Introduction:

The treatment of elbow tendinopathies with radial pressure waves (RSWT) has showed good and excellent results in over 75% of the cases in most of the series in the literature. In the past ten years we have used a two-session RSWT protocol with 2000 therapeutic radial shockwaves above 2 BAR, preceded by 2000 analgesic shockwaves with high number of repetitions per second, followed by another analgesic 2000 shockwaves. This protocol has allowed us to have 81% success rate in the treatment of chronic elbow tendinopathies. Our protocol includes a follow up visit two weeks after the final SWT session. If the patient reports a VAS pain scale improvement lower than 50%, we proceed to a third and final session, usually with a higher power focused device. Our group has been working in the past year with High Intensity Laser therapy (HIL) for acute musculoskeletal painful conditions with excellent results. We hypothesize that the use of HIL may have a significant control of pain if combined with RSWT. In this study we compare the outcome of a combined therapy of RSWT and HILT on the third session of Focused Shockwaves in patients that did not improve pain over 50% in their follow up evaluation.

Methods:

We performed a case control study on 21 patients diagnosed for chronic lateral epicondyle elbow tendinopathy, that did not improve pain control over 50% in the VAS scale on the follow up visit two weeks after the second RSWT session. We had 14 female and 7 male subjects with and average age of 35.5 y/o (19-52 y/o). They were divided in two groups of 10 and 11 patients. The two groups were statistically similar. They all signed an informed consent. In all cases we used for the first two sessions a Radial SWT generator (BTL-5000 Power – BTL Industries Czech Rep). All subjects were tested and evaluated by ISMST & ONLAT certified specialists. In the Cases Group (RSWT+HIL ) we applied a progressive protocol using 200 shocks on 15 Hz, 200 shocks on 10 Hz and 200 shocks on 5 Hz, plus the application of 2500 laser shots over the elbow epicondyle painful region. We used a HIL unit (BTL Industries Czech Rep). The laser treatment was then repeated every 4 days in four more sessions. In the Control Group (RSWT+FSWT) we used a our regular protocol of 1000 focused shockwaves using an electrohydraulic device (MTS Orthogold – OE155 – soft focused applicator - MTS Medical – Konstanz, Germany). We followed up the patients for four months, with a monthly record of VAS pain score, the Roles and Maudsley scale, and a record for any adverse effects. All data was recorded and analyzed using a One-Way ANOVA, and the P value was based in <0.01. The study was done independently with no financial or material support from the manufacturers of the mentioned devices.

Results: 

Both the cases group and the control group patients improved pain and function in the fourmonth follow up. The RSWT+HIL treated patients had a 71% VAS pain reduction after 5 months, as compared with a 70% in the RSWT+FSWT control group. The Roles and Maudsley scores showed good and excellent results in 70% of the cases group patients, as compared with 73% in the control group. 9/11 patients improved 25%-50% their pain in the four-month follow up, and 2/11 improved over 50% in the cases group. The control group had similar results, with 7/10 patients that improved 25%-50% and 3/10 over 50%. All reported data in pain control, functional score and improvement rates were not statistically significant. No patients showed increase in pain or any complications.

Discussion: 

The use of HIL has proven efficacy and safety in pain control of musculoskeletal lesions, and its regenerative power is still under research. Shockwave medicine has proven to be a great tool in tissue regeneration, neovasculogenesis and healing, but pain control is still a short and long-term issue. This study shows a possible use of the best of both technologies in benefit of our tendinopathy patients. We do have better results in our cases with RSWT that did not require a third session, with a 81% pain control, as compared with the 71% and 70% of the patients included in this study, who were the poor-results individuals who required a third treatment session. In future studies we will compare primary patients using RSWT, FSWT and combined RSWT+HILT.

Conclusion:

The use of a combined therapy of radial shockwaves and high intensity laser therapy showed similar results as the use of focused shockwaves in the recurrent pain after a primary shockwave treatment for tennis elbow.