Understanding Tennis Elbow and Shockwave Therapy
What is Tennis Elbow?
Tennis elbow, or lateral epicondylitis, is a condition characterized by pain and inflammation on the outer part of the elbow due to repetitive strain on the tendons. It is common among athletes, particularly tennis players, but also affects individuals in occupations requiring repetitive arm movements, such as carpenters and office workers. Research suggests that up to 3% of the population experiences tennis elbow at some point, with a higher prevalence in individuals aged 30 to 50.
What is Shockwave Therapy?
Shockwave therapy is a non-invasive treatment that utilizes high-energy acoustic waves to stimulate biological healing responses in musculoskeletal tissues. Initially developed for breaking kidney stones (lithotripsy), this technology has evolved into an effective modality for treating various orthopedic conditions, including tennis elbow.
The mechanism behind shockwave therapy lies in its ability to promote neovascularization (new blood vessel formation), increase cellular activity, and break down calcifications within tendons. Additionally, it desensitizes nerve endings, providing significant pain relief. Clinical trials have demonstrated that 70–80% of patients with chronic tennis elbow report improvement after shockwave therapy.
Two primary types of shockwave therapy exist:
- Focused Shockwaves: Deliver energy to a precise depth, ideal for deep tissue injuries.
- Radial Shockwaves: Distribute energy over a broader area, often used for superficial musculoskeletal conditions.
A randomized controlled trial published in The American Journal of Sports Medicine found that shockwave therapy resulted in a 60% greater reduction in pain compared to placebo treatments after six weeks. These promising results position shockwave therapy as a superior alternative to corticosteroid injections, which may provide only temporary relief and weaken tendon structures over time.Shockwave therapy is a non-invasive treatment that uses acoustic waves to promote healing in musculoskeletal conditions. These high-energy pulses stimulate blood flow, accelerate tissue regeneration, and reduce pain by disrupting pain signals. Clinical studies indicate that 70-80% of patients report significant pain relief after a series of shockwave treatments, making it an effective alternative to corticosteroid injections and surgery.
Patient Evaluation and Candidacy for Shockwave Therapy
Not every case of tennis elbow is suitable for shockwave therapy. Before initiating treatment, healthcare providers conduct a thorough evaluation to determine candidacy.
First, a clinical assessment is performed, which includes:
- Pain evaluation: Measuring severity using the Visual Analog Scale (VAS).
- Functional limitation assessment: Testing grip strength and wrist extension against resistance.
- Imaging tests: Ultrasound or MRI scans may be used to detect degenerative changes in the tendon.
Shockwave therapy is most effective for chronic cases lasting over six months that have not responded to conventional treatments such as rest, bracing, or physical therapy. Patients with severe tendon degeneration (tendinosis) often benefit the most. However, certain conditions contraindicate shockwave therapy, including:
- Bleeding disorders (e.g., hemophilia).
- Use of anticoagulant medications (e.g., warfarin).
- Pregnancy (as a precaution).
- Presence of malignancies in the treatment area.
Studies suggest that patients with mild-to-moderate cases have an 80–90% success rate, while those with severe degeneration may require additional sessions.
Pre-Treatment Preparation and Planning
Before initiating shockwave therapy for tennis elbow, careful preparation ensures optimal treatment outcomes. Proper planning includes educating the patient, precisely localizing the affected area, and setting treatment parameters tailored to the individual’s condition. These steps enhance efficacy, improve patient compliance, and minimize potential discomfort.
Patient Education and Informed Consent
Patient education is a critical component of pre-treatment preparation. Understanding the mechanism of shockwave therapy, expected benefits, and potential side effects helps build trust and improve adherence to the treatment plan.
During the consultation, clinicians should explain:
- The goal of shockwave therapy: To stimulate tendon healing, reduce pain, and improve function.
- The procedure itself: Patients should know what to expect regarding sensations (mild discomfort, tingling, or pressure) during treatment.
- Expected outcomes: Most patients experience significant improvement within 6–12 weeks. However, results may vary depending on the severity of the condition.
