Total Visitors : 109,041


Effects of Extracorporeal Shock Wave Therapy On The Quality of Life And Pain in Patients With Lateral Epicondylitis

Lateral Epikondilitli Hastalarda Ekstrakorporeal Şok Dalga Tedavisinin Yaşam Kalitesi ve Ağrı Üzerine Etkileri

Abdulkadir Aydın, Tahsin Çelepkolu, Ramazan Atiç, Celil Alemdar, Zekiye Sevinç Aydın, Remzi Çevik


How to cite / Atıf için: Aydin A, Celepkolu T, Atiç R, Alemdar C, Aydin ZS, Cevik R. Effects of Extracorporeal Shock Wave Therapy On The Quality of Life And Pain in Patients With Lateral Epicondylitis. Euras J Fam Med 2018;7(1):29-36


An Erratum has been published for this article. Please refer to for the Erratum.


Original Research / Orijinal Araştırma


Aim: We aimed to evaluate the effects of extracorporeal shock wave therapy (ESWT) on clinical and functional status, quality of life and level of pain for short and long terms in patients with lateral epicondylitis.

Methods: In total, 34 patients with lateral epicondylitis were included in the study. The patients received three sessions of ESWT administered 1day apart. The Short Form (SF-36) Health Survey evaluating the quality of life, the Turkish version of the patient-rated tennis elbow evaluation (PRTEE-T) evaluating the level of pain during various activities of daily living, the Nirschl pain phase scale evaluating pain during activity of the affected arm and patient-rated visual analogue scale (VAS) evaluating pain localised in the affected arm were used before andafter therapy and at 6 and 12 weeks after therapy.

Results: There were significant decreases in the PRTEE-T, Nirschl and VAS scores at 6 and 12 weeks and significant increases in the SF-36 survey scores. There was a significant decrease in the total PRTEE-T,Nirschl and VAS scoresat 6 and 12 weeks. There were significant increases in all subscale scores of the SF-36 survey. Furthermore, there was a sustained decrease in the PRTEE-T, Nirschl and VAS scores and increase in the SF-36 score from 6 to 12 weeks.

Conclusion: This study revealed that ESWT is effective in treating lateral epicondylitis by improving the quality of life, reducing pain during activity, decreasing pain during activities of daily living and reducing pain localised in the arm.

Keywords: epicondylitis, shock waves, ultrasonic, pain, quality of life


Amaç: Bu çalışmada Lateral Epikondilitli hastalarda Extracorporeal Shock Wave Therapy (ESWT)’nin, klinik, fonksiyonel durum, yaşam kalitesi ve ağrı üzerine, kısa ve orta vadede etkinliğini değerlendirmeyi amaçladık.

Yöntem: Lateral Epikondiliti olan toplam 34 hasta çalışmaya alındı. Hastalara gün aşırı birer seans olmak üzere toplam 3 seans ESWT uygulandı. Hastalara tedavi öncesi, tedavi sonrası, tedaviden 6 hafta ve 12 hafta sonra, hastaların yaşam kalitesini değerlendirmek için Kısa form (SF-36), çeşitli günlük yaşam aktivitelerinde ağrıyı değerlendirmek için hasta tarafından değerlendirilmiş tenisçi dirseği değerlendirme formu (PRTEE-T) Türkçe versiyonu, etkilenmiş kolunun egzersiz esnasında ağrısının değerlendirilmesi için Nirschl ve etkilenen koldaki lokal ağrıyı değerlendirmek için hasta tarafından puanlanan Vizüel Analog Skala (VAS)'ı kullandık.

Bulgular: PRTEE-T, Nirschl ve VAS skorlarında 6 ve 12. haftada önemli ölçüde azalma ve SF-36 skorlarında önemli ölçüde artış elde ettik. Toplam PRTEE-T skorları 6. haftada ve 12 haftada önemli ölçüde düştü. Nirschl skoru 6. haftada ve 12 haftada önemli ölçüde düştü. VAS skoru 6. haftada ve 12 haftada önemli ölçüde düştü. SF-36 skorunun bütün alt parametrelerinde 6. haftada ve 12 haftada önemli ölçüde artış oldu. Ayrıca 6. haftadan 12. haftaya kadar PRTEE-T, Nirschl ve VAS skorlarında düşme, SF-36 skorlarında artış devam etti.

