lateral epicondylitis ( le ) is a common musculoskeletal condition that affects 13% of the 
 adult population and 2% and 23% of the working population1 . males and females are affected equally , and it commonly presents 
 between the ages of 35 and 50 years2 . the 
 tendinous origin of the extensor carpi radialis brevis is the area of the most pathologic 
 change . overuse or repetitive trauma in this area causes fibrosis and microtears in the 
 involved tissues3 . tenderness on palpation of the lateral 
 epicondyle and origin of the wrist extensor muscles is suggestive of le4 . the primary goals of le treatment are reduction in pain , preservation of motion , 
 flexibility , and strength , and improved endurance5 . nonoperative management is the keystone of le treatment , with 
 improvement reported in up to 95% of the cases . physical therapy , activity modification , 
 nonsteroidal anti - inflammatory drugs , and injections are the primary nonoperative 
 modalities6 . a recent systematic review 
 and meta - analysis revealed that beyond 8 weeks , the glucocorticoid injection was no more 
 effective than placebo7 . extracorporeal shock wave therapy ( eswt ) has been used in the treatment of le that is 
 refractory to conservative treatment4 . in 
 eswt , extracorporeal shockwaves are applied to lesions to help revascularization and 
 stimulate or reactivate the process of connective tissue and bone healing , thereby relieving 
 pain and improving function8 . there are 
 conflicting reports in the literature regarding the effectiveness of eswt in le . although 
 some studies have reported significant improvement in hand grip strength ( hgs ) , pain score , 
 and functional score after eswt9,10,11 , a recent 
 systematic review of eswt revealed platinum level evidence for little to no benefit from 
 this procedure in the treatment of lateral elbow pain12 . this study aimed to determine and compare the effectiveness of eswt and steroid injection 
 treatment in patients with le . this study was approved by the local ethics committee of our institution and performed in 
 accordance with the principles stated in the 1975 declaration of helsinki . sixty - four consecutive patients 
 ( 54 females and 10 males , age range 2657  years ) diagnosed with le , who were admitted to our 
 outpatient physical medicine and rehabilitation clinic , were included in this study . the 
 diagnosis of le , which was defined as elbow pain that is maximal over the lateral 
 epicondyle , increases with pressure on the lateral epicondyle , and resists dorsiflexion of 
 the wrist and/or middle finger , was based on a detailed physical examination13 . patients were excluded if they had a 
 history of cervical radiculopathy , corticosteroid treatment , or physical therapy in the past 
 6 months , hand or elbow deformity , or metabolic , inflammatory , or neuromuscular 
 diseases . sociodemographic characteristics of patients including age , gender , weight , height , body 
 mass index ( bmi ) , duration of elbow symptoms , and side of involvement were recorded . the 
 patients were randomly divided into eswt ( n=32 ) and local corticosteroid injection ( n=32 ) 
 groups , and were evaluated at baseline and at 4 and 12 weeks post - treatment . patient 
 evaluation included measurement of hgs , assessment of pain intensity , and administration of 
 the short - form mcgill pain questionnaire ( sf - mpq)14 , 
 15 . pain intensity was evaluated using 
 a 10-cm horizontal visual analog scale ( vas ) after resistive wrist dorsiflexion . the jamar 
 hand dynamometer ( kg ) the percentages of improvement in the study parameters were 
 recorded for each group , and the groups were compared in terms of these values . for the eswt group , 3x2000 shock waves with 1.6 bar intensity and 16  hz frequency were 
 applied without local anesthesia at weekly intervals using a masterpuls mp2004 radial shock 
 wave therapy system ( storz medical , swiss ) . in the local steroid injection therapy group , 
 20  mg methylprednisolone acetate with 1  ml prilocaine was administered using a peppering 
 technique at the point with maximal tenderness in the lateral epicondyle area . all patients 
 used lateral epicondyle bandages during the treatment period ; none of them received 
 analgesics , antiinflammatory drugs , or exercise program . all statistical analyses were performed using the statistical package for the social 
 sciences ( spss ) , version 13.0 , for windows ( spss , chicago , il , usa ) . the normality of the distribution for all 
 variables was assessed using the kolmogorov - smirnov test . patient gender and the affected 
 side in both groups were compared using the  test . intergroup comparisons were 
 made using the student s t - test for normally distributed variables and the mann - whitney u 
 test for non - parametric variables . within - group comparisons were performed using one - way 
