Beyond the Injury: Evidence-Based Modalities for Complex Musculoskeletal Recovery
1
TABLE OF CONTENTS
3
Why Injuries Like ACL Tears and Tennis Elbow Remain Clinically Challenging and How Evidence-Based Modalities Can Help Anterior Cruciate Ligament Reconstruction (ACLR), Key Insights Into Neuromuscular Impacts and Recovery Challenges
5
7
ACL Injuries & Photobiomodulation
9
Case Study: Siya Kolisa’s Recovery From ACL Tear to Lifting the World Cup
11
Understanding Neuromuscular Electrical Stimulation (NMES): Mechanism and Clinical Application in ACL Rehabilitation
15
ESWT to Enhance Rehabilitation and Graft Maturation
16
Evidence to Support the Use of ESWT to Improve Outcomes After ACL Reconstruction
17
Lateral Epicondylitis – Approaches and Treatment Interventions
18
Clinical and Sonographic Evaluation of the Effectiveness of ESWT in Patient With Lateral Epicondylitis Short-term Efficacy Comparison of HILT and LILT in the Treatment of Lateral Epicondylitis
19
20
Patient-centred Rehabilitation and Phased Recovery: A Clinician’s Guide
22
Effectiveness of High Power Laser Therapy on Pain and Isokinetic Peak Torque Athletes with Proximal Hamstring Tendinopathy: A Randomized Trial Lightforce Therapy in Professional Sport: Interview with Bruno Boussagol, PT/Osteo - Health Manager XV France – Rugby
23
26
Treatment Tools for Muscle Injuries
27
About Enovis TM
2
INTRODUCTION: WHY INJURIES LIKE ACL TEARS AND TENNIS ELBOW REMAIN CLINICALLY CHALLENGING AND HOW EVIDENCE-BASED MODALITIES CAN HELP Injuries such as anterior cruciate ligament (ACL) tears and lateral epicondylitis (tennis elbow) are among the most common yet clinically challenging musculoskeletal conditions. They often resist straightforward resolution, despite advances in surgical techniques, rehabilitation strategies, and our understanding of biomechanics and pain science. These conditions demand more than just structural repair. They require comprehensive neuromuscular recovery, pain modulation, and tissue remodelling—factors that traditional rehab alone may not fully address. As such, clinicians are increasingly turning to evidence-based modalities like high- intensity laser therapy (HILT), shockwave therapy, and neuromuscular electrical stimulation (NMES) to complement conventional care and enhance clinical outcomes.
3
WHY THESE INJURIES ARE DIFFICULT TO TREAT
While these conditions differ in anatomy and mechanism, they share several features that make treatment complex, prolonged, and often incomplete.
1. Multifactorial Pathophysiology Both ACL injuries and tendinopathies like tennis elbow involve more than just structural damage. ACL injuries involve not only ligament disruption but also arthrogenic muscle inhibition (AMI), proprioceptive loss, and kinetic chain disturbances, complicating recovery beyond the structural level. Similarly, tennis elbow involves chronic tendon degeneration, not just inflammation, often with persistent neurogenic and mechanical factors that resist quick resolution. 2. Delayed or Incomplete Neuromuscular Recovery Following ACL reconstruction, AMI leads to lasting quadriceps weakness, even in the absence of pain or instability, heightening the risk of suboptimal performance and reinjury. 1,2 In tennis elbow, deficits in motor control and the adoption of compensatory movement patterns can sustain symptoms long after structural tendon healing.
3. High Risk of Recurrence and Chronicity Both conditions are associated with high recurrence rates.
Return-to-sport after ACL reconstruction often occurs before full neuromuscular recovery, increasing the risk of re-injury. Tennis elbow, if biomechanical and occupational factors are unaddressed, frequently recurs or becomes chronic. 1,3
4. Biopsychosocial Influences Pain perception, movement fear, and patient expectations all influence recovery. In chronic tendinopathy, central sensitization can amplify pain, while in ACL patients, fear of reinjury can limit effort and engagement in rehabilitation, even when physical recovery appears adequate. 5. Rehabilitation Demands Time, Precision, and Patient Adherence Effective rehab requires targeted, progressive loading, neuromuscular retraining, and patient engagement over weeks or months. Suboptimal compliance or rushed timelines—often driven by return-to-play or return-to-work pressures, can undermine long-term outcomes.
In light of these complexities, adjunct therapies with strong mechanistic and clinical support can play a vital role in improving outcomes—particularly in patients who plateau or show suboptimal response to standard care. In this eBook, we’ll review how incorporating evidence-based modalities like NMES, ESWT, and HILT into rehabilitation protocols can target these diverse mechanisms, offering measurable benefits in muscle function, pain control, and tissue quality— and ultimately supporting more robust, long-term recovery for patients.
4
Anterior Cruciate Ligament Reconstruction (ACLR) UNDERSTANDING ACL INJURY AND REHABILITATION Key Insights into Neuromuscular Impacts and Recovery Challenges
Anterior Cruciate Ligament (ACL) injuries are among the most complex musculoskeletal injuries, not only due to structural damage but also because of their systemic neuromuscular consequences. Here are the broad impacts of ACL injury and their implications for rehabilitation.
Primary Symptoms • Pain and Swelling: Common acute symptoms post-injury, contributing to limited mobility and discomfort. • Reduced Range of Motion (ROM): Joint effusion and muscle guarding often restrict knee mobility in early stages.
