.31 3.38±1.71
Pretherapy vs. 2 weeks posttherapy p=0.02 p=0.02 p=0.06 p=0.16 p=0.2 p=0.002
Pretherapy vs. 12 weeks posttherapy p=0.006 p=0.005 p=0.02 p=0.01 p=0.009 p<0.001
Pretherapy vs. 24 weeks posttherapy p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p<0.001
Group B
Pretherapy 5.62±1.88 6.73±1.12 8.19±1.17 6.31±1.23 6.81±1.17 6.27±1.31
2 weeks posttherapy 5.19±1.5 6.31±1.01 7.5±1.07 5.92±1.02 6.04±1 5.38±1.13
12 weeks posttherapy 4.31±1.26 5.54±0.95 6.77±0.91 5.38±0.8 5.88±1.21 4.5±1.1
24 weeks posttherapy 3.5±1.1 5.04±0.96 5.65±1.02 4.69±0.93 5.58±1.24 3.35±1.23
Pretherapy vs. 2 weeks posttherapy p=0.01 p=0.004 p=0.001 p=0.02 p=0.001 p=0.001
Pretherapy vs. 12 weeks posttherapy p<0.001 p<0.001 p<0.001 p=0.001 p=0.001 p<0.001
Pretherapy vs. 24 weeks posttherapy p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p<0.001
Köksal et al. ESWT in acut and chronic epicondylitis 467

rank test and differences between groups using Mann- Baseline nighttime pain values were higher in LE
Whitney U test. Results were evaluated with a 95% cases comparing both baseline and posttherapy scores of
confidence interval and a significance level of p<0.05. chronic and acute LE cases (p=0.04). Similarly, it was
Institutional Review Board approval and informed con- found that the pain when pressed values were higher in
sents were obtained for all patients. acute LE cases at Weeks 2 (p=0.03) and 12 (p=0.02)
posttherapy (Table 2, Figure 1).
Results Pain while lifting chair and pain pressed values were
Twenty-four patients (14 men, 10 women) were included higher in acute LE cases compared to chronic cases at
in Group A, and 30 patients (18 men, 12 women) were Week 12 posttherapy (p=0.02 in both), while pain while
included in Group B. The right elbows of 16 patients working values were higher in chronic cases at Week 24
and left elbows of 8 patients were affected in Group A, posttherapy (p=0.02) (Table 2). Both groups benefited
while the right elbows of 18 patients and left elbows of from the therapy equally when the efficiency of the ther-
12 patients were affected in Group B. NSAI adminis- apy was considered in terms of values while pain while
tration was discontinued in all patients 2 weeks prior to resting, pain while stretching, pain while nighttime.
beginning ESWT. Average symptom duration was 1.6
months in Group A and 8.4 months in Group B. Aver- Discussion
age age of patients in Group A was 47 (range: 32–61) We analyzed the results of ESWT therapy applied to
and 48 (range: 32–66) in Group B. Mild pain was ob- cases of acute and chronic LE. Our results show that
served at the application site in 50% of patients in both there is a significant clinical improvement in the pa-
groups. Ice application was recommended for such pa- rameters of pain while resting, pain while stretching,
tients, and they did not require medication. Ecchymose, pain when pressed, pain while working, and nighttime
hematoma, or swelling was not observed in any patient. pain at Weeks 2, 12, and 24 posttherapy compared to
When the pretherapy pain scores were compared the baseline values in chronic LE cases. It is also seen
with those obtained at Weeks 2, 12, and 24 postther- that all parameters decreased and a clinical improve-
apy, no significant improvement was observed in pain ment was achieved at Weeks 12 and 24 posttherapy in
while lifting chair, pain during working, and pain when acute LE cases. It was observed that parameters such as
pressed in Group A at Week 2 posttherapy, while these pain while resting, pain while stretching, and nighttime
parameters were significantly improved at Weeks 12 pain decreased, a clinical improvement was achieved at
and 24 posttherapy compared to the baseline. All other Week 2 posttherapy compared to baseline values, and
values in both Group A and Group B were significantly that pain when pressed, pain while lifting chair, and pain
improved at Weeks 2, 12, and 24 posttherapy compared while working also decreased at Week 2 posttherapy
to the baseline values (Table 1). There was no difference compared to baseline values, although it was not statisti-
in pre- and posttreatment scores regarding the domi- cally significant. When the baseline values and values at
nant hand. Weeks 2, 12, and 24 posttherapy of acute and chronic

Table 2. Comparative statistical results of the groups.

Pain while Pain while Pain when Pain while Pain while Nighttime
resting stretching pressed lifting chair working pain

Pretherapy A: 5.79±1.91 A: 7.25±1.29 A: 8.5±0.98 A: 6.63±1.21 A: 6.38±1.01 A: 7.04±1.2


