tennis elbow ( te ) is not an inflammation of the outside portion of the elbow but rather is 
 the degeneration of the extensor tendon of the humeral lateral epicondyle ( le ) due to 
 microscopic injuries .
common symptoms include pain , tenderness over the le , pain upon 
 gripping , and dorsiflexion against resistance of the wrist , middle finger , or both1,2,3,4,5 .
conservative treatments such as 
 nonsteroidal anti - inflammatory drugs , local steroid injections , strengthening exercises , 
 stretching , taping , ultrasound ( us ) , iontophoresis , laser , acupuncture , and massage are 
 usually used6,7,8,9,10,11 .
meanwhile , surgical intervention is required for cases of te when 
 conservative management is deemed ineffective12 .
one non - invasive treatment for te - associated pain is extracorporeal shock wave therapy 
 ( eswt ) .
although the underlying mechanism of eswt is not completely clear , it likely 
 involves hyperstimulation analgesia ; it alleviates pain as a result of moderate - to - intense 
 sensory input that is usually applied at the site of greatest discomfort .
. however , there is a lack of comparative studies of the analgesic 
 effects of various electrotherapy methods on chronic te .
therefore , the present study 
 compared the analgesic effects of eswt and us therapy in patients with chronic te .
this study was performed in the 
 department of physiotherapy mining in jaworzno , poland .
the exclusion criteria were local 
 soft - tissue infection , malignant disease , pacemaker , epileptic disorders , rheumatoid 
 arthritis , diabetes mellitus , neurological abnormalities , infectious diseases , 
 cardiovascular disease , lung or endocrine disease , skin ulcerations , reduced range of motion 
 at the elbow , previous surgical intervention of the te , previous conservative treatment of 
 the te 6 months before start of the study , and history of local corticosteroid injection 6 
 months before the study .
the inclusion criteria were age > 18  years , pain in the lateral 
 epicondyle of the humerus persisting longer than 12 months ( table 1table 1.baseline characteristicscharacteristicseswt groupus grouppatients ( n)2525occupation : physical worker / white - collar worker 
 ( n)19/715/10age ( yr)47.9  4.4 * 49.0  4.5*duration of symptoms ( months)14.9  2.1 * 15.1  1.9*dominant arm ( right / left)25/025/0treatment side ( right / left)25/025/0previous unsuccessful treatment 6 months 
 prioryes yes / no ( n)25/025/0*values are mean  sd including local steroid - injection , cryotherapy , phonophoresis , 
 iontophoresis , laser therapy , kinesiotherapy , taping , massage , or orthoses . ) .
* values are mean  sd   including local steroid - injection , cryotherapy , phonophoresis , 
 iontophoresis , laser therapy , kinesiotherapy , taping , massage , or orthoses .
the remaining patients were 
 randomly allocated to receive eswt or us therapy ; randomized was performed by an independent 
 statistician blinded to the baseline characteristics of the participants using a 
 randomization list generated by medcalc statistical software version 15.2.1 ( medcalc 
 software byba , ostend , belgium ) .
finally , a total of 50 individuals in 2 groups were 
 analyzed ( fig .
this study was designed in accordance with the rules for human experimental studies 
 and approved by the bioethical committee of the holycross college in kielce ( resolution 
 1/12/kb ) .
the eswt group received 1,000 , 1,500 , and 2,000 pulses during the first , second , and third 
 through fifth treatments , respectively ( pressure , 2.5 bar ; frequency , 8  hz ; energy density , 
 0.4  mj / mm ) .
the 
 treatments were performed using a rosetta eswt ( cr technology , korea ) .
treatment was administered at the anterior aspect of the le and three 
 points around it at a radius of 1.52  cm .
meanwhile , the us group received continuous ultrasound waves : intensity , 
 0.8  w / cm ; 100% fill ; carrier frequency , 1  mhz .
the treatments were performed using a us 13 evo 
 cosmogamma ( emildue , italy ) .
the applicator head was applied to the le of the humerus at a right angle in 
 order to maximize energy absorption by the tissue .
pain of the affected upper limb during gripping was 
 measured by a martin vigorimeter ( nexgen ergonomics inc . ,
canada ) , which is a dynamometer 
 with a rubber balloon that is compressed by hand ; the air pressure inside the balloon under 
 the influence of compression in kiloponds per square centimeter ( kp / cm ) was 
 recorded on a manometer . moreover ,
resting pain , pain felt during palpation of the le of the 
 humerus , and pain during the thomsen test ( i.e. , wrist extension against resistance ) were 
 measured .
during the thomsen test , with the shoulder flexed at 60 , elbow extended , forearm 
 pronated , and wrist extended to approximately 30 , pressure was applied to the dorsum of the 
 second and third metacarpal bones in the direction of flexion and ulnar deviation in order 
 to stress the extensor carpi radialis brevis and longus .
finally , pain during the chair test 
 was evaluated ; with the shoulder flexed at 60 and the elbow extended , the subject attempted 
 to lift a chair weighing 3.5  kg .