Sonuç: Lateral epikondilitin konservatif tedavisinde ESWT'nin uygulanmasında, yaşam kalitesini artırmada, aktivite esnasında ağrıyı azaltmada, günlük yaşam aktivitelerinde ağrıyı azaltmada ve koldaki lokal ağrıyı azaltmada etkili olduğunu bulduk.

Anahtar kelimeler: epikondilit, şok dalgaları, ultrasonik, ağrı, yaşam kalitesi 


Lateral epicondylitis is a degenerative injury that most commonly occurs in the origin of the common extensor tendon and is related to activities that place repetitive excessive stress on the lateral forearmand elbow musculature (1,2).  The prevalence of lateral epicondylitis was reported to be 1%–3% in the entire population and was seen more frequently in various professions (3). The patients often present with overuse and burning pain in the lateral aspect of the elbow. These complaints mostly occur in the dominant arm. Pain is accentuated by resisted wrist extension together with arm extension. Such pain negatively affects a patient’s professional life and quality of life. The range of motion of the elbow joint often remains unaffected. There are many treatment options; however, there is currently no gold standard treatment because of uncertainties surrounding the aetiology and pathophysiology of this condition (4). Conservative treatment approaches are most commonly preferred, particularly in patients presenting with acute tendinitis. However, the effectiveness of the therapy decreases with increased disease duration. Commonly used physical therapy modalities, such as rest, electrotherapy (i.e. ultrasound, iontophoresis, laser, interferential current therapy and electrical stimulation), lateral epicondylitis orthosis or splints, manipulation, soft tissue mobilisation, stretching and strengthening exercises (2,5) and extracorporeal shock wave therapy (ESWT) (6,7), are being more frequently used in recent years. However, the effects of ESWT in managing lateral epicondylosis were still controversial in previous studies (8-10).

Additionally, until now, no specific treatment has proved to be effective (11). Studies have reported a success rate of 48%–73% for ESWT in refractory cases of lateral epicondylitis (12). Medical therapy includes corticosteroid injections, non-steroid anti-inflammatory drugs and analgesics. Among patients unresponsive to conservative therapy, 5%–10% require surgical treatment (13). Shock waves are actually sound waves. The use of shock waves to break kidney stones was introduced in various centres in Germany approximately 20 years ago. Shock wave therapy as a part of physical therapy has become intensively used in the treatment of many musculoskeletal diseases. The aim of the present study was to evaluate the effectiveness of ESWT in the treatment of lateral epicondylitis in the short and long terms. 


After obtaining the approval of the Dicle University Faculty of Medicine Non-interventional Clinical Trials Ethics Committee, this prospective study was conducted in Physical Medicine and Rehabilitation Department of the university hospital between June 2011 and September 2014. Thirty four patients (17 female/17 male; age range between 23 and 60 years (mean age, 40.59±9.58) with the diagnosis of unilateral LE were enrolled. Patients with pain localised in the lateral aspect of the elbow joint, tenderness in the lateral epicondyle and pain during resisted wrist extension were included. Patients who have previously undergone ESWT and surgery to the elbow joint; those with other pathologies that could cause pain in the elbow joint; those with bilateral lateral epicondylitis, tendon rupture of the lateral epicondyle, osteoporosis, malignancy and haemophilia; thoseunable to cooperate because of impairment in cognitive function and those who did not consent to participate were excluded from the study. All patients were informed about the study procedure, and they have given written consent to participate.