- Possible side effects: Temporary soreness, mild swelling, redness, or bruising at the treatment site, which typically resolves within a few days.
Informed consent must be obtained before the procedure. This involves discussing risks, benefits, alternative treatment options, and the number of sessions required. Patients should be encouraged to ask questions, ensuring they fully understand the process. A well-informed patient is more likely to follow post-treatment guidelines, enhancing overall results.
Treatment Area Localization
Accurate identification of the affected tendon is crucial for effective shockwave therapy. Misalignment or incorrect application can reduce efficacy and prolong recovery.
Localization involves a combination of:
- Clinical examination: The clinician palpates the lateral epicondyle to identify tender areas. Patients may be asked to perform wrist extension against resistance to pinpoint the most affected region.
- Ultrasound imaging: In cases of chronic or severe tendinopathy, ultrasound imaging provides detailed visualization of degenerative changes in the tendon. It helps confirm the diagnosis and ensures precise shockwave application.
Proper positioning of the patient is also essential. Typically, the patient sits or reclines with the forearm supported on a cushion to maintain relaxation during treatment. Once the treatment area is confirmed, a skin-safe coupling gel is applied to facilitate the transmission of shockwaves.
Setting Treatment Parameters
Customizing treatment parameters based on the patient’s condition and tolerance level is essential for maximizing effectiveness. The main parameters include:
- Energy levels: Ranging from 0.08 to 0.25 mJ/mm² depending on the severity of the condition. Higher energy levels are used for chronic cases.
- Frequency: Between 8 and 12 Hz, ensuring optimal stimulation of biological healing processes.
- Number of pulses: Typically 1,500–3,000 per session, adjusted based on the patient’s response.
- Number of sessions: Generally, 3–5 sessions spaced one week apart. Additional sessions may be required for patients with severe tendinosis.
Clinicians should begin with lower energy levels during the first session and gradually increase intensity based on patient feedback. Ensuring patient comfort while maintaining therapeutic efficacy is a delicate balance that requires experience and real-time adjustment.
Shockwave Therapy Procedure
Preparation and Setup
Before administering shockwaves, the patient is positioned comfortably, ensuring the affected arm is relaxed. A generous amount of ultrasound gel is applied to the treatment site to enhance acoustic wave conduction and minimize energy loss. The clinician selects the appropriate shockwave applicator based on whether focused or radial shockwaves are being used:
- Focused shockwaves penetrate deeper into tissues, making them suitable for chronic or severe cases.
- Radial shockwaves spread energy across a wider surface area, often used for more superficial or diffuse tendinopathies.
The practitioner ensures that the applicator is in full contact with the skin to avoid dissipation of energy and ensure effective penetration into the tendon.
Administration of Shockwaves
The procedure begins with the gradual delivery of shockwaves at a low intensity. Patients typically report a sensation of rhythmic tapping or mild discomfort as energy is transmitted to the affected tendon.
During treatment:
- The clinician monitors the patient’s response and adjusts intensity if necessary.
- Shockwaves are delivered in a circular or linear motion, depending on the tendon’s structure and the extent of degeneration.
- The treatment lasts 5–10 minutes per session, depending on the number of pulses delivered.
Pain during treatment is a normal response, indicating that shockwaves are effectively stimulating the healing process. However, the intensity should be kept within a tolerable range. If discomfort becomes excessive, the energy level can be temporarily reduced before gradually increasing again.
Session Protocol and Frequency
A standard shockwave therapy protocol for tennis elbow includes:
- Sessions spaced one week apart, allowing time for tissue repair between treatments.
- A total of 3–5 sessions, with additional treatments for severe or recurrent cases.
- Gradual symptom improvement over 6–12 weeks, with pain reduction and functional restoration observed progressively.
Most patients experience a 30–50% reduction in pain after the second session and 70–80% improvement after the final session. Long-term follow-up studies show that benefits can last over a year, making shockwave therapy a viable long-term solution for chronic lateral epicondylitis.
