Applications in Musculoskeletal Disorders - part 6 docx

6 Extracorporeal Shock Wave Application in the Treatment
of Chronic Tennis Elbow
Introduction
The causes of tennis elbow remain unclear
(Chard and Hazleman 1989, Pienimäki et al.
1998). While most authors attribute pain at
the lateral epicondyle to overstrain of the
insertion of the m. extensor carpi radialis bre-
vis and consequent local angiofibroblastic
tendinosis (Finestone and Helfenstein 1994,
Foley 1993, Kraushaar and Nirschl 1999, Roe-
tert et al. 1995), there are reports suggesting a
reflex chain between intervertebral joint dys-
function and peripherally localized soft-tissue
pain syndromes (Sutter 1995, Waldis 1989,
Wanivenhaus 1986, Wyke 1979). Wright et al.
(1994) write that neuronal changes within the
spinalcordmightbemoreimportantthan
peripheral nociceptor sensitization in the
development of chronic musculoskeletal dis-
orders such as tennis elbow. This is in accor-
dance with reports of an association between
lateral epicondylitis and a dysfunction in the
cervical spine and at the cervicothoracic junc-
tion in more than 80% of patients (Ehmer
1998). Cyriax (1982), however, argues that at
the age of 40-60 years it is hightly probably
that any patient suffering from chronic lateral
epicondylitis would have radiographical evi-
dence of cervical spondylosis as well. He
denies that pain in the elbow provoked by

wrist movements could have the neck as its
origin. Labelle et al. (1992) conclude that con-
servative procedures in tennis elbow lacked
any scientific basis. Boyer and Hastings (1999)
also find no conclusive studies on operative
and nonoperative treatment concepts.
Newtreatmentmethodshavesincebeen
undergoing trials. The finding that physical
stimuli are capable of activating endogenous
nociceptive control systems has led to the use
of shock waves in the treatment of persistent
tennis elbow (Rompe et al. 1996a). Extracor-
poreal shock wave therapy (ESWT) was said to
fulfill major properties of hyperstimulation
analgesia, but the exact mechanism of pain
reduction produced by ESWT is still unknown
(Melzack 1994). Nevertheless, success rates of
50% were achieved in prospective, con-
trolled studies on recalcitrant tennis elbow
and plantar fasciitis (Heller and Niethard
1998). The current study reports a comparison
of patients treated with shock waves and
manual therapy of the cervical spine with age-
matched cases receiving only shock wave
therapy (SWT) in a single unit (Rompe et al.
2001a).
Fig. 6.1 Treatments
received before ESWT.
LA: Local anesthetic.
Materials and Methods

Included in this study were patients present-
ing with chronic lateral epicondylitis of the
elbow in our university hospital.
Inclusion Criteria
Inclusion criteria were: pain over the lateral
epicondyle for more than 6 months; unsuc-
cessful conservative therapy during the 6
months prior to referral to our hospital; at least
10 physical therapy visits (electrotherapy, ion-
tophoresis,cryotherapy,orultrasound)(Fig.
6.1); at least three local injections (steroid and/
or local anesthetic) (Fig. 6.2); at least two of the
following provocation tests positive: 1. palpa-
tion of the lateral epicondyle; 2. resisted wrist
extension(Thomsentest:withtheshoulder
flexed to 60°, the elbow extended, the forearm
pronated, and the wrist extended about 30°,
pressure is applied to the dorsum of the second
and third metacarpal bones in the direction of
flexion and ulnar deviation to stress the m.
extensor carpi radialis brevis and longus); 3.
resisted finger extension (with the shoulder
flexed to 60°, the elbow extended, the forearm
pronated, and the fingers extended the middle
finger is actively extended against resistance);
4. Chair test (with the shoulder flexed to 60°,
and the elbow extended the patient attempts
to lift a chair weighing 3.5kg); signs of cervical
dysfunction with persistent pressure pain at
the C4/C5 and/or C5/C6 level, protraction posi-