The patients received three sessions of ESWT administered 1 day apart. Using the ESWT device (Storz Masterpuls MP50 model), 2000 impulses were delivered at a frequency of 8 Hz and a pressure of 2.4 bar. In acute painful conditions, pressure (1.2–1.8 bar) and frequency (4–8 Hz) were adjusted according to the patient’s tolerance during the first session. The device had a frequency range of 1–11 Hz and pressure range of 1–3 bar/11 MPa. The patient was seated in a comfortable position during ESWT. A pillow was placed below the arm or the arm was placed on the treatment table. The therapy head of the ESWT device was first placed on the lateral epicondyle, and then the impulses were delivered. The site of pain was located, and the therapy head was moved around the painful spot in a circular fashion; four impulses were delivered. In total, 2000 impulses were delivered to all site (Figure 1). Local anaesthesia was not used in the study. All patients were instructed to perform wrist extensor stretching exercises and forearm isometric exercise.

Figure 1. Extracorporeal Shock Wave Therapy (ESWT) application in lateral epicondylitis

Pain was evaluated on a scale of 0–10 (0 point indicating no pain and 10 points indicating unbearable pain) using the patient-rated visual analogue scale (VAS) before and after therapy and at 6 and 12 weeks after therapy. The patients were instructed to mark the number that best corresponded to their level of pain. Low scores indicated lower level of pain in the affected arm. The patients were then instructed to mark the most appropriate option indicating the severity of pain during exercise on a Nirschl scale of 1–7 in order to evaluate pain in the affected arm during exercise (Table 1). Low scores indicated lower intensity of pain during exercise in the affected arm (14).

Table 1. Nirschl lateral epicondylitis pain evaluation scale

The Turkish version of the patient-rated tennis elbow evaluation form (PRTEE-T) was validated by Altan et al. (15). Pain in the affected arm in various activities of daily living, pain in the arm during specific activities of the arm and pain in the arm during daily activities and personal care activities were evaluated using PRTEE-T. Lower scores indicated better performance in activities of daily living. The SF-36 Health Survey form was used to evaluate the patients’ quality of life. Kocyigit et al. evaluated the validity and reliability of the Turkish version of this questionnaire (16). The SF-36 Health Survey is composed of 36 items, and the scale contains eight subscales: physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning and mental health. The scores in each subscale ranged from 0 to 100. Higher scores indicated better quality of life (17).

The patient satisfaction questionnaire was administered three times, immediately after ESWT, at 6 weeks and at 12 weeks, to evaluate whether the patients were satisfied with the relief in arm pain. They were instructed to mark the option that best corresponded to the level of pain: worse than before, same as before, better, quite good and very good. The data obtained from the patients were analysed using SPSS 16.0 statistical software package that runs under Windows operating system. Analysis of variance was used to evaluate the differences between the variables before therapy, at the end of the therapy and at 6 and 12 weeks after therapy. The Pearson test was used to evaluate the relationship between the duration of symptoms, VAS, Nirschl, PRTEE total, pain in the affected arm and functional insufficiency scores and the quality of life scores. The level of statistical significance was set at p


The mean age of the patients was 40.59 ± 9.58 years, and 50% of them were females. The right hand was the dominant hand in 94.1% of the treated patients; 70.6% of the patients had symptoms of lateral epicondylitis in the right arm, and 76.48% had never had an attack before (Table 2).

Table 2. Clinical and demographic characteristics of the participants

According to the results of the patient satisfaction questionnaire, 76.4% of the patients were satisfied after therapy compared with the pre-treatment period, and this rate increased to 94.1% at 6 weeks and 100% at 12 weeks. The data obtained from the patient satisfaction questionnaire for ESWT showed that the patients made satisfactory progress from the first control. The satisfaction reached a maximum level at 12 weeks (Table 3).

Table 3. Patient satisfaction rates

In terms of the quality of life scores, there was a significant improvement in all the subscales of the SF-36 survey, particularly at 6 and 12 weeks (P<0.001). There was a significant improvement in the total PRTEE-T, Nirschl and VAS scores immediately after therapy and at 6 and 12 weeks after therapy when compared with the pre-treatment scores (P

Table 4. Changes in pain, functional status and quality of life of patients before and after therapy


In the present study that evaluated the effectiveness of ESWT in patients with lateral epicondylitis, it was found that ESWT makes a significant contribution to improve the patients’ quality of life. It particularly contributes to the performance of specific movements during activities of daily living. In addition, it makes a significant contribution to reduce the pain during activity and exercise and to reduce the localised pain.

