Abstract
Background:
Lateral elbow tendinopathy (LET) is a common musculoskeletal disorder caused by overuse, resulting in microtrauma to the extensor tendons. Because of its complex pathophysiology and high recurrence rate, LET poses significant treatment challenges. The effectiveness of extracorporeal shock wave therapy (ESWT) in treating LET remains controversial.
Purpose:
To evaluate the therapeutic benefits of ESWT by comparing its effects to those of both placebo ESWT and conventional physical therapy.
Study Design:
Systematic review; Level of evidence, 1.
Methods:
A systematic review of randomized controlled trials (RCTs) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcome measure was pain, assessed using the visual analog scale. Secondary outcome measures included maximal grip strength, Disabilities of the Arm, Shoulder and Hand score, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, and Roles and Maudsley score. The risk of bias for each included study was assessed using the Cochrane risk of bias tool.
Results:
Eleven RCTs were included, of which only 4 studies had a low risk of bias. Among these 4 studies, Aldajah et al (2022) demonstrated significant benefits of ESWT in pain reduction, muscle strength, and function. Guler et al (2018) observed improvements within the ESWT group, but no significant differences compared to placebo. Karaca et al (2022) found no significant differences in pain, grip strength, and PRTEE scores. Staples et al (2008) reported no statistically significant differences in pain and function between the ESWT and placebo groups.
Conclusion:
Although some studies report positive effects of ESWT, the evidence remains inconclusive. Future research should focus on optimizing ESWT protocols, addressing potential biases, and identifying patient subgroups that would benefit most from this treatment. ESWT may be a valuable adjunct to physical therapy in managing chronic LET.
Keywords
Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a frequent musculoskeletal disorder with an annual incidence of 1% to 3%. 16 It accounts for approximately 7 per 1000 primary care consultations annually. LET is typically caused by repetitive, quick, eccentric contractions and gripping activities, often related to work or sports. 14
The pathophysiology involves overuse leading to microtrauma, primarily affecting the extensor carpi radialis brevis muscle due to its vulnerability to abrasion against the lateral edge of the capitellum during elbow movements.9,14 Risk factors include female sex, older age (peak incidence, 35-55 years), diabetes mellitus, smoking, dominant hand use, sports involving repetitive arm movements, and a history of shoulder tendinopathy.3,8,10
As described in the tendinopathy continuum model by Cook and Purdam, 5 there are several stages ranging from a normal tendon to a degenerative tendinopathy. Load management and individual factors greatly influence the risk of progression to a more severe condition.
LET is diagnosed based on a classic triad of symptoms during physical examination. 4 This involves tenderness around the lateral epicondyle and common extensor tendons, pain aggravated by resisted wrist extension and gripping activities, and increased discomfort with elbow extension, forearm pronation, and wrist palmar flexion. However, this triad may not always be fully present in practice and should be viewed as a guide for clinical assessment and reference for the typical pain pattern associated with tendinopathy. Additional diagnostic tests include the Tomsen test, handgrip dynamometer, Mill test, chair test, and coffee cup test. 17
Although ultrasonography can visualize tendon structure, it is not essential for diagnosis, as LET is primarily a clinical diagnosis, supported by the tendinopathy continuum model proposed by Cook and Purdam. 5
LET is generally a self-limiting condition, with symptoms resolving in 80% of cases within 6 to 12 months. 3 However, in some instances, symptoms may persist for >2 years, making it a challenging condition to treat due to its complex nature and high recurrence rate. 17 Treatment is often nonoperative, focusing on relative rest, load management, symptomatic relief (eg, nonsteroidal anti-inflammatory drugs and braces), and therapeutic physical therapy exercises. Adjunctive treatments, such as extracorporeal shock wave therapy (ESWT), laser therapy, and various pharmacological injections, may also be considered. 9
Despite nonoperative treatments being effective for 90% of patients with LET, systematic reviews have not provided sufficient evidence to recommend a specific treatment, nor have they established the superiority of adjunctive therapies like ESWT. Therefore, there remains a lack of compelling evidence suggesting the most effective treatment approach.