tion of the head.
Fig. 6.2 Atrophy of the skin after multiple corticoste-
roid injections.
6 Extracorporeal Shock Wave Application in the Treatment of Chronic Tennis Elbow40
Exclusion Criteria
Exclusion criteria were: age less than 18
years; pregnancy; previous operations on the
lateral epicondyle; previous manual therapy
to the cervical spine; bilateral epicondylitis;
osteoarthritis of the elbow joints; pathologi-
cal, neurological, and/or vascular findings of
the upper extremity; provocation of pain in
the lateral elbow when examining the cervical
spine; local infection of the upper extremity;
tumorous disease of the upper extremity;
rheumatoid arthritis; coagulopathy; other
treatments or drugs used in the 6 weeks
beforethetrialsbeganandduringthefirst3
months after ESWT.
Group I
Group I comprised 30 patients suffering from
lateral elbow pain and neck pain. All patients
were referred to our shock wave unit for treat-
ment of a recalcitrant epicondylitis. These
patients received SWT and manual therapy to
the cervical spine.
There were 16 women, 14 men, with a mean
age of 47 years (range: 35–65 years) and a
mean duration of pain of 38 months (range:
12–180 months). There were 27 right-handed

individuals; the dominant side was affected in
25 cases. A mean of 5.4 ± 1.5 conservative
treatment procedures had been carried out
without success. The patients were not able to
workforanaverageof4.4±7.2weeksbefore
the first ESWT.
Group II
For each elbow studied, a control matched by
age (3-year band) and sex at first conservative
treatment was drawn at random from a series
of 146 patients who had undergone a mono-
therapy with low-energy shock waves in the
same unit in the past 3 years (group II).
There were 16 women and 14 men, with a
mean age of 48 years (range: 37–68 years) and
ameandurationofpainof40months(range:
12–208 months). There were 26 right-handed
patients; the dominant arm was affected in 27
patients. An average of 5.5 ± 1.8 unsuccessful
conservative therapy procedures had been
carried out. The mean period of inability to
work was 4.5 ± 8.9 weeks before the first
ESWT started.
Method of Treatment
The ESWT was applied by an easily maneuver-
able therapy unit especially designed for
orthopedic use (Sonocur Plus, Siemens AG,
Erlangen, Germany), with the shock wave
head suspended from an articulating arm for
flexible movement of the head in three planes.

The shock wave head was equipped with an
electromagnetic shock wave emitter. Shock
wave focus guidance was established by in-
line integration of an ultrasound probe—a
7.5 MHz sector scanner—in the shock head.
According to the consensus report (Wess et al.
1997) the features of the device, measured
with a fiberoptic hydrophone, are listed in
Table 6.1.
Both groups were treated under the same
conditions and the patients were treated sin-
gly to avoid influencing one another. Three
times, at weekly intervals, 1000 impulses of
0.16 mJ/mm
2
were administered at the ante-
rior aspect of the lateral epicondyle at a fre-
quency of 4 Hz (Fig. 6.3). No local anesthesia
was applied to the treated area, although the
treatment is moderately painful.
After the last ESWT, patients from group I
were referred to physiotherapists certified for
manual therapy who had been instructed to
perform soft mobilization therapy of the cer-
vical spine and of the cervicothoracic junction
to relieve pain in the C4/C5 and C5/6 motion
segments, and to correct the observed pro-
traction of the head due to an increased
kyphosis of the neck (Butler 1995). Therefore,
extension mobilization of the cervicothoracic

Method of Treatment 41
Table 6.1 Fiberoptic data on the shock wave device
1
Physical Value Unit Energy level 1
(Minimum
value)
Energy level 2
(Mean value)
Energy level 3
(Maximal
value)
Peak positive pressure P
+
Mpa 5.5 14.2 25.6
–6 dB focal extend in x,y,z direction f
x(-6dB)
f
y(-6dB)
f
z(-6dB)
mm
mm
mm
6.0
6.0
58
5.2
5.2
55
4.8