Lateral epicondylitis has been a frequently encountered musculoskeletal disease in recent years, both in acute and chronic form. It is easy to diagnose, and there are a wide range of treatment options. Local injections, analgesic and anti-inflammatory medications and conventional therapies, such as various physical therapy options (transcutaneous electrical nerve stimulation, low energy laser and ultrasound), have been widely used in the treatment of lateral epicondylitis (5,7). ESWT has become available in the treatment of musculoskeletal diseases in the last decade, and studies have been published reporting its effectiveness in lateral epicondylitis (18,19). Many researchers have suggested that ESWT could be useful in the treatment of lateral epicondylitis in patients unresponsive to conservative therapy or as an alternative to surgical therapy (20,21). However, there are also studies reporting the ineffectiveness or minimal efficiency of ESWT in lateral epicondylitis (9,11). In their study, Rompe et al. reported that ESWT had reduced pain in 50 patients with chronic lateral epicondylitis and improved the functional status in 90% of the patients (12). Ching-jen evaluated parameters on a 100-point scoring system and reported significant improvement compared to pre-treatment values in pain, functional status and stretching tests in three groups of patients who underwent ESWT at different doses (19). In the study by Radwan et al., ESWT was found to be as effective as percutaneous tenotomy in patients with chronic lateral epicondylitis resistant to therapy. In that study, the Roles–Maudsley score was used to evaluate the functional status, and they reported an effectiveness of 65.5% for ESWT and 74.1% for percutaneous tenotomy at the end of 12 weeks (22). The results immediately after therapy and at 12 weeks in the present study were consistent with those reported by Radwan et al. Rupert et al. performed a 52-week follow-up study of ESWT in patients with lateral epicondylitis and reported considerably significant reduction in pain and restrictions during sports activities and activities of daily living compared to the placebo group (23). 

Furia performed ESWT in patients with lateral epicondylitis who were unresponsive to non-surgical therapies and evaluated patients at 4–12 weeks after therapy. The researcher reported good or very good improvement in 69.5% of the patients at 4 weeks and very good or good improvement in 78.7% of the patients at 12 weeks. The researcher used RAND physical functioning scores to evaluate physical functioning and found significant improvement at 4 and 12 weeks compared to the pre-treatment period. Furthermore, the researcher reported no significant complications in the cases and also stated that the effectiveness of ESWT in the treatment of lateral epicondylitis reached maximum level at the end of 3 months (24). In a recent randomized controlled trial study Yang et al show that the ESWT, in addition to the conventional physical therapy program, can significantly reduce the pain intensity caused by lateral epicondylosis, increase maximal grip strength, and improve upper extremity function and work performance. This favorable effect can last for at least 6 months (6). Similarly, Wong et al show that acupuncture and ESWT on the lateral epicondylitis treatments were effective in pain relief in treating lateral epicondylitis (7). 

In the digital era, tendinitis cases are increasing due to video-on-call and keyboard use (25). It indicates that side effects of drugs treatment in tendinitis will also increase. We think that ESWT can be used not only in lateral epicondylitis but also in other tendinitis. Thus, drug use will be reduced and side effects will be decrease.

The present study noted significant improvement in all pain parameters immediately after therapy and at 6 and 12 weeks after therapy compared with the pre-treatment values. The most significant improvement in pain parameters was noted at 12 weeks. VAS pain score improved by 57.4% at 6 weeks and by 76.7% at 12 weeks compared with the pre-treatment values. In this regard, the present study found improvement rates that are consistent with those reported by Rompe et al., Radwan et al. and Furia. In their 8-week follow-up study, Colins et al. reported the effectiveness of ESWT in improving pain that worsened with activity (26). The present study also achieved similar Nirschl scores at 6 and 12 weeks.