As described above, one of the nonoperative options is ESWT. Extracorporeal shock waves are single-pressure pulses of acoustic waves that dissipate mechanical energy at the interface of 2 substances with different acoustic impedance for microsecond duration. 2 Over the past 3 decades, it has proven to be a highly effective treatment for renal calculi. 15
In tendinopathy, ESWT is usually applied at the loco dolenti identified during physical examination, with or without ultrasound guidance, for a duration ranging from a few seconds to minutes. 13
ESWT is believed to stimulate soft tissue healing through 4 mechanisms. 9 First, it inhibits the function of afferent pain receptors immediately after treatment. Second, it downregulates the expression of inflammatory cytokines. Third, it enhances angiogenesis, and lastly it reaches optimum improvement of cellular proliferation and synthesis of the extracellular matrix after 1 month. Mostly, ESWT is used as a supplement to exercise rather than a treatment on its own. It is recommended when other nonoperative treatments fail. 8 ESWT seems safe and is noninvasive, easy to use, and usually well accepted by patients. 19
However, ESWT is one of the nonoperative treatments with inconsistent and controversial scientific evidence regarding its efficacy. 7 Additionally, there is no evidence that ESWT has a better clinical efficacy compared to other nonoperative treatment options. 19
The objective of this study was to evaluate the efficacy of ESWT in treating LET by comparing its effects to those of a sham or placebo ESWT and physical therapy. In sham ESWT, the treatment is designed to mimic the active procedure as closely as possible, but without any therapeutic effect. This is achieved by deflating the treatment head, omitting coupling gel, or ensuring no skin contact is made.4,6,7,11-13,15,16 By using this comparison, we aimed to determine whether ESWT offers a true therapeutic benefit beyond the placebo effect.
Methods
Search Strategy
This study was conducted to review the most relevant and scientifically valid randomized controlled trials (RCTs) to have a better understanding of the effectiveness of ESWT in the treatment of LET. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in determining search strategy and reporting for this systematic review. The search terms used in the PubMed and Cochrane databases are listed in Appendix Table I. The initial search was done on April 15, 2024. To ensure the review reflected the most current evidence, an updated literature search was conducted in the PubMed and Cochrane Library databases before manuscript submission. This search identified several recently published RCTs; however, these studies did not meet the a priori inclusion criteria because they used radial ESWT, which was defined as an exclusion criterion in the review protocol. As a result, no newly identified studies qualified for inclusion in the final analysis.
Outcome Measures
The aim of our study was to investigate the effect of active focused ESWT compared to sham ESWT or conventional physical therapy in chronic LET. Our primary outcome measure was pain, measured with the visual analog scale (VAS). Our secondary outcome measures were maximal grip strength using a hand dynamometer, Disabilities of the Arm, Shoulder and Hand (DASH) score, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, and Roles and Maudsley score.
Inclusion and Exclusion Criteria
The screening for the eligibility of possible relevant studies was independently performed by 2 authors/reviewers (V.A. and V.E.). All discrepancies were resolved by reaching a consensus.
The inclusion and exclusion criteria for this systematic review are listed in Appendix Table II.
After the initial review of the PubMed and Cochrane databases, 223 articles were obtained. Applying the flow diagram (Figure 1), this number was reduced to 11 RCTs that met the inclusion criteria. To ensure that no additional articles were missed, the reference lists of the included RCTs and earlier systematic reviews were examined.
Flow diagram of search strategy and article inclusion. ESWT, extracorporeal shock wave therapy; RCT, randomized controlled trial.
Risk of Bias Assessment
We assessed the risk of bias of every article in the following domains by using the Cochrane risk of bias tool Version 2. The risk of bias for each domain was categorized as low risk, high risk, or some concerns. The worst risk of bias for any of the domains determines the overall risk of bias for this article. If there are “some concerns” for multiple domains in an article, then it might result in a high risk of bias overall. 18 We have considered the risk of bias in each study when deciding how much importance to give to its conclusions.
Patient and Study Characteristics
The following data were extracted from all included articles: the first author's name, year of publication, intervention, control, outcome, sample size, mean age, sex, mean symptom duration, ESWT protocol (frequency, interval, pulses, duration, and dose), and follow-up duration.