4.8
49
5MPafocal extent,lateral f
x(5 Mpa)
f
y(5 Mpa)
mm
mm
2.2
2.2
7.8
7.8
19
19
Positive energy flux density ED
+
mJ/mm
2
0.016 0.09 0.22
Total energy flux density ED mJ/mm
2
0.04 0.24 0.56
Positive energy of –6dB focus E
+(-6 dB)
mJ 0.38 1.6 3.5
Total energy of –6 dB focus E
(-6 dB)
mJ 1.1 4.0 9.0
Positive energy of 5MPa focus E
+(5 Mpa)

mJ 0.5 1.8 9.2
Total energy of 5 MPa focus E
(5 Mpa)
mJ 1.8 4.8 24
Positive energy of 5mm focal area E
+(5 mm)
mJ 0.24 1.26 3.5
Total energy of 5mm focal area E
(5 mm)
mJ 0.63 3.0 9.0
Rise time t
r
ns 750 615 481
Pulse width t
p+
ns 1380 1160 920
1
The Sonocur Plus provides eight user-selectable
energy levels. The physical data listed in the table are
typical values for the minimum energy, medium
energy, and maximum energy. The shock wave param-
eters are described according to the consensus meet-
ing in February 1997 (Wess et al. 1997). All measure-
ments were made using a fiberoptic hydrophone.
Fig. 6.3 ESWT with the ultrasound-guided Sonocur
Plus device.
Fig. 6.4 Mobilization of the cervical spine.
6 Extracorporeal Shock Wave Application in the Treatment of Chronic Tennis Elbow42
Fig. 6.5 Evaluation of grip strength with the JAMAR
hand dynamometer.

junction (e.g., Maitland (1991) grade IV)
(Fig. 6.4) and flexion mobilization of the high
cervical joints was recommended (e.g., Mait-
land grade IV). For the intermediate cervical
segments traction and glide movements were
suggested (e.g., Maitland grade II or III minus).
No therapeutic procedures were to be admin-
istered to the lateral elbow. Ten treatment
sessions were held after the last ESWT.
Follow-ups, by an independent observer, were
done 3 months and 12 months after the last
application of the extracorporeal shock waves.
Method of Evaluation
At all follow-ups the patients were asked
abouttheirpainassessmentcomparedtopre-
treatment conditions. The total outcome was
rated following Roles and Maudsley (1972):
—Excellent: No pain, full movement, full
activity;
—Good: Occasional discomfort, full
movement, full activity;
—Acceptable: Some discomfort after pro-
longed activities;
—Poor: Pain limiting activities.
The Roles and Maudsley outcome score at the
12-month follow-up was defined as the main
outcome measure. The extent of pain was
specified using a Visual Analogue Scale (VAS)
ranging from 0, i.e., no pain, to 10, i.e., maxi-
mal pain. The examination was carried out

independently of the treating physician and
comprised the same four diagnostic tests that
determined entry into the study. Additionally,
grip strength was measured bilaterally at the
extended and pronated forearm with a vigori-
meter (Jamar Dynamometer, Preston Health-
care,Jackson,UnitedStates),thepressure
being registered in kp/cm
2
. Reduction of pain
andgripstrengthcomparedtotheunaffected
side were regarded as secondary outcome
parameters (Fig. 6.5).
Statistics
For statistical analysis, the Wilcoxon–Mann–
Whitney test for two independent samples,
the t-test for the normally distributed vari-
ables of the vigorimeter measures, and the
Fisher exact test and its extension to r× c
tables were used to compare the two groups.
Comparison between different examinations
were done by means of the Wilcoxon test and
t-test, respectively, for dependent samples,
and the McNemar test. The level of signifi-
cancewassetat95%.Testedcomparisons
with p-values 5%wereconsideredtobesig-
nificantly different.
Method of Evaluation 43
Table 6.2 Total outcome according to Roles and Maudsley
0 months 3-month