In the present study, the authors used the SF-36 Health Survey to evaluate physical functioning. This study achieved 51.7% improvement at 6 weeks and 64.3% improvement at 12 weeks. Although our results are not consistent with those in the study by Furia, the improvement rate is quite comparable. Furthermore, the findings on patient satisfaction are consistent with those reported by Furia; this achieved 44.15%–67.6% improvement in patient satisfaction at 6 weeks and up to 100% improvement at 12 weeks. Here ESWT proved to be effective in the treatment of lateral epicondylitis in the short and long terms considering significant improvement in all parameters. The most remarkable improvement was noted at 12 weeks. An important limitation of this study was that the late-term outcomes were not evaluated. Furthermore, the small number of patients and a lack of a control group could be regarded as other limitations. However, the evaluation of the quality of life and the evaluation of both general and local pain during arm activities in daily life can be regarded as the strength of the present study.

This study found that ESWT improved the quality of life of patients with lateral epicondylitis, reduced the pain during activity, reduced the pain arising from compelling activities of daily living and reduced the localised pain in the arm.  Lateral epicondylitis cases are frequently referred to family physicians, and diagnosis of this situation are comfortable in the primary care with clinical examination. We think that ESWT can be used comfortably in the primary care as a treatment alternative of this clinical situation. Especially ESWT can be safely and effectively used in patients with lateral epicondylitis who can not tolerate non-steroidal anti-inflammatory drugs. In the following years this method may be a preferred method at treatment of lateral epicondylitis in primary care. Musculoskeletal system diseases are frequently evaluated by primary care physicians and referrals are considered appropriate (27).  The use of ESWT in primary care on tendinitis will reduce of referred to the second or third stage hospital in case of these diagnoses.


We think that this method that using in in the lateral epicondylitis can reduce using of drugs and it is an easy to use method in the primary care. We also think that it is an appropriate choice for patients suffered from lateral epicondylitis especially for patients who avoid anti-inflammatory use because of their side effects and doctors who do not want to prescribe these drugs. We hope that randomized and controlled trials that will evaluate a larger number of patients with a longer follow-up period will support us. 

Conflict of Interest

There was no conflict of interest for the study.


1. Asmundson GJ, Abramowitz JS, Richter AA, Whedon M. Health anxiety: current perspectives and future directions. Curr Psychiatry Rep 2010;12(4):306–12.

2. Ferguson E. A taxometric analysis of health anxiety. Psychol Med 2009;39(2):277–85.

3. Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The health anxiety inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32(5):843–53.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington DC: American Psychiatric Publishing; 2000. 886 p.

5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington VA: American Psychiatric Publishing; 2013. 991 p.

6. Goodwin L, Fairclough SH, Poole HM. A cognitive-perceptual model of symptom perception in males and females: the roles of negative affect, selective attention, health anxiety and psychologi¬cal job demands. Journal of Health Psychology 2013;18(6):848-57.

7. Alberts NM, Sharpe D, Kehler MD, Hadjistavropoulos HD. Health anxiety: comparison of the latent structure in medical and non-medical samples. J Anxiety Disord 2011;25(4):612–4.

8. Tyrer P, Cooper S, Crawford M, Dupont S, Green J, Murphy D, et al. Prevalence of health anxiety problems in medical clinics. J Psychosom Res 2011;71(6):392–4.

9. Alberts NM, Hadjistavropoulos HD, Jones SL, Sharpe D. The Short Health Anxiety Inventory: a systematic review and meta-analysis. J Anxiety Disord 2013;27(1):68–78.

10. Hedman E, Ljótsson B, Andersson E, Andersson G, Lindefors N, Rück C, et al. Psychometric properties of internet-administered measures ofhealth anxiety: an investigation of the Health Anxiety Inventory, the IllnessAttitude Scales, and the Whiteley Index. J Anxiety Disord 2015;31:32-7. doi: 10.1016/j.janxdis.2015.01.008

11. LeBouthillier DM, Thibodeau MA, Alberts NM, Hadjistavropoulos HD, Asmundson GJ. Do people with and without medical conditions respond similarly to the Short Health Anxiety Inventory? An assessment of differential item functioning using item response theory. Journal of Psychosomatic Research 2015;78(4):384-90.

12. Aydemir O, Kirpinar I, Sati T, Uykur B, Cengisiz C. Reliability and validity of the Turkish Version of the Health Anxiety Inventory. Arch Neuropsychiatr 2013;50(4):325–331.