Results
Study Characteristics
We included RCTs published from 1996 to 2022. The characteristics of the included RCTs are summarized in Table 1. Eight studies compared active ESWT with sham ESWT.4,6,7,11-13,15,16 The remaining 3 studies compared ESWT with a physical therapy program.1,9,14
Characteristics of Included RCTs a
DASH, Disabilities of the Arm, Shoulder and Hand; EQ-5D, EuroQol 5D (assessment for quality of life); ESWT, extracorporeal shock wave therapy; PRTEE, Patient-Rated Tennis Elbow Evaluation; RCT, randomized controlled trial; VAS, visual analog scale; 
, low risk of bias; 
, some concerns; 
, high risk of bias.
The size of the intervention and the control groups varies between 14 and 137 patients. The median of the group size at the beginning of the trials for active treatment was 36 patients and for the control group 32 patients.
The follow-up ranged from no follow-up after the last intervention 1 to 12 months of follow-up. The median follow-up duration was 3 months. Two studies had a follow-up of 6 months.13,16 Three studies had a follow-up of 12 months.7,11,12
Aldajah et al 1 is the only study that included no follow-up; the participants in both groups were clinically assessed at baseline (before the first session) and at the end of the treatment sessions (end of the fifth session). In their study, the included participants received either ESWT or conventional therapy on consecutive days.
Doses of the extracorporeal shock waves varied from 0.02 to 0.60 mJ/mm2. Rompe et al 13 classified the shock wave treatment on the basis of the energy flux density per shock, as low (<0.08 mJ/mm2), medium (<0.28 mJ/mm2), and high (<0.60 mJ/mm2).
Five studies used low-energy extracorporeal shock waves.4,7,12-14 One study used medium-dose shock waves, 15 and 2 studies used high-energy shock waves.11,16 Three studies did not include any mention of dosage parameters.1,6,9 The study by Haake et al 7 is the only one that used local anesthesia.
Most of the trials described a similar therapeutic protocol (3 sessions, weekly intervals).4,7,12-14,16 However, Aldajah et al 1 performed ESWT daily for 5 days. In 1 trial, the ESWT group received 2 sessions per week. 9 Speed et al 15 used monthly intervals. Two studies did not mention anything about the frequency of ESWT performed or the number of treatments.6,11
Patient Characteristics
Patients included in these RCTs were typically aged 18 years or older; 1 study included patients up to 80 years old. 1 The mean ages in the intervention and control groups ranged from 34 years to 49.8 years and from 39 to 49.2 years, respectively. Among all participants, 53% were female.
All participants had a confirmed diagnosis of LET, characterized by pain localized at the lateral epicondyle, tenderness over the lateral epicondyle and the common extensor origin tendons, and pain exacerbated by specific provocative tests (such as resisted wrist extension, resisted middle finger extension, and palpation of the lateral epicondyle). Specific diagnostic tests included the Thomsen test, the Maudsley test, and the chair test. In the included RCTs, ultrasound was not used in the diagnostic process. However, in 4 studies, the ultrasound device was used for positioning the shock wave device.7,11,15,16
The period of symptoms required for inclusion in the RCTs differed largely. Some trials required that participants have a minimum duration of 6 weeks, 16 3 months, 9 or 12 months 13 of symptoms before inclusion in the trial. Two trials specified that symptoms had to be present for >3 weeks and <12 months.4,6 Six trials did not define a required minimum and/or maximum duration of symptoms.1,7,11,12,14,15 The mean duration of symptoms ranged from 4.1 6 to 27.6 7 months in the active group and from 4.4 6 to 22.8 7 months in the control group.
The article by Chung and Wiley 4 is the only one in which patients were previously untreated.
Risk of Bias Assessment
The results of the risk of bias assessment using the Cochrane risk of bias tool are presented in Figure 2. 18
Risk of bias assessment of the selected 11 studies. D1, bias arising from the randomization process; D2, bias due to deviations from intended intervention; D3, bias due to missing outcome data; D4, bias in measurement of the outcome; D5, bias in selection of the reported result; , low risk of bias; , some concerns; , high risk of bias.
Results
Clinical Effectiveness
Four studies found benefits of ESWT for treating tennis elbow.1,12-14
Pettrone and McCall 12 observed that the mean pain score for the active treatment group decreased from 74 at baseline to 38 at 12 weeks on the VAS compared with a decrease from 76 to 51 for the placebo group. The difference between the groups with respect to the mean pain scores was significant (P < .024). Furthermore, the ESWT group showed a significant improvement in functional scores for the upper extremities (P = .0013) when compared to the control group. However, there was no significant difference in the improvement of maximal grip strength between groups (P = .09).