NEUROLOGICAL CONSEQUENCES
SECONDARY COMPLICATIONS
Reduced Proprioception •
Patellofemoral Joint Pain Syndrome (PFJPS) • May develop due to altered gait mechanics and poor quadriceps control.
Affects both the injured and uninjured limbs.
•
Impairs joint position sense and coordination, increasing injury risk.
•
Must be monitored throughout rehab progression.
ACL Injury as a “Brain Injury” •
Neuroplastic changes occur early post-injury. Impacts motor control and coordination. Highlights the need for early neuromuscular re-education.
Muscle Atrophy •
Particularly significant loss of Type I (slow-twitch) fibers (up to 60–80%). Results in fatigue, reduced endurance, and impaired function.
•
•
•
Functional Impacts include •
Arthrogenic Muscle Inhibition (AMI) • Reflexive inhibition of surrounding musculature, especially the quadriceps. • Disrupts voluntary activation, prolonging recovery. • Requires targeted neuromuscular strategies (e.g., NMES, eccentric loading).
Gait Abnormalities: Compensatory patterns may persist even post-rehabilitation. Reduced Functional Performance: Impairs return to sport and daily activities. Loss of Strength Symmetry: • Evaluated using Leg Symmetry Index (LSI). • Persistent deficits increase reinjury risk.
•
•
5
Long-term risks of ACL injuries include increased risk of recurrence, especially if neuromuscular deficits are unaddressed. There is also a higher risk of knee osteoarthritis, 1 as early-onset degenerative changes are common post-ACL injury.
Clinical Takeaways
Address both neurological and musculoskeletal aspects in rehab.
Emphasize early proprioceptive and neuromuscular retraining.
Monitor and correct gait mechanics.
Ensure strength parity before return to training decisions.
ACL injuries go far beyond ligament damage. The neurological, muscular, and biomechanical disruptions underscore the need for comprehensive, evidence-based rehabilitation. Understanding the full scope of the injury is key to optimizing recovery and preventing long-term consequences.
6
UNDERSTANDING ACL INJURIES AND THE ROLE OF LASER THERAPY IN REHABILITATION
ACL injuries are both common and potentially devastating for athletes, often requiring lengthy rehabilitation and, in some cases, surgical intervention. High-Intensity Laser Therapy (HILT) is emerging as a valuable tool in improving recovery outcomes, supporting tissue healing through Photobiomodulation (PBM) at the cellular level. Devices like LightForce ® Therapy enable this targeted, non-invasive treatment to enhance post-injury and post-surgical healing. But why is the ACL so prone to injury? The knee is inherently a stability joint. However, its function is heavily influenced by the mobility and control provided by the hip and ankle. If optimal movement patterns and range of motion are compromised in these adjacent joints, the knee often becomes excessively mobile to compensate. As athletic demands increase—during running, cutting, lunging, squatting, or jumping—the ACL is subjected to greater strain in maintaining knee stability. Over time, this load can exceed the ligament’s capacity, resulting in a tear. From a neuromuscular perspective, injury risk increases when the body struggles to decelerate force efficiently. Muscles are designed to function through a triphasic contraction cycle: concentric (shortening), isometric (stabilizing), and eccentric (lengthening). When neuromuscular control is impaired, particularly in the eccentric phase, muscles are unable to absorb force effectively. The body then shifts the burden to passive structures like ligaments, increasing injury risk when neural thresholds are exceeded.
Muscle groups commonly found to be weak or inhibited in individuals with ACL injuries include:
These deficiencies can compromise force distribution and joint control, making the athlete more susceptible to injury.
Rectus femoris
Gluteus maximus
KEY TAKEAWAY: ACL injuries are rarely isolated to the knee alone. A comprehensive treatment and rehabilitation strategy must include addressing neuromuscular imbalances, improving joint mechanics above and below the knee, and incorporating adjunct modalities like HILT to accelerate recovery and optimize outcomes.
Gluteus medius
Rectus abdominals
Oblique abdominals
7
PHOTOBIOMODULATION THERAPY (PBMT) - A PROVEN WAY TO IMPACT TISSUE AT A CELLULAR LEVEL
Photobiomodulation therapy (PBMT) is a form of light therapy based on the photochemical process called photobiomodulation (PBM). In photobiomodulation therapy, a light source is placed near or in contact with the skin, the light energy penetrates the skin reaching the mitochondria of damaged or diseased tissue leading to positive biological change, resulting in expediting the healing process and alleviating pain. 4-6 PBM mechanisms of action The application of a therapeutic dose of light to impaired or dysfunctional tissue leads to a cellular response mediated by mitochondrial mechanisms involved in pain relief and tissue repair processes. 5
The primary target (chromophore) for the process is the cytochrome c complex which is found in the inner membrane of the cell mitochondria. Cytochrome c is a vital component of the electron transport chain that drives cellular metabolism. As light is absorbed, cytochrome c is stimulated, leading to increased production of adenosine triphosphate (ATP), the molecule that facilitates energy transfer within the cell. 5-7 In addition to ATP, laser stimulation also produces free nitric oxide and reactive oxygen species. Nitric oxide is a powerful vasodilator and an important cellular signaling molecule involved in many physiological processes. Reactive oxygen species have been shown to affect many important physiological signaling pathways including the inflammatory response. In concert, these molecules have been shown to increase growth factor production and promote extracellular matrix deposition.
