Physical therapy, corticosteroid injection, and extracorporeal

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1 DOI /s y ORIGINAL ARTICLE Physical theray, corticosteroid injection, and extracororeal shock wave treatment in lateral eicondylitis Clinical and ultrasonograhical comarison Rukiye Gündüz & Fevziye Ünsal Malas & Pınar Borman & Seher Kocaoğlu & Levent Özçakar Received: 3 March 2011 /Revised: 16 August 2011 /Acceted: 8 January 2012 # Clinical Rheumatology 2012 Abstract The aim of this study was to comare clinically and ultrasonograhically the theraeutic effects of hysical theray modalities (hot ack, ultrasound theray, and friction massage), local corticosteroid injection, and extracororeal shock wave treatment (ESWT) in lateral eicondylitis (LE). Fifty-nine elbows of 59 atients with LE were randomized into three treatment s receiving either hysical theray, a single corticosteroid injection, or ESWT. Visual analogue scale (VAS) was used to assess ain intensity, Jamar hydraulic dynamometer for gri strength, finger dynamometer for inch strength (before treatment, on the first, third, and sixth s of treatment). All subjects were also evaluated with ultrasonograhy before and 6 s after treatment. In all s, VAS scores of the atients were found to decrease significantly on the first, third, and sixth s of treatment. With resect to gri strength evaluations, the increase after treatment was significant only on the first in II; on the first and third s in I; and on the first, third, and sixth s of treatment in III. Pinch strength and ultrasonograhical findings did not change during follow-u in any. We imly that hysical theray modalities, corticosteroid injection, and ESWT have favorable effects on ain and gri strength in the early eriod of LE treatment. The increase in gri strength lasts longer with ESWT. On the other hand, R. Gündüz : P. Borman : S. Kocaoğlu : L. Özçakar Physical Medicine and Rehabilitation Clinic, Ankara Training and Research Hosital, Ankara, Turkey F. Ü. Malas : L. Özçakar (*) Deartment of Physical Medicine and Rehabilitation, Hacettee University Medical School, Ankara, Turkey lozcakar@yahoo.com ultrasonograhic findings do not change in the first six s of these treatment methods. Keywords Corticosteroid injection. Extracororeal shock wave treatment. Lateral eicondylitis. Physical theray. Ultrasonograhy Introduction Lateral eicondylitis (LE) is the most common cause of elbow ain in the adult oulation [1]. It is an overuse tye of injury ertaining to the common extensor tendon of the dominant uer extremity. The diagnosis is generally clinical [2, 3]; however, in atients with ersistent findings desite treatment or in atients who are lanned to undergo surgery, imaging might be necessary. In this regard, sonograhic evaluation for injuries of the extensor tendon, the cortex of the lateral eicondyle, or nearby soft tissues is noteworthy [4]. The treatment of LE is mainly conservative and encomasses education and ergonomic advice of the worklace, dee tendon friction massage, mobilization and maniulations, hysiotheray alications, stretching/strengthening exercises, slints and orthoses, and local corticosteroid injections [5 10]. A number of treatments, including acuuncture, exercise theray, maniulations and mobilizations, ultrasound, honohoresis, and iontohoresis, showed ositive effects in the reduction of ain or imrovement in function for atients with LE [9]. In a recent systematic analysis, shockwave theray and Cyriax theray had also been determined as effective hysical theray interventions for the treatment of LE [10]. Although few, comarison between treatment alternatives has been studied in the literature with conflicting results and no single intervention

2 has been roven to be the most efficient [6 10]. Accordingly, the aim of this study was to comare clinically and ultrasonograhically the theraeutic effects of hysical theray, local corticosteroid injection, and extracororeal shock wave treatment (ESWT) in LE. Methods The study comrised 59 consecutive atients who were diagnosed as LE between August 2008 and Aril Figure 1 summarizes the flowchart regarding atients enrollment. All atients were informed about the study rocedure, and they have given written consent to articiate. The study rotocol was aroved by the local ethics committee. Inclusion criteria were as follows: ain on the lateral side of the elbow that was severe enough to interfere with their daily living activities (for less than 3 s), tenderness over the lateral eicondyle comared with that of the normal elbow, and ain during extension of wrist and fingers against resistance. Subjects with the resence of any of the following were excluded: revious treatment for isilateral LE, other elbow athologies, cervical vertebrae/uer limb disorders, revious elbow surgery, joint limitations due to a revious radius/ulna