Rompe et al 13 found that the ESWT group experienced a significant reduction in pain (P < .001) and an increase in grip strength (P < .001) compared to the control group at each follow-up.
Aldajah et al 1 found that the ESWT group had significantly improved outcomes in pain, muscle strength, and function, as indicated by the VAS (P < .001), maximal grip strength (MGS) (P < .05), and DASH scores (P < .001), when compared to the control group.
Additionally, Sarkar et al 14 reported a significantly lower VAS score in the ESWT group after 4 weeks (P = .005) and observed a tendency for greater improvement of pain-free grip strength, although this improvement did not quite reach statistical significance (P = .043) as their criteria for significance was a P value <.025. The hand function, measured by the DASH score, improved over time with a significantly lower DASH score (P = .001) in the ESWT group at the end of the fourth week.
However, 7 studies4,6,7,9,11,15,16 found no benefit of ESWT compared to placebo treatment.
Staples et al 16 reported that while both groups showed significant improvements in pain and function at the 6-month follow-up, no statistically significant differences were found between the ESWT and placebo groups at the 6-week and 6-month follow-ups after adjusting for the symptom duration (P > .05).
Similarly, Karaca et al 9 found no statistically significant differences between the ESWT and control groups in terms of pain (VAS), maximal grip strength, and PRTEE score (P > .05).
Guler et al 6 found significant improvements in pain and functional scores such as grip strength and PRTEE score (P < .05) in the ESWT group, but there was no statistically significant difference between the ESWT and placebo groups (P > .05) measured.
In line with this, Speed et al 15 observed that both the ESWT and sham therapy groups demonstrated significant improvement after 2 months, showing no evidence of extra benefit from ESWT (P > .05). This study highlighted a strong placebo effect.
According to Melikyan et al, 11 there was a decrease in pain score and DASH score, reflecting a significant improvement of the functional level (P > .001) for both groups. However, there was no significant difference at any point in the pain or DASH score, including baseline values (P = .72 for pain score; P = .32 for DASH score). Neither was there a difference in the rate of improvement of the score between the intervention and control groups (P = .3 for pain score; P = .87 for DASH score).
Haake et al 7 further supported this perspective, concluding that ESWT was ineffective in treating chronic LET, as no benefit compared to placebo was observed in both primary and secondary endpoints (P > .05).
Additionally, Chung and Wiley 4 found no significant differences in success rates (P = .533) between the ESWT group (39%) and the placebo group (31%), with both groups demonstrating similar improvements in grip strength.
Safety
Six of the included studies provided information on the side effects associated with ESWT. Chung and Wiley 4 reported no severe or moderate adverse events. In addition, Karaca et al 9 did not find any side effects after ESWT application.
Haake et al 7 reported reddening of the skin, pain, and hematoma as the most frequent side effects of ESWT. Additionally, Staples et al 16 observed that participants in the ESWT group reported increased pain, bruising or red spots, or a burning sensation in the arm after treatment. In contrast, the placebo group only reported increased pain and lumps in the elbow region as adverse events.
According to Speed et al, 15 2 patients in the ESWT group withdrew after 2 treatments due to worsening symptoms. Two patients in the sham group withdrew for unspecified reasons. No other adverse effects were reported.
Pettrone and McCall 12 did not find any serious adverse effects of ESWT. A total of 28 patients (50%) in the active treatment group compared with 13 patients (22%) in the placebo group experienced moderate treatment-related pain that was transient. 12 Ten patients (18%), all in the active treatment group, experienced nausea during treatment. 12 Two active treatment patients had to stop treatment sessions before receiving the full 2000 impulses because of these symptoms. 12
Discussion
We analyzed 11 RCTs that evaluated the effectiveness of ESWT compared to sham ESWT or a physical therapy program for LET. The results of these studies were mixed. Among the 4 studies with a low risk of bias, only 1 study 1 demonstrated the benefits of ESWT, while 3 studies6,9,16 reported no significant improvement in pain or grip strength scores compared to placebo or physical therapy alone.