Physiological effects
Long lasting pain relief by having a direct influence on nociceptive activation 8
A significant reduction in inflammatory markers and neurotransmitters 8
Increased synthesis of ATP 8
Impacts the biochemical pathways involved in tissue repair 8
Increased microcirculation 8
8
CASE STUDY: SIYA KOLISI
Kolisi partially tore the ACL in his right knee during a United Rugby Championship game for the Sharks against Munster on 22 April 2023.
With a lengthy and complex recovery ahead, it was unlikely that Kolisi would be able to play in the upcoming Rugby World Cup (RWC) later that year.
Siya initially accepted the grim prognosis, but his wife Rachel encouraged him to seek another opinion when his initial surgeon said he had no chance in playing in the RWC.
He canceled his scheduled surgery at the last minute and flew to Cape Town for a second opinion.
Dr. van der Merwe gave him a 70% chance of making it to the World Cup and performed a groundbreaking procedure.
Key Milestones: 1. Injury Date - April 22, 2023 2. Second Opion & Surgery - April 24th, 2023 3. Start Rehab - April 26, 2023 4. Return to Training - August 20, 2023 5. World Cup Participation - September 10, 2023
Dr. van der Merwe used an intricate surgical technique—developed alongside Dr. Neil van der Walt. This approach involved using hamstring tendons to reconstruct the ligament and emphasized early mobility and mental resilience as key components of the rehab process.
Siya began his rehab journey in hospital with NMES (muscle stimulation) and Lightforce laser therapy. Both of these modalities were used as combination therapy throughout. The Springboks physio, Rene Naylor led his treatment.
PROTOCOLS USED:
4 SESSIONS DIRECTLY AFTER ONE ANOTHER - COMBINED IN ONE SESSION.
1. Wound area 2. Medial front knee 3. Lateral front knee 4. We’ve added the hamstring because he had a hamstring graft.
Springboks Physio Rene Naylor with Siya Kolisi
Week 1: Day 1 after surgery up to Day 7: Morning and Evening (protocol Post Op knee) Week 2: Only in the Morning and after NMES session if he had pain. Week 3: 4 times per week and after sessions if he had pain or felt uncomfortable. Week 4 - 10: 3 times per week and after sessions if he had pain or felt uncomfortable. Week 10 - 12: As needed by player to treat pain and inflammation around the surgical area.
Case details courtesy of Rene Naylor. Results from this case study are not predictive of future results.
9
Siya Kolisi getting treatment at his local club from the LightForce Laser
Remarkably, Kolisi made his return to play in just 119 days —about four months post-surgery—far ahead of the typical recovery timeline. His comeback was hailed “a medical miracle” and described by teammates and experts as a major emotional boost for the Springboks.
In October 2023, Kolisi captained South Africa to their fourth World Cup title, becoming the first ever back-to-back captain to win away from home.
Medical innovation: A unique surgical approach and intensive rehab with the right modalities in combination. Support system: Strong backing from his family, medical team and faith. Mental resilience: Kolisi’s determination and belief played a crucial role. KEY FACTORS IN RECOVERY 4 SESSIONS DIRECTLY AFTER ONE ANOTHER - COMBINED IN ONE SESSION.
Springboks Physio Rene Naylor (centre) with Enovis’ Beate Stemmet (left) and Pieter Verwey (right)
10
UNDERSTANDING NEUROMUSCULAR ELECTRICAL STIMULATION (NMES): MECHANISM AND CLINICAL APPLICATION IN ACL REHABILITATION
With Insights from Matthew Buckthorpe’s research.
Following anterior cruciate ligament reconstruction (ACLR), patients often experience profound quadriceps dysfunction, including atrophy, impaired voluntary activation, and disrupted motor unit recruitment. Traditional strength training alone may be insufficient, especially in the presence of arthrogenic muscle inhibition (AMI). In this context, neuromuscular electrical stimulation (NMES) has emerged as a clinically validated adjunct, supported by current research including that of Dr. Matthew Buckthorpe.
How NMES Works: The Science Behind the Stimulation
NMES uses surface electrodes to deliver targeted electrical impulses that directly depolarize peripheral motor neurons, bypassing impaired central drive. This produces involuntary muscle contractions and offers several unique physiological benefits:
•
Direct activation of inhibited motor units
• Synchronous, spatially fixed recruitment patterns differing from voluntary contraction • Increased muscle protein synthesis and mitochondrial activity • Enhanced circulation, neuromuscular junction efficiency, and neural plasticity
These adaptations collectively promote muscle hypertrophy, strength restoration, and improved neuromuscular control.
“
NMES appears to be a promising intervention for use after ACLR....NMES undoubtedly should aid in the quest to achieve complete recovery of quadriceps strength.
