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M. Haake, I. R. König, T. Decker, C. Riedel, M. Buch, H.-H. Müller, M. Vogel, V. Auersperg, O. Maier-Boerries, A. Betthäuser, J. Fischer, M. Loew, I. Müller, H. C. Rehak, L. Gerdesmeyer, M. Maier, and W. Kanovsky
Extracorporeal Shock Wave Therapy in the Treatment of Lateral Epicondylitis: A Randomized Multicenter Trial
J Bone Joint Surg Am 2002; 84: 1982-1991 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Study Designs Need Clinical Input
Brian Day   (5 December 2002)

Study Designs Need Clinical Input 5 December 2002
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Brian Day,
Orthopaedic Surgeon
Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada

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Re: Study Designs Need Clinical Input

bday{at}telus.net Brian Day

It is ironic that the authors used the phrase “inappropriate study designs” to discredit previous studies on the value of extracorporeal shock wave therapy (ESWT). The study design in the above paper was seriously flawed in 2 major respects.

First, local anaesthesia was used which precludes accurate targeting of the pathology. The site of pathology in lateral epicondylitis is determined by clinical examination and is the point of maximal point tenderness and pain, as described to the examiner by the patient. Infiltration of local anaesthesia prior to the application of low energy ESWT – which focuses the therapeutic energy at a small and localized area - precludes accurate targeting which is dependent on patient feedback. Less accurate targeting may be still have a therapeutic effect when high energy ESWT is used, because the dispersed energy may still be great enough to achieve a therapeutically effective dose.

The second flaw in their design lay in the use of ultrasound imaging. Pain cannot be visualized with ultrasound and its use is inappropriate with low dose ESWT. Pettrone et al(1) used an appropriate and superior study design in another prospective randomized study, and their results (like those of numerous other studies) have confirmed the effectiveness of this therapy. Their described technique has been used with great therapeutic benefit in over 5000 treatments at our center. One would have hoped that at least one of the 17 authors would have been familiar enough with the clinical application of low energy ESWT to have recognized the lack of validity in the protocol used. 1. Pettrone F, CS Lefton, DW Romness, BR McCall, DJ Covall, JR Boatright: Evaluation of extracorporeal shock wave therapy for chronic lateral epicondylitis: AAOS, Paper 271, 2002.