B: 5.62±1.88 B: 6.73±1.12 B: 8.19±1.17 B: 6.31±1.23 B: 6.81±1.17 B: 6.27±1.31
p=0.69 p=0.14 p=0.36 p=0.45 p=0.14 p=0.04
2 weeks posttherapy A: 5.08±1.14 A: 6.67±1.31 A: 8.17±1.13 A: 6.33±0.92 A: 6.08±0.97 A: 6.04±1.37
B: 5.19±1.5 B: 6.31±1.01 B: 7.5±1.07 B: 5.92±1.02 B: 6.04±1 B: 5.38±1.13
p=0.79 p=0.21 p=0.03 p=0.21 p=0.92 p=0.046
12 weeks posttherapy A: 4.71±1.46 A: 6.13±1.7 A: 7.71±1.49 A: 5.96±1.16 A: 5.46±1.28 A: 4.83±1.49
B: 4.31±1.26 B: 5.54±0.95 B: 6.77±0.91 B: 5.38±0.8 B: 5.88±1.21 B: 4.5±1.1
p=0.25 p=0.07 p=0.02 p=0.02 p=0.20 p=0.37
24 weeks posttherapy A: 3.67±1.63 A: 4.71±1.83 A: 5.88±1.9 A: 4.58±1.61 A: 4.63±1.31 A: 3.38±1.71
B: 3.5±1.1 B: 5.04±0.96 B: 5.65±1.02 B: 4.69±0.93 B: 5.58±1.24 B: 3.35±1.23
p=0.78 p=0.26 p=0.83 p=0.91 p=0.02 p=0.95
A: Group A; B: Group B.
468 Acta Orthop Traumatol Turc

Before therapy A Before therapy B 2 weeks after therapy A 2 weeks after therapy B 12 weeks after therapy A
12 weeks after therapy B 24 weeks after therapy A 24 weeks after therapy B

8.5
8.19
8.17

7.71
7.5
7.25

7.04
6.81
6.77
6.73
6.67

6.63

6.38
6.33
6.31

6.31

6.27
6.13

6.08
6.04

6.04
5.96
5.92
5.88

5.88
5.79

5.65
5.62

5.58
5.54

5.46
5.38

5.38
5.19
5.08

5.04

4.83
4.71
4.71

4.69

4.63
4.58
4.31

4.5
3.67

3.38
3.35
3.5

Pain during rest Pain during stretching Pain when pressed Pain while lifting chair Pain during working Nighttime pain

Fig. 1. Comparison of acute and cronic LE pain scores. [Color figure can be viewed in the online issue, which is available at www.aott.org.tr]

LE cases were compared, it was observed that nighttime quired for comparing efficiency in acute cases.[10] It was
pain was higher in acute LE cases. Efficiency of ESWT reported that topical diclofenac administration was ef-
on pain when pressed was lower in acute cases than fective in decreasing elbow pain.[11] It is recommended
chronic cases at Weeks 2 and 12 posttherapy, and simi- that surgical therapy should be applied in patients who
larly, its efficiency on pain while lifting chair was lower in do not respond to conservative therapy but benefit from
acute cases than chronic cases at Week 12 posttherapy. It shock wave therapy.
was found that the effect of ESWT on pain while work- In a randomized controlled study conducted in 198
ing was lower in chronic cases at Week 24 posttherapy. patients by Bisset et al., they reported that the most ef-
Prevalence of LE has been reported as 1–3% in vari- fective strategy was corticosteroid injection in order to
ous studies.[1] This problem is observed rarely in patients achieve short-term outcomes; however, this application
<30 years and most commonly in patients in their 30s. was less effective than physical therapy—including el-
The disease generally occurs on the dominant side, and bow and wrist manipulations, frictions, stretches, exer-
the right side is affected twice as frequently as the left cises (isometric and isotonic) with a treatment of pulsed
side. In our series, the dominant sides of 18 patients ultrasound, and acupuncture—due to recurrence of
were affected in both groups. symptoms and its long-term outcomes.[5]
Causes of LE are multifactorial. The natural course The mechanism of action of shock wave therapy is
of LE is not clear, and there is not sufficient evidence not clear. The operating logic of ESWT is to create an
in the literature that supports any definitive therapy acute or new injury at lesion site over chronic condition,
method. In a randomized clinical study in which the thereby triggering self-repair mechanisms of the body.
patients were followed using a wait-and-see procedure As a result, vascularization and blood flow increase. It is
by only limiting their activities, it was reported that suggested that hyperstimulation relieves pain by its anal-
equivalent outcomes with physical therapy and better gesic effects.[5,12] Positive impacts of shock wave therapy
outcomes than corticosteroid treatment were achieved in on improvement after injury of the Achilles tendon have
the elimination of the primary symptoms.[8] It has been been suggested.[13,14]
demonstrated that corticosteroid injection is effective in In a prospective randomized controlled study con-
a short period of 2–6 weeks.[9] In a prospective random- ducted by Chung and Wiley, they reported that there
ized study that compared corticosteroid injection with was no significant difference between the shock wave
ESWT application, it was found that corticosteroid therapy group and the placebo group.[15] Chung and
injection was more effective in elimination of pain, but Wiley applied shock wave therapy in patients with LE
it was reported that longer follow-up periods were re- who were not treated previously (patients with symp-
Köksal et al. ESWT in acut and chronic epicondylitis 469

toms for <1 year and >3 weeks), but they were unable such a disputed therapy method, and these constitute
to show its efficiency with long-term outcomes.[15] In the weaknesses of the study.
another study with a similar patient group conducted We suggest that ESWT is effective in the treatment
by the same authors, it was found that ESWT was of acute LE as it is in the treatment of chronic LE. In
more effective in treatment of patients with symptoms addition, the current data suggests that the progression
for <16 weeks than in patients with symptoms >16 from acute phase to chronic phase in cases of LE may be
weeks.[16] In our study, average symptom duration was prevented by treatment with ESWT.
1.6 months in Group A and 8.4 months in Group B.
In a study conducted by Haake, the efficiency of shock Conflics of Interest: No conflicts declared.
wave therapy was not shown in treatment of LE.[17] Ko
reported that perfect and good outcomes were achieved References
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