- Buckthorpe et al., 2019 2
11
CLINICAL APPLICATIONS OF NMES IN ACL REHABILITATION
1. Muscle Re-education NMES is particularly useful in the early phase post-ACLR when voluntary control is reduced. By artificially activating muscle fibers, NMES reinforces the brain-muscle connection through cortical and spinal-level plasticity, aiding in motor relearning. Buckthorpe supports combining NMES with functional tasks (e.g. sit-to-stand), which enhances neuromuscular re-education (Buckthorpe et al, 2023). 2 2. Prevention of Muscle Atrophy During periods of limited activity or weightbearing, NMES helps preserve quadriceps muscle mass. Research shows that early NMES application within the first 1–3 weeks post-op mitigates disuse atrophy and supports faster return of strength (Palmieri-Smith et al., 2022). 3 3. Strength Augmentation When paired with voluntary contractions, NMES has been shown to amplify motor unit recruitment, especially in the presence of persistent inhibition. Buckthorpe highlights its role within a multimodal strength strategy, alongside blood flow restriction (BFR) and progressive loading (Buckthorpe et al, 2019; 2023). 1,2 4. Improved Force Control and Motor Unit Behavior Beyond raw strength gains, NMES enhances force steadiness and motor unit coordination— Bickel et al 2011), 22 crucial for safe, controlled movements in the return-to-sport phase. A systematic review and meta-analysis by Hauger et al. (2018) concluded that NMES in addition to standard physical therapy significantly improves quadriceps strength and physical function in the early post operative period compared to standard physical therapy alone. 10
Conclusion
NMES is more than just a passive modality—it’s an evidence-backed intervention that addresses early-stage neuromuscular deficits post-ACLR. Research in this field affirms NMES value as part of an integrated, progressive rehabilitation plan, especially when strength and movement quality are used as benchmarks for progression, and not time alone.
12
Outcomes measured at baseline, week 3, and week 6 included: • Neuromuscular function: MVIC, force steadiness, and motor unit behavior • Muscle quality: muscle thickness, echo intensity, and ultrasound-based texture analysis After 6 weeks of NMES: • Strength (MVIC) and force steadiness (FS) significantly improved in the ACLR leg, restoring symmetry with the non-surgical side. • Motor unit behavior normalized, indicating improved neuromuscular control. • Muscle quality (thickness, echo intensity, and texture) showed meaningful improvements. • At 3 weeks, structural changes were evident, but strength and FS gains had not yet emerged—suggesting that muscle quality improves before function. This study reinforces NMES as a valuable adjunct to post-ACLR rehabilitation, extending its role beyond basic strength gains to the restoration of neuromuscular control and muscle architecture. Clinicians should consider: • Longer NMES protocols (6+ weeks) to achieve neuromuscular recovery. • Early intervention to promote qualitative muscle improvements, even before strength returns. • Targeting NMES on the affected limb only, to restore symmetry in performance and activation. NMES via the Chattanooga Wireless Pro system offers meaningful improvements in quadriceps strength, force control, and muscle quality in ACLR patients. While early muscle adaptations emerge within three weeks, continued NMES over six weeks is necessary to elicit robust functional and neuromuscular recovery. This supports integrating NMES as a routine, evidence-based component of ACLR rehabilitation strategies. Jo & Kim (2025) 9 , evaluated the effects of NMES on neuromuscular function and muscle quality in male patients recovering from ACLR, specifically targeting individuals who had regained independent gait. Ten male patients recovering from their first ACL reconstruction received neuromuscular electrical stimulation (NMES) to the affected quadriceps 3 times per week for 6 weeks. Each session involved 30 contractions using the Chattanooga Wireless Pro device. Electrode placement targeted the vastus lateralis, vastus medialis, and rectus femoris. Stimulation parameters were standardized across sessions: 400 µsec pulse width, 100 Hz frequency, 6.25:12 sec on:off ratio, and 50% of maximum voluntary isometric contraction (MVIC) intensity.
Improve Results for ACLR patients with Wireless Pro. Watch this short video which presents a study that has shown that the Chattanooga Wireless Pro Muscle Stim device can help patients return to an active lifestyle after ACL reconstruction. The authors of the study believe that we have reached a milestone in rehabilitation following ACL reconstruction that will lead to the revision of current rehabilitation protocols.
13
As these studies demonstrate, NMES is most effective when: • Initiated early in the rehab process, ideally as soon as swelling and pain allow • Used regularly over several weeks (e.g., 3x/week for 6 weeks, as in the study above) • Applied at an intensity sufficient to achieve meaningful muscle contraction, often targeting 50% of the patient’s MVIC (maximum voluntary isometric contraction)
Electrode placement and stimulation parameters should be tailored to the specific muscle group and clinical goals. Consistency in delivery is key to ensuring measurable gains in both structure and function.
Further your learning with Enovis Medical Education
Enhancing Outcomes in Female Rehabilitation Jimmy Reynolds, Sports Physiotherapist, Director Alpha Physiotherapy Enovis Education: Enhancing Outcomes in Female ACL Rehabilitation, www.youtube.com/watch?v=pJ7vuEhgavg An in-depth review of the current evidence surrounding the rehabilitation of ACL Injuries in Female Athletes. Presented by Physiotherapist Jimmy Reynolds, and with a clinical discussion with Knee Consultant Mark Bowditch, this is not one to be missed.