 repeated measures analysis of variance or friedman test based on data distribution . demographic characteristics of each group are shown in table 1table 1.demographic characteristics of the participants according to groupseswt group ( n=32)injection group ( n=32)age ( meansd ) ( years)38.79.142.66.6gender ( f / m ) ( % ) 26/6 ( 81.3/18.8)28/4 ( 87.5/12.5)weight ( kg)75.910.176.510.6height ( m)1.610.051.600.05bmi ( kg / m ) 293.5 304.6disease duration ( meansd ) ( months ) 8.53.5 7.93.0side of involvement ( there were no significant differences in age , gender , weight , height , bmi , 
 and affected side between the groups ( p>0.05 , for all ) . the mean disease duration in the 
 eswt group was 8.53.5 months and in the injection group was 7.93 months . in the injection group , the baseline mean hgs value was better than that in the eswt group , 
 and the vas score was significantly higher than that in the eswt group ( 24.57.5 vs. 193 , 
 p<0.001 ; 7.80.9 vs. 6.81.3 , p=0.001 , respectively ) . there was no difference between 
 groups in the baseline sf - mpq score ( 19.48.4 vs. 18.74.5 , p>0.05 ) . in both groups , there were statistically significant increases in the mean hgs values and 
 decreases in the mean vas and sf - mpq scores over time ( p<0.001 , for all ) ( table 2table 2.within-group comparison of hgs , vas score , and sf - mpq score according to the 
 follow - up durationbaselinepost - treatment post - treatment4th week12th weekeswt grouphgs ( kg ) * 193.0 243.528.81.6vas * 6.81.3 2.10.9 0.70.6sf - mpq*18.48.4 9.24.7 5.12.5injection grouphgs ( kg)*24.57.529.2 8.530.78.4vas * 7.80.9 3.11.5 2.41.6sf - mpq*18.74.5 9.53.3 7.13.4values are expressed as meanstandard deviation . * p<0.01eswt : extracorporeal shock wave therapy ; hgs : hand grip strength ; vas : visual 
 analog scale ; sf - mpq : short - form mcgill pain questionnaire ) . the percentages of improvements in the study parameters for 
 each group during the follow - up period are shown in table 3table 3.comparison of groups according to the percentage of improvement in hgs , vas 
 score , and sf - mpq score during the follow - up periodeswt groupinjection group(n=32)(n=32)improvement in hgs at 4th week 27.613.9 20.515.2improvement in hgs at 12th week*55.120.628.521.9improvement in hgs between 4th and 12th weeks*22.213.6 7.59.6improvement in vas at 4th week*70.111.059.818.3improvement in vas at 12th week*90.48.969.719.2 improvement in vas between the 4th and 12th weeks*68.927.6 32.436.01improvement in sf - mpq at 4th week50.912.449.311.7improvement in vas at 12th week*70.810.9 62.613.3 improvement in vas between the 4th and 12th weeks*44.617.926.421.2values ( % ) are expressed as meanstandard deviation . * p < 0.01eswt : extracorporeal shock wave therapy ; hgs : hand grip strength ; vas : visual analog 
 scale ; sf - mpq : short - form mcgill pain questionnaire . there was no statistically significant difference in the percentage of 
 improvement in hgs and the sf - mpq score between groups at 4 weeks post - treatment ( p=0.077 , 
 p=0.584 ) , whereas the eswt group showed better results in the vas score than the injection 
 group ( p=0.009 ) . the percentages of improvements in hgs , vas score , and sf - mpq score were 
 higher in the eswt group than in the steroid injection group at 12 weeks post - treatment 
 ( p<0.001 , p<0.001 , p=0.009 , respectively ) . additionally , the percentages of 
 improvements in hgs , vas score , and sf - mpq score between 4 weeks and 12 weeks post - treatment 
 in the eswt group were higher than those in the steroid injection group ( p<0.001 , 
 p<0.001 , p=0.001 , respectively ) . values are expressed as meanstandard deviation . * p<0.01 eswt : extracorporeal shock wave therapy ; hgs : hand grip strength ; vas : visual 
 analog scale ; sf - mpq : short - form mcgill pain questionnaire values ( % ) are expressed as meanstandard deviation . * p < 0.01 eswt : extracorporeal shock wave therapy ; hgs : hand grip strength ; vas : visual analog 
 scale ; sf - mpq : short - form mcgill pain questionnaire in our study , the effectiveness of eswt and local corticosteroid injection therapy was 
 compared between groups and within groups during the 12-week follow - up period . both the eswt 
 and corticosteroid injection treatment showed statistically significant improvements in hgs , 
 vas score , and sf - mpq score over time compared to baseline values . numerous treatments used 
 in clinical practice for management of le have been evaluated in the literature , but there 
 has been no consensus on the best treatment . local glucocorticosteroid injections have been 
 used formerly in patients with le . a systematic review by smidt et al . demonstrated 
 statistically significant differences in terms of pain , global improvement , and grip 
 strength in the corticosteroid injection group compared to placebo , local anesthetic , and 
 conservative treatment including nonsteroidal anti - inflammatory drugs , elbow support , and 
 physical therapy , but no beneficial effects were demonstrated at the intermediate and 
 long - term follow - up17 . similar results 
 also have been reported by others in the literature7 , 
 18,19,20 . on the other hand , 2 other studies found 
 no significant differences in the vas and functional scores , even in the short - term , in the 
 steroid injection group compared to the placebo injection group21 , 22 . in our study , post - treatment improvements in the vas score , hgs , and the sf - mpq score in the steroid 