follow-up
12-month
follow-up
Group I
(n=30)
Group II
(n=30)
Group I
(n=30)
Group II
(n=30)
Group I
(n=27)
Group II
(n=25)
Excellent – – 13.3% 23.3% 22.3% 24.0%
Good – – 26.7% 26.7% 33.3% 36.0%
Acceptable – – 43.3% 33.3% 33.3% 20.0%
Poor 100% 100% 16.7% 16.7% 11.1% 20.05
Table 6.3 Pain rating on the Visual Analogue Scale (VAS)
1
0 months 3 months 12 months
Group I Group II p-value Group I Group II p-value Group I Group II p-value
Pressure pain 6.21± 2.65 6.15 ± 2.43 0.28 3.99 ± 2.74 3.59 ±2.29 0.65 2.27 ± 2.59 1.97± 2.05 0.82
Thomsen test 6.18± 1.72 6.24 ± 1.74 0.60 3.69 ± 2.52 3.86 ± 2.28 0.55 1.93 ±1.97 2.09 ± 2.01 0.71
Resisted finger
extension
4.62 ± 3.29 4.97 ± 2.84 0.18 2.77 ± 2.29 3.01 ± 3.32 0.58 1.45± 1.84 1.66 ± 1.79 0.57
Chair test 5.46 ± 2.11 5.59 ± 2.13 0.54 2.98 ± 2.46 3.00± 2.40 0.81 1.91± 2.51 1.97 ± 2.27 0.76
1

mean ± standard deviation
Results
There was no difference between the groups
concerning the affected side, sex, age, period
of pain, period of inability to work, and num-
ber of conservative treatment procedures.
All the patients were examined at 3 months.
Twelve (40%) patients in group I and 15 (50%)
patients in group II reached an “Excellent” or
“Good” result. Additionally, the patients were
asked to estimate the improvement of pain in
percent, 0% meaning no relief, 100% meaning
complete relief of symptoms. Mean subjective
improvement of the symptoms was rated at
62 ± 27% in group I and at 60 ± 34% in group II.
Mean grip strength increased to 91% of
theunaffectedsideingroupIandto94%in
group II.
After12monthsweevaluated27patients
from group I and 25 from group II. At this
point in time we observed 15 (55.5%) “Excel-
lent” or “Good” results in group I and 15 (60%)
“Good” or “Excellent” results in group II (Table
6.2). Mean subjective improvement was 75 ±
23% in group I and 72 ± 33% in group II. Mean
grip strength compared to the contralateral
side now amounted to 100% in group I and to
101 % in group II.
The data concerning VAS ratings for 3
monthsand12monthsaresummarizedin

Table 6.3. With the numbers available there
was no statistically significant difference
between group I and group II concerning the
Roles and Maudsley score (extended Fisher
test) and the VAS rating (Wilcoxon test for
independent samples). Within the two groups
there was a highly significant improvement in
the VAS and of the Roles and Maudsley out-
come score at both follow-ups compared with
pretreatment conditions (p 0.0001).
Additional Treatment
No patient reported additional treatment at
the assessment of results at 12 weeks.
Between 3 and 12 months, three patients in
group I and two patients in group II had
undergone a release operation. In group I two
patients required occasional pain medication;
6 Extracorporeal Shock Wave Application in the Treatment of Chronic Tennis Elbow44
Fig. 6.6 Hematoma
after low-energy ESWT
of the lateral elbow.
three regularly. In group II four patients took
pain medication on a regular basis; three
occasionally. With the numbers available
there was no statistically significant differ-
ence between group I and group II with regard
to additional treatment.
Complications
Besides petechial bleeding (Fig. 6.6), which
occurred in 7 out of 60 patients, no adverse

