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Therapeutic Ultrasound for Lateral Epicondylitis

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Introduction

Lateral epicondylitis

Lateral epicondylitis, also known as lateral epicondylalgia (LE)[1] or tennis elbow, and now acknowledged as lateral epicondyle tendinopathy (LET), is a musculoskeletal condition that causes pain at the lateral side of the elbow. [2] Pain is not the only problem in LE; grip strength and activities of daily living (ADLs) may also be affected as a result of LE. [3] A repetitive strain to the common extensor (CE) tendon, at the origin of the extensor carpi radialis brevis (ECRB) tendon is commonly considered the reason behind LE.[4] Lesions may also include the extensor digitorum, extensor carpi radialis longus (ECRL), and extensor carpi ulnaris. Other sources of lateral elbow pain such as posterolateral elbow instability, posterior interosseous nerve, inflammatory osteoarthritis, primary osteoarthritis, posterolateral plica and osteochondritis dissecans need to be excluded, especially at young ages presenting with a traumatic history.[5]

The use of ultrasound in physiotherapy is often reported as a non-invasive tool for the diagnosis,[6] [7] as well as management of LE.[8][9] Ultrasonographically guided interventions, e.g. for radiofrequency thermal lesioning (RTL) or injection therapy- despite using ultrasound, differ in mechanism of action, tissue target, invasiveness and therapeutic goals and are not in the scope of this page.[10]

This page describes the therapeutic application of ultrasound for LE.

Mechanism of Action

Therapeutic ultrasound for LE may work by delivering sound waves that result in thermal and mechanical effects.[11] The therapeutic aim of ultrasound beams of energy is to reduce pain, promote healing by improving blood flow and tissue metabolism, and accelerate collagen synthesis and tendon repair.

Thermal Effects (Continuous Mode)

Frictional Heating: Acoustic energy makes tissue molecules (especially in high-protein tissues like muscle and tendon) vibrate, producing heat.

Clinical Benefits: Increased blood flow, reduced muscle spasm, increased metabolic rate, and increased collagen extensibility for tissue remodelling.

[11]

Mechanical Effects (Pulsed Mode)

Acoustic cavitation: This phenomenon refers to the formation and oscillation of gas bubbles within tissue fluids because of pressure variations, changing cellular function and increasing permeability.

Acoustic streaming: Fluids flow along cell membranes because of the waves, and this promotes cellular activity and nutrient delivery.

Clinical Benefits: Better repair/regeneration, quicker inflammatory resolution, and less swelling.

[11]

Equipment & Conductive Media

Ultrasound therapy uses a probe to transmit wave energy from the ultrasound machine to the tissue. The probe is a handheld transducer with piezoelectric crystals. When stimulated by electric current, these crystals create the ultrasound waves at frequencies above the range of human hearing (20 hertz to 20000 hertz) by vibrating. This phenomenon is known as the ‘piezoelectric effect'.[12] The physiotherapist uses the probe by moving it in a circular motion over the painful area.[11]

Hypoallergenic contact gel needs to be applied to the patient’s skin, or the area needs to be immersed in water (also known as immersion ultrasound) so that the ultrasound waves pass into the body’s tissues. Immersion ultrasound has been reported as a useful alternative in cases of irregularly shaped body parts (such as the elbow surface) because of the high transmission coefficient and low reflection in water.[13]

There are cases where the ultrasound application is used for promoting transport of compounds into the skin.[11] This method known as sonophoresis or phonophoresis, uses sound waves to heighten cell membrane permeability and increase the absorption of pharmaceutical agents (e.g. naproxen 10%, dexamethasone in LE).[14][15]

Technique & Application Parameters

Local or Water Application

Position: The patient is in a sitting position with the affected elbow in a supported and relaxed position i.e. flexed (60-90 degrees), forearm pronated, fingers relaxed. The application area needs to be clean and checked for skin conditions or metal implants that may contraindicate ultrasound use. In immersion ultrasound, the patient submerges the affected limb in water.