fracture, osteoorosis, malignancy, hemohilia, neurological deficit(s) in the isilateral uer limb, and cognitive dysfunction. Demograhic data of the subjects were recorded. Visual analogue scale (VAS) was used to assess ain intensity in the last 24 h, on the area of lateral eicondyle. Gri strength was measured by Jamar hydraulic dynamometer as described elsewhere [11]. Mean of three evaluations was recorded. Pinch strength was measured by finger dynamometer (inch meter) from first and the second fingers. Mean of three evaluations was recorded for each finger. Clinical evaluations for LE including the assessment of ain intensity, gri and inch strengths were erformed and scored as described by Verhaar et al. [12]. Fifty-nine elbows of 59 subjects were randomly allocated to attend either hysical treatment modalities including hot ack, ultrasound (US) theray and friction massage, or steroid injection theray, or ESWT treatment. Casual randomization using sealed numbered enveloes without strata or blocks was erformed by an administrative assistant. The same hysician blinded to the randomization evaluated all the atients before treatment and on the first, third, and sixth s of treatment. Grou I (n019) received hysical treatment modalities including hot ack (15 min), ultrasound theray (1 W/cm 2, 5 min) and friction massage (5 min) for ten sessions. Grou II (n020) received a single injection of 20 mg methylrednisolone acetate and 1 ml rilocaine. Grou III (n020) was treated with ESWT (ressure 1.4 bar, frequency 4.0 Hz, number 500) for ten sessions (1 day interval between the sessions). All subjects were also evaluated with ultrasonograhy (8 16 MHz linear robe; Diasus Dynamic Imaging, UK) before and 6 s after treatment by another hysician blinded to atient data. The thickness/echogenicity of the common extensor tendon and bony cortex of the lateral eicondyle were assessed during sonograhic imaging (while atients were seated, elbows flexed and ronated). Fig. 1 Flowchart diagram for the articiants who were randomized into three s as receiving hysical theray, corticosteroid injection, and ESWT Assessed for eligibility(n=85) Enrollment Randomization Excluded (n= 26) Not meeting in clusion criteria (n=23) Refused to articiate (n=3) Physical Theray (N=19) Corticosteroid injection (N=20) ESWT (N=20) Analyzed (N=19) Analyzed (N=20) Analyzed (N=20)

3 Table 1 Demograhic features of the subjects according to s Grou I Grou II Grou III Age 43.6± ± ± Sex Male 5 (26.3%) 8 (40.0%) 8 (40.0%) Female 14 (73.7%) 12 (60.0%) 12 (60.0%) Body mass index 27.4± ± ± Side of involvement Right 15 (78.9%) 13 (65.0%) 15 (75.0%) Left 4 (21.1%) 7 (35.0%) 5 (25.0%) Dominant hand Right 19 (100%) 18 (90.0%) 20 (100%) Left 0 (0%) 2 (10.0%) 0 (0%) Disease duration 30 (7 90) 30 (2 90) 30 (1 90) Statistical analysis was erformed with Statistical Package for Social Sciences, version Shairo Wilk test was used to analyze normal distribution of the data. Descritive statistics were exressed with mean±standard deviation, median (min max), and ercentage values. Grous were comared with one-way ANOVA, Kruskal Wallis, and chisquare tests where aroriate. Correlation analysis was done with Searman correlation coefficients. Wilcoxon and McNemar tests were used to comare reeated measures/ evaluations within each. Statistical significance was set at <0.05, and Bonferroni correction was used for avoiding tye I error. Results Demograhic features of the subjects are given in Table 1. The three s were similar with resect to age, sex, body mass index, dominant hand, disease duration, and side of involvement (all >0.05). In all s, VAS scores of the atients were found to decrease significantly on the first, third, and sixth s of treatment (Table 2). Further, in III, the scores ertaining to the sixth evaluations were lower than those of the first. With resect to gri strength evaluations, the increase after treatment was significant only on the first in II; on the first and third s in I; and on the first, third, and sixth s of treatment in III (Table 3). Pinch strength values were found not to have changed between follow-u measurements in any (Table 4). Overall, the changes regarding VAS, inch and gri strength measurements were found to be similar between the s on the first, third, and sixth s of treatment (Tables 5, 6, and 7). When comared with the initial measurements, the extensor tendon thicknesses did not change significantly on the sixth control in any (Table 8). Further, the changes were also similar between the s (Table 9). Likewise, cortical irregularities or echogenicity Table 2 The VAS ain scores of the atients in different treatment s in regard to follow-u duration VAS ain BT AT first AT third AT sixth Physiotheray 8 (5 9) a,b,c 3(0 8) a 2(0 8) b 2(0 5) c Injection 8 (6 10) a,b,c 2.5 (0 8) a 2(0 8) b 2(0 8) c ESWT 8 (5 8) a,b,c 3.5 (0 8) a,d 2(0 8) b 