Shockwave therapy for tennis elbow

What is Lateral Epicondylitis (Tennis Elbow)?

Lateral Epicondylitis, or tennis elbow as it is more commonly known, was first described as a disease affecting tennis players, mainly those hitting repetitive backhands, by Morris in 1882.

The disease was originally thought of as a disease of inflammation of the muscles attaching to the lateral epicondyle, the outer part of the lower humerus.  More recently there have been in-depth histological studies, which show a different pathological process at play.  The condition is now described by most as a failed reparative process.  Histologically there is a distinct lack of inflammatory cells; instead the muscle tissue and tendon are invaded with immature fibroblasts.  A lesser-known fact is the poor vascularity and vulnerable arterial supply in the area, which along with altered autonomic control of vasconstrictor and vasodilator affect the over all vascularity in the region.
The mechanical forces at play in the region, both eccentric and concentric forces, lead to microscopic tears in the common extensor tendon.  Coupled with compensatory mechanics due to altered shoulder and wrist mechanics and the poor healing response in the tendon lead to risk factors for developing and maintaining tennis elbow pathology.
Tennis elbow (Lateral Epicondylitis) often presents with pain, which may or not have some localised swelling over the region.  The pain may be localised or radiate down into the forearm, with symptoms such as reduced grip strength or pain when performing gripping and twisting movements.  Full range of flexion and resisted movements which use the extensor muscle group often result in pain.
There is a special classification system used to help identify the level of pain experienced by the patient and the phase this occurs in.  The classification devised by Nirschl and Ashman can be found below
  1. Phase 1 Mild pain after exercises, lasting less than 24 hours
  2. Phase 2 Pain after exercise, lasting greater than 48 hours, resolves with warm up
  3. Phase 3 Pain with exercise, does not alter ability to exercise
  4. Phase 4 Pain with exercise that alters ability to exercise
  5. Phase 5 Pain caused by heavy activities of daily living
  6. Phase 6 Pain caused by light activities of daily living, intermittent pain at rest that does not interfere with sleep
  7. Phase 7 Constant pain at rest, interferes with sleep
The people that are most likely to suffer from tennis elbow are typically aged between 35 and 50 years, and are just as likely to be men as they are women.  The estimated occurrence of tennis elbow is between 1% to 3%.
Radiographic investigations are often used to help assess the extent of the changes within the bone or tendon.  Ultrasound and MRI are the chosen investigations due to the specificity of the tests, with MRI being better at looking at the precise changes within the tendon, surrounding soft tissues and bone.

What other treatments are available for Tennis elbow?

There have been numerous studies to isolate the most effective form of management for tennis elbow.  Treatment of tennis elbow ranges from a “wait-and-see” approach to steroid injections and surgery.  Physiotherapy appears to be amongst one of the better performing conservative procedures for the resolution of lateral Epicondylitis.  On the whole there seems to be little which performs very well for tennis elbow on a consistent basis.
Shockwave therapy has recently been investigated over the past decade as an alternative to other forms of treatment for tennis elbow.  Extracorporeal shockwave therapy has been used to address the failed healing process in most other tendon related disorders.  As well as stimulating the healing response the shockwave therapy reduces afferent signals from pain receptors, which helps in a quick and effective reduction in the patients symptoms.
The following procedures are all non-operative approaches to managing lateral Epicondylitis, most of which are evidence based and have research to back them up.
  1. Leave it for 8-12 months
  2. Physiotherapy
  3. Injection therapy (Botox, Prolotherapy and Corticosteroid injection)
  4. Splints and straps
  5. Taping
  6. Manipulation
  7. Deep frictions
  8. Ultrasound
  9. Iontophoresis/Phonophoresis
  10. Occupational Therapy
  11. Shockwave therapy
  12. Anti-inflammatory medication
  13. Laser therapy
  14. Topical nitric oxide
  15. Topical diclofenac
  16. Acupuncture
Operative procedures, which are tried after conservative measures fail to reduce pain around the epicondyle and tennis elbow related pain include;
  1. Release of the common extensors origin
  2. Debridement of tissue in the extensor carpi radialis brevis tendon
  3. Release of the posterior interosseous nerve
  4. Arthroscopic release
  5. Anconeus rotation
  6. Denervation of the lateral epicondyle

How is shockwave therapy applied to tennis elbow?

Shockwave therapy for Tennis elbow is applied following a set protocol.  The clinician will carry out a thorough case history taking which isolates the area that is painful and begins to understand the clinical history behind the condition.  It is important to make sure that the condition being treated is actually a Tennis elbow related condition and is therefore treatable with shockwave therapy.
During the examination period a tender point where the pain is maximal will be located, upon which a water-based medium will be applied.  This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your Tennis elbow will begin.  At first the clinician will ensure the discomfort is kept to a minimum.  After a while as the impulses increase little pain is felt.  Although, more often than not there is some pain felt over the area of application.  After treatment you should feel very little pain and this may last for a few days.  After then an aching sensation can occur.  After subsequent treatments there will be a definite improvement in symptoms leading to reduction in the original pain felt.

 

How long will shockwave therapy take to work?

Generally most applications of shockwave for Tennis elbow and most conditions will resolve within 3-4 sessions of 30 minutes (roughly).  This obviously can depend on the exact presentation of the condition.  Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.
It is vital that you continue to work with a physical therapist to maintain the exercise regime you should already be carrying out for Tennis elbow, prior to consulting for shockwave treatment.  This will involve balancing exercises, strength exercises and a good eccentric loading programme depending on your stage of Tennis elbow.

What is the evidence for shockwave therapy and this condition?