Frequency: 3 MHz is preferrable at the 1-2.5 muscle depth of the superficial location of the common extensor tendon (it absorbs more quickly).[16]

Mode: Pulsed (20-50%) is traditionally preferred for acute/ subacute phases to minimise the effects of heat. Continuous (100%) is allowed for chronic LE, where deep heating is not contraindicated.

Intensity: May range from 0.1 to 1.5 W/cm2 depending on the stage of the condition (lower for the acute stage and the first applications, and higher in chronic cases) and the mode (pulsed or continuous). Again, the superficial location of the extensor tendon does not favour high intensities.

Duration: May be 3-7 minutes in the area of maximal tenderness in the lateral epicondyle. This may be even lower in the first therapeutic sessions.

Evidence for Ultrasound Therapy for Lateral Epicondylitis

Ultrasound therapy may be used as part of physiotherapy and a conservative care plan. Reviews have studied the effect of therapeutic ultrasound in the management of LE[8][17][9] or treatments for LE including ultrasound therapy. [18] [19] Some other have assessed the comparative value of ultrasound to shockwave therapy.[20][21][22]

Older reviews indicated that the value of therapeutic ultrasound for tennis elbow show promise, warranting further investigation.[8][19] In the acute phases, a German narrative review proposes ultrasound with topical NSAIDs, steroid injections, and acupuncture as a means to reduce acute pain and inflammation, though benefits might not last long-term.[23] Despite early suggestions in favour of ultrasound use for pain relief acute-to-mid-term,[24] more recent reviews suggest that these benefits may be better achieved with other treatments.[9][20] [21] [22] For example, extracorporeal shockwave therapy is considered a superior option for pain relief in LE; [20] [21][22] low level laser therapy (LLLT) has been reported as a superior treatment option for enhancing grip strength and providing longer-lasting pain relief in patients with lateral epicondylitis.[25] Furthermore, low-intensity ultrasound therapy (LIUS) for over a 12-week period has not demonstrated a significantly greater therapeutic effect compared to placebo in chronic LE. [26]

One important factor that needs to be considered when looking at reviews on the value of therapeutic ultrasound in LE is parameters and administration for optimal results. To date, there is no universal approach to therapeutic ultrasound application and administration that could potentially enhance outcomes for patients experiencing LE, and further research is recommended to solidify any preliminary favourable findings.[17] Uniform reporting of therapeutic ultrasound treatment parameters is also necessary to allow therapy ultrasound systems and protocols assessment, cross-comparison of studies using different systems and validation of therapeutic bio-effects. [27]

Conclusion

Although therapeutic ultrasound is a common physiotherapy modality, its actual therapeutic benefit in LE is still largely unknown. Further research that uses uniform reporting of treatment parameters is warranted to establish optimal treatment protocols, combinations with other treatment modalities and long-term outcomes in LE. Since evidence to date suggests that other modalities may be more effective, its use as part of a multimodal care plan must be cautious until new evidence arises.