Want to view the Chattanooga portfolio of clinical and portable therapy? Go to www.chattanoogarehab.com/electrotherapy
14
ESWT TO ENHANCE REHABILITATION AND GRAFT MATURATION
ESWT (Extracorporeal Shockwave Therapy), which encompasses both Radial Shockwave (RSW) and Focus Shockwave (FSW) therapy, is a non-invasive treatment option that has support in the literature for helping improve patient outcomes following ACL reconstruction. 11,12
Two ESWT Technologies Radial Pressure Wave Therapy (RPWT) or Extracorporeal Pulse Activation Therapy (EPAT)
Focus shockwave (FSW)
Radial shockwave (RSW, RPW, EPAT) “Pressue wave”
A wave is produced by a small explosion generated underwater inside an ‘applicator’. This wave is focused through a lens and transmitted into the tissue. Energy values - mJ/mm 2 (EFD)
Radial shockwaves properly called Pressure waves are balistically generated by compressed air or electromagnetic energy. The compressed air or electromagnetic field is used to drive a projectile through a cylinder located inside the handpiece to a ‘shock transmitter’. Energy values - Bar pa
How does ESWT help tissue? High energy waves, called shockwaves, which can be created via different mechanisms, results in a phenomenon called mechanotransduction. Simply put, it is the process of imparting brief, physical deformation to cells that leads to biochemical changes. These changes have the potential to positively impact pain and tissue repair. 13
15
Evidence to support the use of ESWT to improve outcomes after ACL reconstruction:
A randomized trial of treatment for anterior cruciate ligament reconstruction by radial extracorporeal shock wave therapy (rESWT) The strategy of rehabilitation plus rESWT had better functional outcomes after ACL reconstruction. As such, this study demonstrates that rESWT is essential for patients with ACL reconstruction. Early use of rESWT can improve joint function, pain relief and ability of daily living. rESWT has a positive effect on the overall rehabilitation of patients. pubmed.ncbi.nlm.nih.gov/38216944/
Radial Extracorporeal Shock Wave Therapy Enhances Graft Maturation at 2-Year Follow-up After ACL Reconstruction: A Randomized Controlled Trial Both enhanced graft maturation and improved functional scores at 24-month follow-up were seen in patients who received radial ESWT during rehabilitation
after hamstring autograft ACLR. pubmed.ncbi.nlm.nih.gov/36760537/
The Effects of Three and Six Sessions of Low Energy Extracorporeal Shockwave Therapy on Graft Incorporation and Knee Functions Post Anterior Cruciate Ligament Reconstruction Six sessions of low energy ESWT improved graft incorporation in the tibial tunnel. pubmed.ncbi.nlm.nih.gov/35519531/
Extracorporeal Shockwave Therapy Improves Outcome after Primary Anterior Cruciate Ligament Reconstruction with Hamstring Tendons This is the first study investigating the effect of repetitive ESWT on ACL reconstruction with clinical outcome measurements, including the duration of return-to-sports activity and an MRI follow-up examination. Return-to-sports parameters, clinical scores and graft maturation were significantly improved in the ESWT group. This study may support an earlier return-to-sports timepoint by ESWT and is of high clinical relevance as ESWT is a cost-effective treatment option with no relevant side effects. pubmed.ncbi.nlm.nih.gov/37240456/
16
LATERAL EPICONDYLITIS – APPROACHES AND TREATMENT INTERVENTIONS Lateral epicondylitis (LE) is a common musculoskeletal condition with clinical symptoms of pain and inflammation over the proximal attachment of the wrist extensor tendon and lateral epicondyle of the humerus. It is frequently known as “tennis elbow” and maximum incidences occur between 30 and 65 years of age. 14 Other symptoms may include stiffness or weakness in the elbow and difficulties in functional activities of the hand. 15 It is caused by a direct injury or repeated stress or motion of the soft tissues surrounding the elbow joint. Over time, this repeated stress and overloading can cause a degenerative condition known as tendinosis. Together, tendinitis and tendinosis further lead to the tendon tearing. Several approaches have been used for the treatment of LE, such as physical therapy (including rest and movement restriction, activity modification, hot−cold application, electrotherapy, massage, and ultrasound), splinting, local injections (corticosteroids and platelet-rich plasma), oral or topical nonsteroidal anti-inflammatory drugs, and surgery. 16,17 Treatments are mainly aimed at reducing pain, controlling inflammation, accelerating healing, and ensuring that the patient can perform activities of daily life. Shockwave Therapy for Lateral epicondylitis To determine the efficacy of ESWT for LE, Yao et al (2020) carried out a systematic review and meta-analysis of a total of 13 articles with 1035 patients to compare the effectiveness of ESWT with other techniques in the treatment of LE. They concluded: Based on the existing clinical evidence, extracorporeal shock wave therapy can effectively relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow, with better overall safety than several other methods” 18 Nambi et al (2022) compared the effects of corticosteroid injection and extracorporeal shockwave therapy on radiological changes in chronic lateral epicondylitis and concluded
Extracorporeal shockwave therapy has added effects on corticosteroid injection for improving pain, percentage of injury, functional disability, handgrip strength, patient perception, kinesiophobia, depression status and quality of life in people with chronic lateral epicondylitis .19
Nambi et al 2022: Significant and long-term (up to 6 months) improvement of pain and function with Radial Shockwave Therapy
Further your education: How to get the best results with Shockwave for Lateral Epicondylitis with Cliff Eaton MSc MCSP
•
Shockwave therapy – does it work for lateral epicondylitis?
•
What other interventions do we have available?
•
Would a combination of interventions provide the best clinical outcomes?
www.chattanoogarehab.com/webinars
17
CLINICAL AND SONOGRAPHIC EVALUATION OF THE EFFECTIVENESS OF EXTRACORPOREAL SHOCK WAVE THERAPY IN PATIENTS WITH LATERAL EPICONDYLITIS
Sadiye Murat, Bilinc Dogruoz Karatekin, Melisa Zengin
Purpose The aim of this study is to assess the
Sonographic Findings: CET thickness significantly decreased in the rESWT group post-treatment and one month after treatment. The median thickness decreased by 15%. There was no significant change in the control group.
clinical and sonographic outcomes of radial extracorporeal shock wave therapy (rESWT) in patients with lateral epicondylitis (LE).