13. Karaer EO, Aktaş S, Aslan S. Panik Bozukluğunda Sağlık Kaygısı Envanteri (Haftalık Kısa Form) Türkçe geçerlilik ve güvenilirlik çalışması. Klinik Psikiyatri Dergisi 2012;15(1):41-48.

14. Prochaska JJ, Spring B, Nigg CR. Multiple health behavior change research: an introduction and overview. Preventive Medicine 2008;46(3):181-8.

15. Bradley LA, Mckendree-Smith NL.Central nervous system mechanisms of pain in fibromyalgia and other musculoskeletal disorders: behavioral and psychologic treatmentapproaches. Curr Opin Rheumatol 2002;14(1):45–51.

16. Magariños M, Zafar U, Nissenson K, Blanco C. Epidemiology and treatment of hypochondriasis. CNS Drugs 2002;16(1):9–22.

17. Byeon H. Association among smoking, depression, and anxiety: findings from a representative sample of Korean adolescents. PeerJ 2015;3:e1288. doi:10.7717/peerj.1288

18. Richardson A, He JP, Curry L, Merikangas K. Cigarette smoking and mood disorders in U.S. adolescents: sex-specific associations with symptoms, diagnoses, impairment and health services use. J Psychosom Res 2012;72(4):269-75. 

19. Chation MO, Cohen JE, O’Loughli J, Rehm J. A systematic review of longitudinal studies on the association between depression and smoking in adolescents. BMC Public Health 2009;9:356. doi: 10.1186/1471-2458-9-356

20. Martinez-Hernaez A, Abbas I. Adolescent smoking and depression/anxiety disorders: evidence for a bidirectional association. European Psychiatry 2015;30(suppl 1):191. 

21. Mykletun A, Overland S, Aarø LE, Liabø HM, Stewart R. Smoking in relation to anxiety and depression: evidence from a large population survey: the HUNT study. Eur Psychiatry 2008;23(2):77-84.

22. Janzen Claude JA, Hadjistavropoulos HD, Friesen L. Exploration of health anxiety among individuals with diabetes: prevalence and implications. J Health Psychol 2014;19(2):312-22.

23. Uçar M, Sarp Ü, Karaaslan Ö, Gül AI, Tanik N, Arik HO. Health anxiety and depression in patients with fibromyalgia syndrome. Journal of International Medical Research 2015;43(5):679–85.

24. Buczkowski K, Marcinowicz L, Czachowski S, Piszczek E. Motivations toward smoking cessation, reasons for relapse, and modes of quitting: results from a qualitative study among former and current smokers. Patient Prefer Adherence 2014;8:1353-63. doi:10.2147/PPA.S67767.

25. McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE. Motivation to quit using cigarettes: a review. Addict Behav 2006;31(1):42-56.

26. Sieminska A, Buczkowski K, Jassem E, Lewandowska K, Ucinska R, Chelminska M. Patterns of motivations and ways of quitting smoking among Polish smokers: a questionnaire study. BMC Public Health 2008;8:274. doi:10.1186/1471-2458-8-274

27. Taylor S, Asmundson GJG. Treating health anxiety: a cognitive-behavioral approach. New York: Guilford; 2004. 299 p.

28. Bobevski I, Clarke DM, Meadows G. Health anxiety and its relationship to disability and service use: findings from a large epidemiological survey. Psychosomatic Medicine 2016;78(1):13–25.

29. Asmundson GJ, Taylor S, Cox BJ. Health anxiety: clinical and research perspectives on hypochondriasis and related conditions. New York: Wiley; 2002. 440 p.

30. Tang NKY, Salkovskis PM, Poplavskaya E, Wright KJ, Hanna M, Hester J. Increased use of safety-seeking behaviors in chronic back pain patients with high health anxiety. Behaviour Research and Therapy 2007;45(12):2821–35.

31. Vranceanu AM, Safren SA, Cowan J, et al. Health concerns and somatic symptoms explain perceived disability and idiopathic hand and arm pain in an orthopedics surgical practice: a path-analysis model. Psychosomatics 2010;51(4):330–7.

Download Full Text Add to Favorites