2(0 8) c,d a The difference between BT and first AT is statistically significant b The difference between BT and third AT is statistically significant c The difference between BT and sixth AT is statistically significant d The difference between first and sixth follow-u AT is statistically significant (<0.003) Table 3 The gri strength scores of the atients in different treatment s in regard to follow-u duration Gri strength BT AT first AT third AT sixth Physiotheray 10 (0 35) a,b 20 (4 40) a 20 (10 40) b 20 (5 40) Injection 20 (0 40) a 25 (5 45) a 22.5 (0 50) 20 (0 50) ESWT 20 (0 50) a,b,c 20 (0 55) a 22.5 (0 55) b 22.5(0 55) c a The difference between BT and first AT is statistically significant (<0.003) b The difference between BT and third AT is statistically significant c The difference between BT and sixth AT is statistically significant

4 Table 4 The inch strength scores of the atients in different treatment s in regard to follow-u duration Table 6 The changes in the gri strength scores of the atients at first, third, and sixth s according to the treatment s Pinch strength BT AT first AT third AT sixth Gri strength Physiotheray Injection ESWT Physiotheray 8(4 16) 9 (7 16) 9 (4 16) 9 (4 16) Injection 8 (4 14) 9 (4 14) 9 (7 14) 9 (7 14) ESWT 8 (0 14) 9 (2 14) 9 (2 14) 9 (2 14) BT AT first BT AT third 5(0 15) 5 (0 20) 5 (0 15) (0 15) 5.5 ( 20 to 20) 7.5 (0 20) ( 15 to 20) 8.5 ( 20 to 18) 7.5 (0 20) of the extensor tendon did not change during follow-u (>0.05). Discussion Our results have shown that ain and gri strength of LE atients imroved after hysical theray, injection, and ESWT; however, those changes were not reflected to ultrasonograhic findings. Thereareseveraltreatment choices in LE. Although hysical treatment modalities have been mentioned to be effective in the early eriod, data regarding their long-term effects are limited [8]. Local corticosteroid injection has been shown to decrease ain in the early eriod, and ESWT has recently been roosed as another nonsurgical treatment alternative [7 10, 13 17]. Trudel et al. [9] reorted at least level 2b evidence for a number of treatment choices including exercise theray, maniulation/mobilization, acuuncture, US, honohoresis, and iontohoresis in their systematic review, while Kohia et al. [10] indicated only shockwave theray and Cyriax theray rotocol as effective hysical theray interventions. In their study, Smidt et al. [16] havecomaredthree treatment s and found that corticosteroid injection yielded more favorable results (ain and gri strength) than hysical treatment modalities (US, massage, exercise) or wait-and-see olicy in the early eriod (at 6 weeks). On the other hand, in the long-term followu (at 52 weeks), hysical theray modalities were found to be better than corticosteroid injection but no different than wait-and-see olicy. The effects of corticosteroid injection have been shown to range from 80% to 90.9% in various studies [17, 18]. Verhaar et al. concluded that corticosteroid injection was more effective than Cyriax hysiotheray at the end of 6 weeks in atients with LE [13]. It has also been reorted to be suerior to ESWT concerning the decrease in ain scores of the subjects (at 3 s) [19]. In our study, decrease in ain was observed on the first, third, and sixth s after treatment in all s. Imrovement in gri strength was resent on the first of injection treatment, on the third of hysical theray and on the sixth of ESWT, indicating the longer beneficial effects of ESWT than in other theraies. Systematic reviews that had evaluated the effectiveness and safety of ESWT in the treatment of LE existed with conflicting results in the literature [6 8, 20 25]. The effect of ESWT in LE treatment has been found favorable in some studies [21 23]. On the contrary, some other studies did not find ESWT better than lacebo [6, 24, 25]. Moreover, latter ones have also mentioned about certain local side effects like erythema, ain, and small hematomas. Some studies indicated limited evidence that showed ESWT suerior to surgery and other conservative theraies and did not suort Table 5 The changes in the VAS ain scores of the atients at first, third, and sixth s according to the treatment s Table 7 The changes in inch strength scores of the atients at first, third, and sixth s according to the treatment s VAS ain Physiotheray Injection ESWT Pinch strength Physiotheray Injection ESWT BT AT first BT AT third 4 ( 8 to0) 4 ( 8 to 0) 3.5 ( 8 to 0) ( 8 to0) 5.5 ( 8 to 0) 4.5 ( 8 to 0) ( 8 to 0) 6 ( 8 to 0) 6 ( 8 to 0) BT AT first BT AT third 0(0 5) 0 ( 3 to 5) 0 (0 9) ( 4 to 5) 0 ( 2 to 5) 0 (0 11) ( 4 to 5) 0 (0 5) 0 (0 11) 0.627