Methods Forty-two patients with LE for at least 3 months were randomized into two groups: • rESWT group (21 patients) • sham-rESWT control group (21 patients). The rESWT group received rESWT treatment on the lateral epicondyle once per week for 3 weeks, 2000 pulses, 10 Hz, 1.8 bar. The sham-rESWT group followed the same treatment schedule. The ESWT applicator was applied to the lateral epicondyle and made sounds, but no shocks were emitted. Both groups received a wrist resting splint, stretching and strengthening exercises, and ice application. Assessments Hand grip strength, pain, functionality, and common extensor tendon (CET) thickness were evaluated before, after, and one month post-treatment. Results Baseline: There were no significant differences between the groups. Post-Treatment and One Month Follow-Up: Significant improvements in pain pressure threshold, grip strength, visual analog scale (VAS), and Patient-Rated Tennis Elbow Evaluation scores were observed in both groups. However, the rESWT group showed superior results in these pain reduction and functional improvement measures compared to the control group. For example, after treatment, the median VAS score decreased by 57% in the rESWT group, whereas the sham group VAS scores decreased by only 14%.
Conclusion: •
While both groups showed improvement, the rESWT group showed statistically superior outcomes in function and pain reduction. • Sonographic evaluation revealed a significant reduction in CET thickness in the rESWT group, indicating that rESWT has a physical impact on treating LE.
Request a demonstration of a Chattanooga® shockwave therapy unit.
Citation: Murat S, Dogruoz Karatekin B, Zengin M. Clinical and Sonographic Evaluation of the Effectiveness of Extracorporeal Shock Wave Therapy in Patients with Lateral Epicondylitis. Medeni Med J. 2024;39(2):109-116. doi:10.4274/MMJ. galenos.2024.60308
18
SHORT-TERM EFFICACY COMPARISON OF HIGH-INTENSITY AND LOW-INTENSITY LASER THERAPY IN THE TREATMENT OF LATERAL EPICONDYLITIS: A RANDOMIZED DOUBLE-BLIND CLINICAL STUDY
Ercan Kaydok, Banu Ordahan, Sezin Solum, Ali Yavuz Karahan Published in: Archives of Rheumatology, 2020 https://doi.org/10.5606/archrheumatol.2020.7347
This clinical trial compared high-intensity laser therapy (HILT) to low-intensity laser therapy (LILT) in treating lateral epicondylitis symptoms. Sixty patients with unilateral lateral epicondylitis were randomized to receive HILT or LILT. Patients were blinded to which treatment they received. Both groups completed 9 treatment sessions in 3 weeks.
•
HILT group: Patients received treatment with a 12 W laser. The first 3 sessions used pulsed wave therapy for 75 seconds, 8 W, 6 J/cm 2 . The following 6 sessions used continuous wave therapy for 30 seconds, 6 W, 120-150 J/cm 2 .
•
LILT group: Patients received treatment from a laser with an output power of 240 mW. Treatment was given over 6 areas of the lateral epicondyle each about 0.5 cm 2 . Power density was 2.4 J/cm 2 for 30 seconds per spot.
Study outcomes included pain assessment (VAS), upper extremity function (QDASH questionnaire), quality of life (SF-36), and grip strength. After 3 weeks of treatment, both the HILT and LILT groups showed significant improvement in pain. Pain scores decreased by 59.7% and 53.5% for the HILT and LILT groups, respectively.
Both groups also showed significant improvement in grip strength, QDASH score, and the SF-36 physical component score. However, the HILT group had significantly better outcomes in these functional scores than the LILT group. It can be concluded from the study that both HILT and LILT are effective treatment options for managing pain and disfunction in lateral epicondylitis, but HILT can give patients even better functional outcomes than LILT.
Request a demonstration of a LightForce® therapy laser or a Chattanooga® shockwave unit.
19
PATIENT-CENTRED REHABILITATION AND PHASED RECOVERY: A CLINICIAN’S GUIDE Cliff Eaton MSc, MCSP, International Clinical Support Specialist at Enovis, provides an overview of the potential interventions for dealing with soft-tissue injuries.
In the case of ACL injuries, many surgeons now prefer to wait until pain and inflammation are under control, hence our early interventions can expedite their surgical intervention. Also, pain and inflammation both result in neuromuscular inhibition via the AMI process, resulting in muscle atrophy and weakness. So, to enhance our post op muscle strengthening, addressing pain and inflammation early on is a really important consideration. Patient education is important to manage their expectations and provide self-help measures. These may include modifying activities of daily life. Patient’s expectation must be managed. Accelerated rehab programmes and early return to sport are now largely dismissed due to the high recurrence rates. Therefore, patients must also be realistic about time scales. Discuss Return to train times rather than Return to Play times. This will help with a patient’s optimism on being able to return to their desired activity.