 injection group were statistically significant at both 4 and 12 weeks post - treatment . in the present study , the effectiveness of eswt compared to the steroid injection therapy 
 was evaluated . there was no statistically significant difference in the improvement in hgs 
 and sf - mpq score between groups at 4 weeks , whereas the improvements in hgs , vas score , and 
 sf - mpq score were higher in the eswt group than in the injection group at 12 weeks . in 
 addition , the eswt group showed better improvement in hgs , vas score , and sf - mpq score 
 between the 4th and 12th week post - treatment than the injection group , indicating the 
 greater beneficial effects of eswt than the steroid injection at the long - term follow - up . a 
 study by speed et al.23 found no 
 difference in vas score between eswt and sham therapy at 3 months . in this study , the 
 authors concluded that there was no evidence of added benefit of treatment compared to sham 
 therapy other than a significant placebo effect of moderate dose eswt . melikyan et al.24 also reported that the differences in hgs , 
 pain , and functional impairment between the eswt and control groups were not statistically 
 significant . by contrast , statistically significant decreases in pain and functional 
 impairment , and an increase in hgs were demonstrated in a 6-month follow - up study by spacca 
 et al11 . additionally , pettrone and 
 mccall10 reported statistically 
 significant improvement in pain and functional activity score with eswt compared to sham 
 therapy . previously , some studies have compared the effectiveness of local corticosteroid 
 injection and eswt . in a 6-month follow - up study by crowther et al.25 , it was found that local corticosteroid injection was more 
 successful and 100 times less expensive than eswt in the treatment of le . three sessions of 
 eswt with 2000 shock waves at weekly intervals were used in their study . gndz et al.26 also compared the therapeutic effects of 
 physical therapy modalities , local corticosteroid injection , and eswt in le and found that 
 all the therapies had favorable effects on pain and grip strength in the early period of le 
 treatment . changes in the vas score and grip strength of the patients at follow - up were not 
 statistically significant among the treatment groups in their study . in addition , the eswt 
 protocol consisting of 10x500 shock waves with 1.4 bar intensity and 4.0  hz frequency 
 administered at a 1-day interval between sessions differed from the protocol used in our 
 study . lee et al.27 demonstrated superior 
 symptom relief and subjective satisfaction levels at the beginning of the treatment in the 
 local steroid injection group compared to the eswt group . however , there were no significant 
 differences in the clinical improvement between the groups afterwards , and the subjective 
 satisfaction level with eswt was even higher . since their study involved a small number of 
 patients with le ( only 5 patients ) , the results regarding the effectiveness of eswt in le 
 treatment are considered inconclusive . additionally , the follow - up period was short , and long - term effectiveness was therefore not 
 assessed . in addition , the use of a lateral epicondyle support may have affected the results 
 of our study . in conclusion , our study showed that both the eswt and local steroid injection 
 were effective in the treatment of le , and the improvement in hgs was greater in the eswt 
 group than in the injection group at the long - term follow - up . however , further follow - up 
 studies involving large samples are required to obtain sufficient evidence regarding 
 effective treatment of le .
[ purpose ] this study aimed to determine and compare the effectiveness of extracorporeal 
 shock wave therapy and local corticosteroid injection in patients with lateral 
 epicondylitis . 
 [ subjects and methods ] sixty - four patients with lateral epicondylitis were 
 randomly divided into extracorporeal shock wave therapy and steroid injection groups . 
 patients were evaluated using hand grip strength , visual analog scale , and short - form 
 mcgill pain questionnaire at baseline and at 4 and 12 weeks post - treatment . [ results ] 
 both 
 groups showed statistically significant increase in hand grip strength and decreases on 
 the visual analog scale and short form mcgill pain questionnaire overtime . 
 there was no 
 statistically significant difference in the percentage of improvement in hand grip 
 strength and on the short - form mcgill pain questionnaire between groups at 4 weeks 
 post - treatment , whereas the extracorporeal shock wave therapy group showed better results 
 on the visual analog scale . 
 the percentages of improvements in all 3 parameters were 
 higher in the extracorporeal shock wave therapy group than in the injection group at 12 
 weeks post - treatment . 
 [ conclusion ] both the extracorporeal shock wave therapy and steroid 
 injection were safe and effective in the treatment of lateral epicondylitis . 
 however , 
 extracorporeal shock wave therapy demonstrated better outcomes than steroid injection at 
 the long - term follow - up .