effects were recorded.
Discussion
The biological working mechanism of shock
wave application (SWA) is poorly understood.
Haake et al. (2001) fail to demonstrate any spi-
nal response to low-energy SWA on the endog-
enous opioid systems in rats. Schmitz (2001)
reports an investigation on alterations of neu-
ropeptides after applying 1500 shock waves of
an energy flux density of 0.9 mJ/mm
2
to the
intact rabbit femur. When measuring the con-
centrations of substance P eluated from the
femurperiosteumcomparedtotheuntreated
contralateral limb, release of substance P had
increased 6 hours and 24 hours after SWA, but
had decreased 6 weeks after SWT. Remarkably,
there was a close relationship between the
time course of the release of substance P and
thewell-knownclinicaltimecourseofinitial
pain occurrence and subsequent pain relief
after SWA for tendon diseases.
According to a review of the literature by
Heller and Niethard (1998), the first prospec-
tive controlled study on the effectiveness of
extracorporeal shock waves for the treatment
of chronic tennis elbow was published in
1996.Atthe6-monthfollow-up48%“Good”
or “Excellent” outcomes in the treatment

group compared to 6% in the control group
were reported according to the Roles and
Maudsley score (Rompe et al. 1996a). Krischek
et al. (1999) prospectively compare the anal-
gesic effects of ESWT in patients with recalci-
trant lateral or medial epicondylitis. With
regard to the Verhaar score (Verhaar et al.
1993) they report 62% “Good/Excellent” out-
comes in patients with tennis elbow after 1
year compared to 28% in patients with golfer
elbow. Perlick et al. (1999a) prospectively
compare the outcome after ESWT and after
Discussion 45
surgery in 60 patients with chronic tennis
elbow. They describe “Good” or “Excellent”
results according to the Roles and Maudsley
score in 43% and 73% at the 12-month follow-
up. Twenty-three percent versus 10% of the
patients reported no improvement at all.
Haake and Boeddeker (2001) analyze early
results of a prospective placebo-controlled,
double-blinded, multicenter trial on 272
patients. Group I was treated three times, at
weekly intervals, with 2000 low-energy
impulses under local anesthesia; group II
received sham therapy. After 3 months an
identical successful outcome was observed in
only25%ofpatientsinbothgroups.vomDorp
et al. (2001) report preliminary results of 40
out of 114 patients involved in a randomized,

placebo-controlled, double-blinded trial.
Three months after three treatments, at
weekly intervals, with 2100 low-energy
impulses without local anesthesia, a reduc-
tion in pain of more than 50% on the VAS was
observed in 60% of patients compared with
15% of patients after placebo therapy.
Besides these comparative studies there are
numerous uncontrolled retrospective reports
on the efficacious use of shock waves in the
treatment of tennis elbow (Auersperg 1998,
Boxberg et al. 1996, Brunner et al. 1997, Göbel
et al. 1997, Lohrer et al. 1998, Tsironis et al.
1997, Wolf and Breitenfelder 1996). As inclu-
sion criteria, treatment procedures, and out-
come measurements were not standardized
the success rates of these studies—58–85%—
have to be viewed with caution. Besides local
hematomas, no shock wave–related complica-
tions have been reported (Sistermann and
Katthagen 1998).
The present study confirmed former results,
leading to “Good/Excellent” results in 56% and
60% of the patients at the 1-year follow-up.
This is comparable with results after local cor-
ticosteroid injection (Day et al. 1978, Verhaar
et al. 1996), but in our patients a mean of 2.1
(range: 1–5) steroid infiltrations had led to no
improvement of the symptoms prior to ESWT.
Although the procedure is approved by

manual therapists, the quality of the literature
concerning manual therapy of the cervical
spine in the treatment concept of lateral epi-
condylitis is poor. In a Medline search we
found only five matches for cervical spine and
tennis elbow between 1976 and 1998 (Wani-
venhaus 1986, Waldis 1989, De Marco et al.
1998, Gunn and Milbrandt 1976, Vicenzino et
al. 1996). This is surprising because following
our experience of now more than 160 patients
with chronic tennis elbow hardly any patient
has no signs of cervical dysfunction such as
localized pressure pain at the lower cervical
spine, limited range of motion, and protrac-
tion of the head. Radiologically there were of
course signs of cervical spondylarthrosis due
to the age of our patients. Patients with neu-
rological deficits or pathological conditons of
the spinal canal in computed tomography (CT)
or in magnetic resonance imaging (MRI) were
excluded from this study.
Gunn and Milbrandt (1976) discuss a reflex
localization of pain from radiculopathy at the
cervical spine in patients with therapy-
resistant tennis elbow who had presented
with hypomobility of the lower cervical
motion segments. Maitland (1991) finds that
mobilization, traction, isometric exercises and
heat, and/or ultrasound, applied to the cervi-
cal spine, improved the signs and symptoms