Rehabilitation of injuries such as ACLs and LE can complex. So let us consider our potential interventions for dealing with these challenges using the acronym PEACE and LOVE, which is gaining popularity over the acronym PRICE, which is essentially used for acute presentations. PEACE and LOVE, put forward by Dubois et al (2020), encompasses the whole rehab process and puts the patient at the centre rather than the injury. 20
Acute management’ •
Protection (Brace/Taping)
• •
Elevation
Avoid anti-inflammatories – Cryotherapy, PBMT
• •
Compression
Education - activity modification • Patient expectation • Time scale
Protection from further exacerbation is recommended immediately after injury for 2-3 days - bracing provides stability and enhanced proprioception during the rehab process. Inflammation (only present in acute presentations) is an essential part of the healing process and should not be retarded by anti-inflammatory medication. Cryotherapy could be used instead, and compression could be incorporated using the Aircast Cryocuff. Current literature suggests that ice only provides an analgesic effect and does not influence the inflammatory process. Modalities like High intensity Laser Therapy, and to a lesser extent Ultrasound, which are inflammatory ‘optimisers’, are very effective at this stage but do require the patient to visit the clinic at least 3 times a week but preferably daily for the first two weeks.
Rehabilitation phase •
Load – progressive optimal loading
• Optimism – perceptions, catastrophizing, pessimism • Vascularisation – ESWT and PBMT • Exercise - restoration of pain free ROM and ADL • S.A.I.D. principle (Specific Adaptation to Imposed Demands)
...
20
... Moving onto rehab we are now aware of the importance, especially for tendons, of prescribing a progressive optimal loading programme to enhance healing. Lin et al (2020) 21 demonstrated that the brain plays an important role in the rehab process, with Dubois et al (2020) 20 suggesting to remain realistic but encourage optimism to enhance the chances for optimal recovery. We must also remember that the brain is the central processor influencing all of the interventions we administer. It is often neglected in the rehab process. Treat it like a muscle. It can weaken if not used. On return to sport’s activities the skill tasks will be diminished, and joint and core stability activation will be delayed. Unless addressed these factors will increase the risk of a recurrent injury. Increasing blood flow to an area does expedite the healing process and for me therefore I incorporate ESWT and PBMT into my patient management. Having gradually loaded the soft tissue pain free to encourage healing we must then, using the SAID principle, to get it to adapt to the specific imposed demands that will be placed on it. Cliff Eaton is a licensed MCSP, internationally published author, and the International Clinical Support Specialist at Enovis. He received his MSc degree in Sports Injury Management from The Manchester Metropolitan University in 2005, and he has been a part of the sports medicine staff for multiple professional sports teams, including his tenure as the Medical Manager and Head of Physiotherapy for Northampton Saints RFC.
21
EFFECTIVENESS OF HIGH POWER LASER THERAPY ON PAIN AND ISOKINETIC PEAK TORQUE IN ATHLETES WITH PROXIMAL HAMSTRING TENDINOPATHY: A RANDOMIZED TRIAL Sachin Verma, Vandana Esht, Aksh Chahal, Gaurav Kapoor, Sorabh Sharma, Ahmad H. Alghadir, Masood Khan , Faizan Z. Kashoo , and Mohammad A. Shaphe P ublished in: BioMed Research International, 2022, https://doi.org/10.1155/2022/4133883
This study was conducted to determine whether high power laser therapy (HPLT), also referred to as Photobiomodulation Therapy (PBMT), has an effect on proximal hamstring tendinopathy (PHT) symptoms.
Forty athletes with PHT were randomized to one of the following 2 groups:
• Conventional therapy: The athletes completed ultrasound therapy, moist heat treatments, and home exercises.
• HPLT/PBMT: Athletes received treatment with a 10 W high power LightForce® therapy laser at 5 W, 50 J/cm² for a total energy dose of 1800 J per session. Treatment was focused on the hamstring tendon near the ischial tuberosity. Each session lasted for 6 minutes.
Both groups completed their designated treatments 3 days a week for 3 weeks.
Pain was assessed using the Numeric Pain Rating Scale (NPRS). The study also used an isokinetic dynamometer to measure isokinetic peak torque (IPT) of the hamstring muscle. The authors suggest that a change in IPT could be another indication of pain relief because athletes experiencing less pain will be able to apply more force on the muscle.
Pain scores and IPT measurements were taken prior to treatment and at the end of 3 weeks of treatment.
While there was not a significant difference between the groups in IPT, the HPLT/PBMT group did have more improvement in IPT compared to the conventional therapy group. The lack of statistical difference between groups could be due to the HPLT/ PBMT group not completing any exercise treatments.
After treatment, both the HPLT/PBMT group and the conventional therapy group had a clinically significant reduction in pain score. However, the HPLT/PBMT group improved more than the conventional therapy group with the average pain score decreasing to a mild level.
This study demonstrated that HPLT/PBMT is more effective than a conventional therapy program at reducing pain from PHT. HPLT/PBMT reduced the average pain score to a mild level, and this decrease in pain may also have resulted in functional improvements for the athlete.
Request a demonstration of a LightForce® therapy laser or a Chattanooga® shockwave unit.