Study Limitations and Bias
Evaluating the efficacy of ESWT for LET requires acknowledging several limitations, including bias and methodological variability across studies. These challenges complicate result interpretation and hinder their translation into clinical practice. This section will discuss key sources of bias and study limitations, and their potential impact on the reliability and generalizability of the evidence.
Study Characteristics
Most studies analyzed patients with confirmed LET, diagnosed based on clinical criteria like pain on palpation and positive tests (eg, Thomsen, Maudsley, and chair tests).
Ultrasound was not explicitly used as a diagnostic tool in the included studies, although it could provide valuable information, such as ruling out tendon rupture, which would contraindicate ESWT. It could also assess neovascularization, which may contribute to pain due to neuronal ingrowth. However, the clinical relevance and objectivity of ultrasound in this context are debatable. While ultrasound might aid in precise transducer placement, no evidence currently supports its role in improving treatment outcomes. Further research is needed to explore this potential. Furthermore, the follow-up duration ranged widely with a median follow-up duration of 3 months, which may have limited the ability of some studies to assess the long-term effects of ESWT. Some studies, like that of Guler et al, 6 omitted prespecified outcome measures (eg, Roles and Maudsley score). Such omissions in outcome reporting can undermine the transparency and completeness of the data. There was also significant heterogeneity in grip strength assessments (maximal vs maximal pain-free grip strength), complicating direct comparisons between studies and contributing to inconsistent findings.
Additionally, small sample sizes (median, 68 participants; median, 40 in low-bias studies) increase the likelihood of incidental findings and reduce reliability, generalizability, and statistical power to detect meaningful differences.
Patient Characteristics
Symptom duration varied significantly across studies, which may impact ESWT efficacy. While ESWT promotes collagen production and reduces neovascularization, including associated neuronal ingrowth, its efficacy may be limited in the acute phase (reactive tendinopathy in the continuum model of Cook and Purdam 5 ) when these processes are not yet present. However, when tendinopathy becomes chronic, it can evolve into a complex, multifactorial pain syndrome, accompanied by secondary pain phenomena such as sensitization and muscle tension, which may not respond well to local therapies like ESWT. In several studies, the mean symptom duration exceeded 12 months.7,12,13,15,16
Across the included studies, the timing of ESWT administration showed substantial heterogeneity, as listed in Table 1. Studies reporting a benefit of ESWT described symptom durations ranging from 8.41 to 24.813 months (with some not specifying duration 14 ), whereas studies finding no superiority of ESWT reported durations ranging from approximately 44,6 to 27.6 7 months, again with several lacking clear specification.9,11
Because of this variability, together with the high risk of bias in several studies suggesting benefit,12-14 no consistent pattern could be identified between symptom duration and treatment effect. Consequently, the hypothesis outlined above—suggesting differential effectiveness of ESWT in distinct phases of tendinopathy—cannot be confirmed based on the current data.
ESWT Protocol
A major source of heterogeneity lies in the variability of ESWT treatment protocols, including differences in energy flux density, frequency, and number of sessions, which likely impact treatment outcomes, making it challenging to develop an evidence-based treatment protocol.
While most studies used a standard protocol of 3 weekly sessions, others varied, with daily 1 or monthly sessions. 15 Some studies, such as those by Melikyan et al 11 and Guler et al, 6 omitted details on treatment frequency.
Energy settings also varied significantly across the studies: 5 studies used low-energy shock waves,4,7,12-14 1 applied medium-dose energy, 15 and 2 utilized high-energy shock waves.11,16 Unfortunately, 3 studies failed to report dosage parameters.1,6,9
Control Group
A major challenge in ESWT studies is achieving effective blinding, especially with sham treatments, which often lack the discomfort of active ESWT, allowing participants to identify the treatment type. Some studies used nondisclosed alternatives or barriers (eg, foil) to create a sham. Blinding is also difficult when physical therapy is involved, as active and passive interventions are hard to mask. Lack of blinding introduces expectation bias, affecting the validity of the results.
In 8 studies using sham ESWT as a control, variations in sham protocols likely influenced placebo effects.4,6,7,11-13,15,16 For instance, Speed et al 15 found no differences between sham and active ESWT groups, suggesting a strong placebo response.
Another point of consideration is the use of sham ESWT and placebo ESWT. Although “sham” is likely to be a more accurate description of the method used to mimic the ESWT, several studies use both “sham” and “placebo” when reporting results. This interchangeable use of terms can lead to inconsistencies in both results and the size of the placebo effect.