5 Table 8 The common extensor tendon thickness scores of the atients in different treatment s in regard to follow-u duration CET thickness (mm) BT AT 6th * Physiotheray 49 (40 62) 45 (37 61) Injection 46.5 (32 55) 43 (37 50) ESWT 43 (26 52) 39.5 (22 52) CET common extensor tendon, *<0.017 was set as statistically significant after Bonferroni correction the use of ESWT due to the lack of convincing evidence in regard to its effectiveness [20, 21]. In our study, ESWT treatment was alied every other day without any local anesthesia for ten sessions and any side effect was not observed. Both VAS scores and gri strength values of the atients were found to be significantly better on the first, third, and sixth s after treatment when comared to those before treatment. In addition the beneficial effects of ESWT on gri strength lasted longer (6 s) than the other two treatment methods in our study. Herein, we attribute the differences between our data and some of the revious study results, to the alied ESWT rotocols that are not uniform in the literature [20 25]. Current studies are heterogeneous in terms of the duration of the disorder; tye, frequency, and total dose of SWT; and eriod of time between theraies, timing of follow-u, and outcomes assessed. Therefore we are unable to make a direct comarison between our chosen rocedure and other study designs for the effectiveness of ESWT. Combined hysical theray interventions have reviously been used in several studies [5, 8, 9]. Stuijs et al. [26] useddeefrictionmassage,ultrasoundtheray,and exercises as a comarator for wrist maniulation in the treatment of LE and reorted similar effectiveness between manual theray and combined hysical treatment modalities at the end of 6 weeks. Stratford et al. evaluated the effectiveness of US alone or in combination with friction massage for decreasing ain in LE and indicated similar results for each [9, 27]. Studies with US, alone or combined with other modalities, Table 9 The changes in the common extensor tendon thickness scores of the atients before theray and sixthsaccordingtothe treatment s CET thickness (mm) Physiotheray Injection ESWT 1( 18 to 5) 3( 15 to 11) 1.5 ( 9 to 3) CET common extensor tendon, concluded more functional and ain imrovement than in lacebo s [5, 8, 9, 14]. Also a systematic review showed beneficial effects of US alone or in combination with other treatments with regard to decreasing ain in the treatment of atients with LE [9]. In our study we have determined similar imrovements in hysical theray modalities, steroid injection theray, and ESWT in regard to ain and gri strength levels at the end of first and third s, suorting the revious data about combined hysical theray modalities in LE. Although the diagnosis of LE is mainly clinical, due to its myriad advantages, US has been used as a convenient imaging method for the diagnosis and follow-u of LE [4, 28 30]. Ultrasonograhic findings (hyoechoic/swollen tendon, enthesoathy) have been found not to correlate with the ain scores of the subjects though [4]. In our study, we have tried to observe whether we could quantify the changes also by using extensor tendon thickness measurements (not studied before). Clarke et al. [29] evaluated sonograhic redictors for tendon healing in atients with LE tendinoathy and found no correlation with clinical findings and thickness of the tendon. Zeisiq et al. [30] followed u 25 atients with LE after intertendinous injection theray but could not indicate a relationshi with structural changes in US and clinical results. Our ultrasonograhic findings not correlating with the clinical findings were in line with the revious studies [29, 30], and we believe that the absence of correlation could stem from the time of evaluation. Therefore, the changes would be ensuing later than the sixth osttreatment. The absence of a lacebo would erhas be considered as a limitation of this study. Herewith, the rimary aim of this study was to comare the three treatment methods, not to show their individual effects. Additionally, more than one lacebo would be needed since all three methods are quite different regarding their way of alication. In the time frame of 3 s, the clinical resentation of LE may vary considerably, therefore our inclusion criterion of atients having LE ain within 3 s may also be a limitation of the study. Likewise, the lack of intention to treat analysis before our setting could be another drawback of the study. In the light of our results, we may conclude that hysical theray modalities, corticosteroid injection, and ESWT with the chosen rocedures have similar and favorable effects on ain and gri strength in the early eriod of LE treatment. Further, the beneficial effects of ESWT on gri strength last longer (6 s) than the other two treatment methods. Last but not the least, the imrovement in ain and gri strength does not seem to be reflected to the ultrasonograhic findings in the first sixth s of treatment. Further studies with longer follow-u would be necessary in this regard.

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