of lateral epicondylitis. Maigne (1988) reports
complete healing of symptomatic tennis
elbow after exclusively manual therapy for
the cervical dysfunction in 51 out of 92
patients, and significant improvement in
another 29 patients. Only two patients
required surgery. However, inclusion criteria,
outcome assessment, and follow-up were not
described. Huguenin (1988) treated 49
patients with chronic tennis elbow with an
ipsilateral cervical segmental dysfunction. All
patients reported neck pain, an induration of
the autochthonous musculature, and limita-
tion of the joint play was described. The type
of manual treatment applied was not
explained. No results were specified, never-
theless the author stated that his good results
documented the connection between seg-
mental dysfunction and peripheral muscular
symptoms. In his opinion a treatment success
could not be expected before 4–8 weeks after
6 Extracorporeal Shock Wave Application in the Treatment of Chronic Tennis Elbow46
manual therapy. de Branche (1988) analyzed
58 cases with local epicondylalgia and a cervi-
cal spine pathology. All the patients received
one to four manipulations of the cervical
spine at weekly intervals. In 28.4% of the
patients a significant improvement was
achieved for 2–4 days; 43.1% for a longer, not
exactly specified, period. Only 15.5%

remained painfree and were rated a success.
The author was not able to establish selection
criteria for manual treatment of the cervical
spine. Vincenzino et al. (1996) focuses on the
immediacy with which manipulative therapy
may initiate improvement in pain and func-
tion. They report a randomized, double blind,
placebo-controlled, repeated measures design
to study the initial effects of a cervical spine
treatment in a group of 15 patients with lat-
eral epicondylitis. All the subjects received
treatment, placebo, and control conditions.
The treatment condition (contralateral lateral
glide treatment technique for the cervical
spine) produced significant improvement in
the pressure pain threshold, painfree grip
strength, neurodynamics, and pain scores rel-
ative to placebo and control conditions. The
authors conclude that manipulative therapy
of the cervical spine is capable of eliciting a
rapid hypoalgesic effect. In their opinion
impairment of lateral epicondylagia is pro-
jected from the hypomobile cervical spine
motion segments and that the improvements
gained following application of the contralat-
eral gliding technique result from treating the
source of the referred pain. Moreover, mobili-
zation of the lower cervical spine is discussed
as being capable of producing a sufficient sen-
sory input to recruit and activate descending

pain inhibitory systems which exert a portion
or all of the pain relieving effects (Bogduk
1994, Grieve 1994).
In the current study, the focus was on possi-
ble additive effects of cervical spine manual
therapy on patients treated with ESWT for
chronic tennis elbow. With the numbers avail-
able we failed to demonstrate a positive effect
of a standardized manual therapy to the cervi-
cal spine. Though, statistically, our treatment
groups did not differ with regard to epidemio-
logical data, it must be made clear that the
patients for both procedures were not ran-
domized, therefore selection and information
bias cannot be ruled out.
Our data underline the value of low-energy
ESWT in chronic lateral epicondylalgia and
question the usefulness of additional cervical
spine manual treatment in these patients. Fur-
ther studies are mandatory to establish the
optimum treatment regime with ESWT for
patients with recalcitrant tennis elbow and to
clarify what role manual therapy of the cervi-
cal spine may play in the treatment of this
enthesiopathy. The mechanisms by which
ESWT or cervical spine manual therapy
achieve improvements in pain and function
are yet to be elucidated and must form the
basis for ongoing research.
Discussion 47

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