Three studies compared ESWT with physical therapy.1,9,14 However, the physical therapy protocols used did not represent the gold standard for tendinopathy treatment.
For instance, in the study by Aldajah et al 1 physical therapy included friction and ice massage and the use of continuous ultrasound (1.5 Hz), without any eccentric exercise program.
In the work of Karaca et al, 9 the physical therapy included cold packs, ultrasound, Transcutaneous Electrical Nerve Stimulaion (TENS), and home-based exercises, with eccentric strengthening and stretching exercises, without supervision and only for 4 weeks, even though tendon training typically requires at least 12 weeks for effectiveness.
Similarly, in the study by Sarkar et al, 14 the physical therapy group followed a supervised exercise program combined with a home exercise routine, but this too lasted only 4 weeks, even though supervision was provided.
It is also important to note that adding passive treatments, such as ESWT, ultrasound, or TENS, can undermine patient self-management. The primary focus should remain on exercise therapy, with ESWT as a potential adjunct to enhance outcomes rather than as a stand-alone treatment. None of the studies specified whether the patients had already undergone an adequate exercise program or what other treatments had been attempted before the study.
Interpretation
It is important to consider that statistical significance does not always imply clinical relevance, and a lack of statistical significance does not rule out meaningful clinical effects. For instance, Guler et al 6 found no significant difference between the ESWT and placebo groups (P > .05), but within the ESWT group, there were notable improvements in pain and function (P < .05). This suggests that ESWT may offer clinically relevant benefits despite the absence of statistical significance, highlighting the need to look beyond statistics when evaluating treatment outcomes.
Clinical Implications
Given the mixed results across RCTs, the current evidence does not conclusively support ESWT as superior to placebo or other treatments like physical therapy. However, positive effects in some studies suggest that ESWT may benefit specific patient subgroups. It is recommended that future research investigates ESWT as an adjunct to, rather than a stand-alone, exercise therapy. Specifically, studies should compare ESWT combined with appropriate exercise therapy to exercise therapy alone in patients with chronic LET (>3 months), using standardized and consistent outcomes. Focus should be on identifying subgroups, such as those with neovascularization and without complex pain syndromes, while optimizing treatment protocols (energy dose, frequency, and duration).
Additionally, further research is needed to determine whether ultrasound-guided ESWT is more effective than applying shock waves directly to the loco dolenti.
Safety remains a priority, as mild to moderate side effects were reported, underscoring the need for careful patient selection and counseling when considering ESWT.
Conclusion
The effectiveness of ESWT for LET remains a topic for debate. While some studies have found significant improvements in pain levels and function, others have reported no differences between ESWT and placebo. Variations in ESWT protocol, patient characteristics, and study characteristics may have contributed to these conflicting findings. Future high-quality, large-scale RCTs with standardized protocols and longer follow-up periods are needed to clarify the role of ESWT in the treatment of LET as an add-on to physical therapy.
Footnotes
Appendix
Inclusion and exclusion criteria for this systematic review
| Inclusion criteria | English written articles, free full text available articles and RCTs comparing active focused ESWT with sham ESWT or conventional physiotherapy in chronic lateral elbow tendinopathy. No limitations were imposed on the publication date. |
| Exclusion criteria | Non-English written articles, no free full text available articles, articles where only radial ESWT procedures are investigated and controlled trials with a crossover design were also excluded. Further we applied exclusion criteria for patients aged under 18, elite athletes, pregnancy, upper extremity tumor, local or systemic infection, additional elbow pathology, previous surgery for lateral epicondylitis or radial nerve entrapment, preliminary operation on the epicondyle, a history of fracture of the affected elbow, posterior interosseus nerve syndrome, radiculopathy, any local dermatological problem, local arthrosis or arthritis of reumatoid arthritis, anticoagulant therapy within the previous six weeks, pacemaker attachment, diabetes mellitus, connective tissue disease or infectious disease, vasculitis, malignancy, hyperthyroidosis, known allergy to local anaesthetic mepivacain/scandicain, traumatic injury, neurological abnormalities, nerve or nerve root irritation or cervical problems. |
Final revision submitted December 8, 2025; accepted January 4, 2026.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