Resources

Lateral Epicondyle Tendinopathy (Tennis Elbow) Toolkit

Ultrasound dose calculations

References

  1. ↑ Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther. 2003 May;8(2):66-79.
  2. ↑ Konarski W, Poboży T. A Clinical Overview of the Natural Course and Management of Lateral Epicondylitis. Orthopedics. 2023 Jul-Aug;46(4):e210-e218.
  3. ↑ Yalvaç B, Mesci N, Geler Külcü D, Yurdakul OV. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc. 2018 Sep;52(5):357-362.
  4. ↑ Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010 Jan;30(1):167-84.
  5. ↑ Blonna D, Hoxha N, Greco V, Rivoira C, Bonasia DE, Rossi R. When Lateral Epicondylitis Is Not Lateral Epicondylitis: Analysis of the Risk Factors for the Misdiagnosis of Lateral Elbow Pain. Am J Sports Med. 2025 Apr;53(5):1195-1201.
  6. ↑ Kerasnoudis A, Venouziou A, Vasiliadis AV. Neuromuscular ultrasound for the differential diagnosis of radial tunnel syndrome and lateral epicondylitis. J Neuroimaging. 2024 Nov-Dec;34(6):799-803.
  7. ↑ Manske RC, Wolfe C, Page P, Voight M. Diagnostic Musculoskeletal Ultrasound for the Evaluation of the Lateral Elbow: Implications for Rehabilitation Providers. Int J Sports Phys Ther. 2025 Jan 1;20(1):137-143.
  8. ↑ 8.0 8.1 8.2 van der Windt DAWM, van der Heijden GJMG, van den Berg SGM, Ter Riet G, de Winter AF, Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999 Jun;81(3):257-271.
  9. ↑ 9.0 9.1 9.2 Luo D, Liu B, Gao L, Fu S. The effect of ultrasound therapy on lateral epicondylitis: A meta-analysis. Medicine (Baltimore). 2022 Feb 25;101(8):e28822.
  10. ↑ Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. Am J Sports Med. 2011 Nov;39(11):2429-35.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Miller DL, Smith NB, Bailey MR, Czarnota GJ, Hynynen K, Makin IR; Bioeffects Committee of the American Institute of Ultrasound in Medicine. Overview of therapeutic ultrasound applications and safety considerations. J Ultrasound Med. 2012 Apr;31(4):623-34.
  12. ↑ Lieu D. Ultrasound physics and instrumentation for pathologists. Arch Pathol Lab Med. 2010 Oct;134(10):1541-56.
  13. ↑ Király M, Varga Z, Szanyó F, Kiss R, Hodosi K, Bender T. Effects of underwater ultrasound therapy on pain, inflammation, hand function and quality of life in patients with rheumatoid arthritis - a randomized controlled trial. Braz J Phys Ther. 2017 May-Jun;21(3):199-205.
  14. ↑ Başkurt F, Ozcan A, Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil. 2003 Feb;17(1):96-100.
  15. ↑ Karbhar AR. The Effect of Phonophoresis Versus Iontophoresis in Lateral Epicondylitis-RCT. Acta Scientific Orthopaedics. 2022; 5(10):95-108.
  16. ↑ Hayes BT, Merrick MA, Sandrey MA, Cordova ML. Three-MHz Ultrasound Heats Deeper Into the Tissues Than Originally Theorized. J Athl Train. 2004 Sep;39(3):230-234.
  17. ↑ 17.0 17.1 Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007 Sep 15;76(6):843-8.
  18. ↑ Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005 Jul;39(7):411-22
  19. ↑ 19.0 19.1 Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):243-66.
  20. ↑ 20.0 20.1 20.2 Alharbi M. Comparative efficacy of extracorporeal shockwave therapy and ultrasound on pain and functional outcomes in lateral epicondylitis: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol. 2025 Jul 16;35(1):307.
  21. ↑ 21.0 21.1 21.2 Yan C, Xiong Y, Chen L, Endo Y, Hu L, Liu M, Liu J, Xue H, Abududilibaier A, Mi B, Liu G. A comparative study of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019 Aug 6;14(1):248.
  22. ↑ 22.0 22.1 22.2 Zhu P, Tang P, Su J, Yang Y, Yang S, Zhang C, Xiao W, Zhou Y, Li Y, Deng Z. Comparison of extracorporeal shockwave therapy, ultrasound therapy, and corticosteroid injections for treatment of lateral epicondylitis: an umbrella review of meta-analyses. J Orthop Traumatol. 2025 Aug 18;26(1):55.
  23. ↑ Schleicher I, Szalay G, Kordelle J. Die Therapie der Epicondylitis - eine aktuelle Übersicht [Treatment of epicondylitis - a current review]. Sportverletz Sportschaden. 2010 Dec;24(4):218-24. [German].
  24. ↑ Dingemanse R, Randsdorp M, Koes BW, Huisstede BM. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review. Br J Sports Med. 2014 Jun;48(12):957-65.
  25. ↑ Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial. J Hand Ther. 2008 Jan-Mar;21(1):63-7
  26. ↑ D'Vaz AP et al.Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford). 2006 May;45(5):566-70. Epub 2005 Nov 22. Level of evidence 1b
  27. ↑ Padilla F, Ter Haar G. Recommendations for Reporting Therapeutic Ultrasound Treatment Parameters. Ultrasound Med Biol. 2022 Jul;48(7):1299-1308.

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