in addition , patients were asked to assess the level of pain immediately and 3 months 
 post - treatment in comparison to that before treatment according to the following criteria : 
 excellent : pain reduction exceeding 70% , full movement , full activity ; good : pain reduction 
 from 5070% , occasional discomfort , full movement , full activity ; acceptable : pain reduction 
 3050% , some discomfort after longer activities ; poor : pain reduction less than 30% , 
 pain - limiting activity .
pain was assessed using the visual analog scale ( vas ) , which is a 10-cm line whose left and 
 right sides correspond to no pain ( 0 ) and unbearable pain ( 10 ) , respectively .
pain was evaluated pre - treatment , and immediately and 3 months 
 post - treatment .
medcalc statistical software version 15.2.1 ( medcalc software byba , ostend , belgium ) was 
 used for statistical analysis .
all data are expressed as mean  standard deviation ( sd ) and 
 range .
one - way anova was used to compare differences in the measured parameters within a 
 group pre - treatment , post - treatment , and 3 months post - treatment .
meanwhile , the independent 
 samples t - test was for intergroup comparisons pre - treatment , post - treatment , and 3 months 
 post - treatment .
pain in all tests decreased significantly over time within each group , although 
 significantly greater analgesic effects were achieved in the eswt group ( table 2table 2.pain scores within groups at different time pointseswt groupmean  sd ( range)us groupmean  sd ( range)pain at grip strengthpre treatment2.8  0.2 ( 2.72.9)2.8  0.1 ( 2.72.8)post treatment3.9  0.1 ( 3.94.0)2.8  0.1 ( 2.82.9)post 3 months5.1  0.2 ( 4.85.5)*2.9  0.1 ( 2.63.1)*resting painpre treatment4.0  0.7 ( 3.05.0)4.2  0.6 ( 3.05.0)post treatment1.9  0.9 ( 0.03.0)4.0  0.6 ( 3.05.0)post 3 months0.2  0.4 ( 0.00.1)*3.7  0.7 ( 3.05.0)*palpation painpre treatment6.4  0.6 ( 5.07.0)6.4  0.5 ( 6.07.0)post treatment3.5  0.6 ( 2.05.0)6.1  0.6 ( 5.07.0)post 3 months1.5  0.8 ( 0.03.0)*5.8  0.8 ( 5.07.0)*pain at thomsen testpre treatment5.7  0.5 ( 5.07.0)5.8  0.7 ( 4.07.0)post treatment2.9  0.7 ( 2.04.0)5.5  0.6 ( 4.06.0)post 3 months1.3  0.4 ( 0.03.0)*5.1  0.8 ( 3.06.0)*pain at chair testpre treatment4.9  0.7 ( 4.06.0)4.9  0.6 ( 4.06.0)post treatment4.0  0.8 ( 2.05.0)4.6  0.6 ( 3.06.0)post 3 months3.9  0.6 ( 3.05.0)*4.4  0.7 ( 3.05.0)**statistically significant ( p < 0.05 ) ) .
in both groups , pain intensity in all tests was similar pre - treatment ; 
 meanwhile , post - treatment and 3 months post - treatment , significant greater decreases of pain 
 were observed in the eswt group than the us group ( table 3table 3.pain scores between groups at different time pointspre treatmentpost treatment3 months post treatmenteswt groupus groupeswt groupus groupeswt groupus grouppain upon grippingmean2.82.83.92.85.12.9sd ( min - max)0.2 ( 2.72.9)0.1 ( 2.72.8)0.1 ( 3.94.0)0.1 ( 2.82.9)0.2 ( 4.85.5)0.1 ( 2.63.1)difference0.01.1 * 2.2*resting painmean4.04.21.94.00.23.7sd ( min - max)0.7 ( 3.05.0)0.6 ( 3.05.0)0.9 ( 0.03.0)0.6 ( 3.05.0)0.4 ( 0.00.1)0.7 ( 3.05.0)difference0.22.1*3.5*palpation painmean6.46.43.56.11.55.8sd ( min - max)0.6 ( 5.07.0)0.5 ( 6.07.0)0.6 ( 2.05.0)0.6 ( 5.07.0)0.8 ( 0.03.0)0.8 ( 5.07.0)diffrence0.02.6*4.3*pain at thomsen testmean5.75.82.95.51.35.1sd ( min - max)0.5 ( 5.07.0)0.7 ( 4.07.0)0.7 ( 2.04.0)0.6 ( 4.06.0)0.4 ( 0.03.0)0.8 ( 3.06.0)diffrenc0.12.6*3.8*pain at chair testmean4.94.94.04.63.94.4sd ( min - max)0.7 ( 4.06.0)0.6 ( 4.06.0)0.8 ( 2.05.0)0.6 ( 3.06.0)0.6 ( 3.05.0)0.7 ( 3.05.0)diffrence0.00.6 * 0.5 * * statistically significant ( p < 0.05 ) difference between means ) . the overall outcomes are shown in table 
 4table 4.overall outcome immediately and 3 months post - treatmentpost treatment3 months post treatmenteswt groupus groupeswt groupus groupn%n%n%n%excellent : vas reduction > 5070% no pain , full 
 movement , full activity10401144good : vas > 5070% occasional discomfort , full 
 movement , full activity12487281352728acceptable : vas reduction > 3050% some discomfort 
 post longer activities3121352141040poor : vas reduction < 30% pain - limiting activity520832 .