Several studies have been published recently, which highlight the effectiveness of shockwave therapy for tennis elbow.  Some articles have also not seen beneficial results in the improvement in lateral Epicondylitis using shockwave therapy.  The research around this area is still within its infancy and a few negative studies in the early days are normal and could potential be due to the methodological changes between studies.
Rompe et al published a systematic and qualitative analysis of the current research on shockwave therapy for tennis elbow in 2007.  The study highlighted the need to read research carefully and understand in particular the population sampled.  Of the studies sampled that had positive results the participants had been chronic therapy resistant cases, in the cases that were negative the participants were almost exclusively acute episodes of lateral epicondylitis.  The study really shows how effective shockwave is for chronic cases of lateral epicondylitis.

Where can I get shockwave therapy for this condition?

One is able to get shockwave therapy at a few specialist clinics in the UK.  There are a growing number of clinics providing this specialist form of treatment.  It is beneficial to make certain the type of machine they use is a swiss dolor clast machine as this is the only one that has been tested to high level in research papers.
At Perfect Balance Clinic we often see people with different types of Tendinopathy who have tried other forms of treatment.  Shockwave for us has been the one form of treatment that has consistently delivered results for Tendinopathy.

How long will the shock wave treatment session last?

If everything goes to plan with your shockwave therapy for Tennis elbow then the treatment should make a significant contribution to reducing the pain and improving the function of your Tennis elbow.  In most cases the shockwave will get rid of the patellar tendinitis.
With some tendon surgery there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result.  Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.

Conclusions

Extracorporeal shockwave therapy is a safe an effective treatment modality in the management of chronic cases of tennis elbow.  In most cases the outcome can better than alterative more invasive procedures.

References

  1. Ashe MC, McCauley T, Khan KM (2004) Tendinopathies of the upper extremity. A paradigm shift. J Hand Ther, 17, 329–334.
  2. Boyer MI, Hastings H (1999) Lateral tennis elbow: is there any science out there? J ShoulderElbow Surg, 8, 481–491.
  3. Buchbinder R, Green S, Bell S et al. (2002) Surgery for lateral elbow pain (Cochrane review). Cochrane Database Syst Rev, CD003525.
  4. Chalmers TC, Smith H, Blackburn B et al. (1981) A method for assessing the quality of a randomized control trial. Control Clin Trials, 2, 31–49.
  5. Chir, 129, 252–260.
  6. Cole BJ, Schumacher HR (2005) Injectable corticosteroids in modern practice. J Am Acad rthop Surg, 13, 37–46.
  7. Crowther A, Bannister GC, Huma H et al. (2002) A prospective study to compare extracor- poreal shock wave therapy and injection of steroid for the treatment of tennis elbow. JBJS, 84-B, 678–679.
  8. Erak S, Day R, Wang A (2004) The role of supinator in the pathogenesis of chronic lateral elbowpain: a biomechanical study. J Hand Surg [Br], 29, 461–464.
  9. Kraushaar BS, Nirschl RP (1999) Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. JBJS, 81-A, 259–278.
  10. Mehra A, Zaman T, Jenkin AI (2003) The use of a mobile lithotripter in the treatment of tennis elbow and plantar fasciitis. Surg J R Coll Surg Edinb Irel, 1, 290–292.
  11. Melegati G, Tornese D, Bandi M et al. (2004) Comparison of two ultrasonographic localisation techniques for the treatment of lateral epicondylitis with extracorporeal shock wave therapy: a randomized study. Clin Rehabil, 18, 366–370.
  12. Nirschl RP, Rodin DM, Ochiai DH et al. (2003) Iontophoretic administration of dexamethasone sodiumphosphate for acute epicondylitis. Am J Sports Med, 31, 189–194.
  13. Rompe JD, Decking J, Schoellner C et al. (2004) Repetitive low energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med, 32, 734–743.
  14. Rompe JD, Hopf C, Kullmer K et al. (1996) Analgesic effects of extracorporeal shock wave therapy on chronic tennis elbow. J Bone Joint Surg, 78-B, 233–237.
  15. Scott A, Khan KM, Roberts CR et al. (2004) What do we mean by the term ‘inflammation’? A contemporary basic science update for sports medicine. Br J Sports Med, 38, 372–380.
  16. Sems A, Dimeff R, Ianotti JP (2006) Extracorporeal shock wave therapy in the treatment of chronic tendinopathies. J Am Acad Orthop Surg, 14, 195–204.
  17. Smidt N, Lewis M, van der Windt DA et al. (2006) Lateral epicondylitis in general practice: course and prognostic indicators for outcome. J Rheumatol, 33, 2053–2059.
  18. Spacca G, Necozione S, Cacchio A (2005) Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Eur Med Phys, 41, 17–25.
  19. Speed C, Nichols D, Richards C et al. (2002) Extracorporeal shock wave therapy for lateral epicondylitis: a double blind randomized controlled trial.J Orthop Res,20,895–898.
  20. Stasinopoulos D, Johnson MI (2005) Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med, 39, 132–136.
  21. Teitz CC, Garrett WE, Miniaci A et al. (1997) Tendon problems in athletic individuals. JBJS, 79-A, 138–152.
  22. Theis C, Herber S, Meurer A et al. (2004) Evidence-based evaluation of present guidelines for the treatment of tennis elbow—a review. Zentralbl
  23. Walker-Bone K, Palmer KT, Reading I et al. (2004) Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum, 51, 642–651.
  24. Whaley AL, Baker CL (2004) Lateral epicondylitis. Clin Sports Med, 23, 677–691.

Leave a Reply