Post-Treatment Recovery and Rehabilitation
Immediate Post-Treatment Care
Patients may experience mild soreness, redness, or swelling after the procedure. These effects are temporary and typically resolve within 24–48 hours. Post-treatment recommendations include:
- Avoiding high-impact activities (e.g., heavy lifting, racket sports) for at least 48 hours.
- Using ice packs if discomfort persists, though excessive icing should be avoided to allow natural inflammatory healing.
- Maintaining hydration and a balanced diet to support tendon repair.
Rehabilitation Exercises
Combining shockwave therapy with targeted exercises significantly enhances recovery. Strengthening and stretching the affected tendon improve flexibility and prevent recurrence. Recommended exercises include:
- Eccentric wrist extensions: Using light weights to strengthen the extensor tendons.
- Forearm stretches: Stretching the wrist extensor muscles to improve tendon elasticity.
- Grip-strengthening exercises: Using resistance tools to restore hand function.
Patients should perform these exercises 3–5 times per week, gradually increasing intensity as symptoms improve. Studies show that rehabilitation exercises combined with shockwave therapy lead to 40% faster recovery times compared to shockwave therapy alone.
Activity Modification
Adjusting daily activities reduces strain on the tendon and prevents reinjury. Strategies include:
- Using ergonomic keyboards and tools for office workers.
- Modifying tennis grip technique for athletes.
- Wearing supportive braces during activities that involve repetitive wrist movements.
Monitoring Progress and Long-Term Management
Follow-Up Assessments and Outcome Tracking
Regular follow-up visits help track progress and adjust the treatment plan. Clinicians evaluate:
- Pain levels using the Visual Analog Scale (VAS).
- Grip strength improvements over time.
- Functional tests (e.g., ability to lift objects without pain).
- Patients are typically assessed at 2, 6, and 12 weeks post-treatment to ensure sustained improvement.
Adjusting the Treatment Plan
If symptoms persist beyond expected recovery time, additional treatments may be required, such as:
- Increasing energy levels in subsequent shockwave sessions.
- Combining shockwave therapy with platelet-rich plasma (PRP) injections.
- Referring patients to physical therapy for advanced rehabilitation techniques.
Preventive Strategies for Long-Term Health
To prevent recurrence, patients should:
- Maintain regular forearm strengthening exercises.
- Use proper technique in sports and occupational activities.
- Avoid excessive repetitive strain and take regular breaks during high-risk tasks.
Your Questions, Answered
Q1: How soon will I feel relief?
Many patients notice improvement after the first session, with significant relief developing over a few weeks. Full benefits typically appear within 6–12 weeks.
Q2: Will it hurt?
You might feel mild discomfort during the procedure, similar to a tapping or tingling sensation, but it’s much less painful than chronic elbow pain. Any soreness afterward fades within 24–48 hours.
Q3: Is it better than physical therapy?
Shockwave therapy works faster than PT alone and enhances recovery when combined with rehabilitation exercises. Studies show 40% better improvement when both are used together.
Q4: Can it replace surgery?
Yes, in over 80% of cases, shockwave therapy prevents the need for surgery by stimulating natural healing. However, severe cases like complete tendon rupture may still require surgery.
Q5: Any side effects?
Side effects are minimal, including temporary soreness, redness, or mild swelling. These symptoms resolve naturally within a couple of days. No downtime is required.
Reference
Effects of extracorporeal shockwave therapy versus ultrasonic therapy and deep friction massage in the management of lateral epicondylitis: a randomized clinical trial: https://pmc.ncbi.nlm.nih.gov/articles/PMC11254923
Extracorporeal shockwave therapy in musculoskeletal disorders: https://pmc.ncbi.nlm.nih.gov/articles/PMC3342893/
Evaluation of lateral epicondylopathy, posterior interosseous nerve compression, and plica syndrome as co-existing causes of chronic tennis elbow: https://pmc.ncbi.nlm.nih.gov/articles/PMC10267267/