three months post - treatment , in the eswt group , 24 patients had excellent or 
 good results compared to only 7 in the us group . furthermore ,
0 and 8 patients in the eswt 
 and us groups had poor outcomes at the end of the study , respectively .
therefore , the 
 results indicate eswt was more effective than us for reducing pain , with long - lasting 
 results .
* statistically significant ( p < 0.05 ) * statistically significant ( p < 0.05 )   difference between means
although the diagnosis of te is fairly straightforward , its management is often difficult . 

eswt and us therapy play 
 important roles in the treatment of te - associated pain ; they are used to provoke painful 
 levels of stimulation to relieve pain , which is termed  hyperstimulation analgesia .
 
 meanwhile , some studies have evaluated the influence of kinesio taping 
 immediately , 12 , 24 , and/or 72 after application23,24,25,26,27 .
lemos et al.28 evaluated the changes in 
 muscle function in healthy subjects induced by kinesio tape application with no or moderate 
 tension to the dominant and non - dominant arms .
the subjects , aged 1830  years , received 
 kinesio taping , kinesio taping without tension , or no treatment ( control ) ; they were 
 assessed before , and 30 minutes , 24 hours , and 48 hours after taping .
the results showed the 
 kinesio group exhibited increased grip strength at all time points after application 
 compared to the controls .
meanwhile , grip strength was significantly greater in the kinesio 
 groups than the controls after 24 and 48 hours for the right hand and after 48 hours for the 
 left hand .
right grip strength improved in the kinesio group compared to that in the kinesio 
 without tension group only 24 hours after application .
spacca et al.13 compared therapeutic 
 effects of active radial shockwave therapy ( rswt ) with sham rswt .
the rswt group received 2,000 impulses ( 1.2 bar at 4  hz for 
 500 impulses , and 1 bar at 10  hz for 1,500 impulses ) .
meanwhile , the sham rswt group 
 received 20 impulses ( 1.2 bar at 4  hz for 5 impulses , and 1 bar at 10  hz for 15 impulses ) . 

the rswt group showed a significantly greater decrease of pain and greater increase of 
 pain - free grip strength post - treatment than the sham rswt group .
the eswt group received 2,000 pulses ( energy flux density , 
 0.030.17  mj / mm ) , while the sham eswt group received 2,000 pulses ( energy flux 
 density , 0.03  mj / mm ) .
pain decreased and pain - free grip strength increased 
 post - treatment , but the differences were not significant14 , 15 .
moreover , rompe et al.29 compared the 
 long - term therapeutic effects of eswt with sham eswt .
the eswt group received 3,000 impulses ( energy flux density , 
 0.08  mj / mm ) , while the sham eswt group received 30 impulses ( energy flux 
 density , 0.08  mj / mm ) .
pain was significantly lower in the eswt group than the 
 sham eswt group , which persisted up to 24 months post - treatment . in the present study ,
pain decreased to a significantly greater extent in the eswt group 
 than in the us group .
furthermore , the therapeutic effect persisted for 3 months 
 post - treatment , indicating the effectiveness of the eswt treatment protocol .
these findings 
 may be valuable for physicians , physiotherapists , and patients with te regarding the 
 selection of the most appropriate treatment on the basis of patients preference and 
 convenience . in summary ,
the results of this study provide evidence that patients with te 
 can obtain significant health benefits with eswt .
 [ purpose ] this study compared the analgesic effects of extracorporeal shock wave therapy 
 with those of ultrasound therapy in patients with chronic tennis elbow . [ subjects ] fifty 
 patients with tennis elbow were randomized to receive extracorporeal shock wave therapy or 
 ultrasound therapy . [ methods ] the extracorporeal shock wave therapy group received 5 
 treatments once per week . 
 meanwhile , the ultrasound group received 10 treatments 3 times 
 per week . 
 pain was assessed using the visual analogue scale during grip strength 
 evaluation , palpation of the lateral epicondyle , thomsen test , and chair test . 
 resting 
 pain was also recorded . 
 the scores were recorded and compared within and between groups 
 pre - treatment , immediately post - treatment , and 3 months post - treatment . [ results ] 
 intra- 
 and intergroup comparisons immediately and 3 months post - treatment showed extracorporeal 
 shock wave therapy decreased pain to a significantly greater extent than ultrasound 
 therapy . [ conclusion ] 
 extracorporeal shock wave therapy can significantly reduce pain in 
 patients with chronic tennis elbow . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION