Comparison of extracorporeal shockwave therapy, ultrasound therapy, and corticosteroid injections for treatment of lateral epicondylitis: an umbrella review of meta-analyses

Abstract

Abstract Background The purpose of this study was to assess the methodological quality of meta-analyses (MAs) and resolve evidence inconsistencies by quantifying overlap in primary studies, thereby providing enhanced evidence on the efficacy of extracorporeal shockwave therapy (ESWT) versus placebo, ultrasound therapy, and corticosteroid injections for lateral epicondylitis. Methods We conducted searches in four databases: PubMed, Embase, Cochrane Library, and Web of Science, until August 2024. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) graded the quality and reliability of the MAs, and the quality of outcomes was graded by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Graphical Representation of Overlap for OVErviews (GROOVE) was applied to analyze overlap and classified the resulting evidence into four categories (I–IV) on the basis of evidence classification criteria. Results A total of nine MAs were included for analysis: five had a high AMSTAR 2 rating, three had a moderate AMSTAR 2 rating, and one had a low AMSTAR 2 rating. GROOVE analysis revealed substantial overlap, informing evidence classification. ESWT can effectively reduce the pain assessed by the visual analogue scale (VAS) compared with placebo (MD = −0.68; 95% CI −1.06, −0.3; P = 0.0004; I 2 = 75%). Compared with ultrasound therapy, ESWT has a significantly large reduction in the level of pain after the treatment at 1-month follow-up (MD = −1.42; 95% CI −2.14, −0.7; P = 0.0001; I 2 = 92%) and 3-month follow-up (MD = −1.65; 95% CI −1.81, −1.49; P < 0.00001; I 2 = 98%). ESWT is better than corticosteroid injection when calculating the pooled effect size of VAS (SMD = 1.13, 95% Cl 0.72, 1.55; P < 0.00001; I 2 = 0). ESWT also has a significant difference in the rate of 50% reduction in pain (RR = 1.38; 95% CI 1.09, 1.75; P = 0.008; I 2 = 41%). However, compared with placebo, it has no clinically important difference of grip strength (MD = 3.33; 95% CI 0.93, 5.73; P = 0.007; I 2 = 30%), and the pain score of Thomsen test (MD = −3.22; 95% CI −14.06, 7.62; P = 0.56; I 2 = 69%). Conclusions ESWT has a significant difference in reducing pain evaluation and relief of pain symptoms, and the effect is better than ultrasound therapy and corticosteroid injections. Level of evidence I. This protocol has been registered in the PROSPERO database CRD42024586419

Keywords

• Lateral epicondylitis
• Extracorporeal shockwave therapy
• Corticosteroid injection
• Ultrasound therapy
• Umbrella review