22
LIGHTFORCE THERAPY IN PROFESSIONAL SPORT: Interview with Bruno Boussagol, PT/Osteo - Health Manager XV France – Rugby
How did you learn about LightForce (LF) therapy, and how long have you been using it with the athletes you follow? I’ve incorporated LightForce therapy into a number of protocols over the last year, working with athletes from very different backgrounds. I’ve worked with golfers, professional rugby players, a downhill Mountain Bike World Champion... My approach was built around the needs I encountered, to be able to meet the demands of the athletes I accompany from time to time. They are subjected to increasingly intense preparation. Competitions are often long and traumatic. Our approach as therapists requires us to adapt and anticipate these changes. LightForce Therapy has a dual role to play in supporting athletes: in prevention, during preparation sessions, and in the programming of care for numerous pathologies. Integration of LightForce Therapy When I became interested in this type of treatment, I contacted therapists with expertise in the field, to understand the added value of photobiomodulation and how I could integrate it into my own practice. I wanted to use this technology by integrating it into my own professional practice. I had to practice to master the tool. When proposing this type of treatment, it’s important to be familiar with the effects, and to be able to clearly explain what you’re looking for in terms of how you’re going to use it. Results can only be validated by athletes, and feedback is generally very positive. Whether as part of prevention or treatment, LF is integrated into a complete care protocol. The aim is to limit the risk of relapse and reduce downtime in the event of pathology. My aim is to improve individual care and performance.
I have used LF to treat a wide range of pathologies, including tendon problems, muscle injuries, and plantar fasciitis, as well as joint injuries such as ankle sprains, knee ligament injuries (medial collateral ligament). I’ve also used photobiomodulation as part of an activation approach, for players who were in the recovery phase and those who were struggling with cumulative workload. What feedback have you had from athletes after this therapy, and could you now work without this technology? The feedback is very positive. When you support a professional athlete in international competitions, you have to gain their trust and respond effectively to their needs. The notion of efficiency is essential. For a therapist, it’s difficult to offer a treatment during a competition and not be able to repeat it the following time. Once a treatment protocol has been validated, we need to be able to offer it at the next competition. The LF is a tool that follows me wherever I go. In what specific contexts do you use this therapy? Rather than reviewing the various pathologies, I’d like to take a look at two situations in which LF has been a real added-value treatment:
...
23
...
Case 1: Management of an inflammatory Achilles tendon condition in a rugby player’s training camp: The therapeutic approach with LightForce therapy was to activate at the periphery of the inflammatory zone, then progressively on the painful area, and then to sweep over the triceps sural muscle body in search of relaxation and an effect on the vascular system. This work was initially carried out in unloading mode. I integrated the protocol proposed by LF, combining eccentric-type exercises with minimal resistance. Photobiomodulation reduced the inflammatory state of the tendon and encouraged the release of endorphins. It also released tension from the muscular body. The sensation of warmth and contact with the massage ball is a real comfort for both patient and therapist. This protocol was then carried out under load and integrated into functional exercises for the foot and propulsion muscles. In this particular case, the physical activity was adapted, and the time available in the field was not affected. The effects were long-lasting, and the situation had no repercussions during the competition. Case 2: LF also enabled me to treat another player who was experiencing pain on the insertion of the patellar tendon at its tibial attachment, in the TTAT area. This problem had arisen following a direct impact during a match. The player finished the match. He had continued his activities under cover of analgesic treatment to mask the pain, without being able to implement a clearly defined therapeutic strategy. When he contacted me, a form of chronicity had set in, with an adaptation of motor control over his running pattern (loss of strength in the quadriceps and consequences for the hamstrings). LF treatment combined with various forms of thigh muscle contraction enabled local action to be taken on the painful area. Work on the quadriceps generated benefits for motor control of the knee. The results obtained locally on the impact zone were surprising. Firstly, on the skin level, the insertion zone cooled down and oedema was reduced. The player’s experience was also interesting. His VAS was halved, with no impact on his workload during preparation sessions, and with no associated medical cover. He was also able to play for longer periods during the competition. Case details courtesy of Bruno Boussagol. Results from this case study are not predictive of future results.
The sessions were daily. The benefit of LF was rapid, and the effects felt by the player were immediate. A global approach My role as care manager with the French national rugby team focuses my practice on rugby players, but the rest of my time as Health Manager is very varied. I’m regularly called upon to provide individual support to great champions in downhill mountain biking and endurance sports... I think it’s important to point out that the results of our interventions are often linked to the overall management of problems. Integrating LF into a general treatment program multiplies the chances of a successful outcome. The mistake would be to believe that photobiomodulation technology alone is responsible for the result. It’s better to have a global approach with multifactorial actions, and to integrate LF technology into this project to optimize treatment efficacy. Can we talk more specifically about muscle I attach a great deal of importance to activating athletes before starting a day’s work. Initially, I would include an unlocking and mobility session to bring the body into optimal condition for high intensity work, whether before training or in preparation for a competition. This is why I use LF primarily in the morning. This step has been added to the process for players identified as “at risk”. These players are generally monitored for musculo- tendinous problems. I offer them dynamic activation with Light Force. The idea is to use photobiomodulation to have a stimulating action. I aim to increase collagen production to optimize the muscular resistance of a chain of muscles. I perform this type of work on functional movements with a view to neuromotor regulation. This can be done with loading or unloading, while maintaining low- intensity motor control, using different types of contraction. Active “conscious” participation by the athlete is required to act on this motor balance of agonist muscles, which activate concentrically, and antagonist muscles, which agree to lengthen. Our action with the LightForce Therapy can be alternated between motor and braking muscles, as required. activation and the period of use you recommend during a competition?
...
24
...
Last but not least, for me, is the practicality. The unit comes with a compact wheeled case, which is very sturdy and easy to carry when I am traveling.
In conclusion Athletes have understood the usefulness of this type of treatment and regularly ask me for LightForce therapy. In the world of professional sports, LightForce therapy has become essential. It must be integrated into a comprehensive treatment program. Because LightForce therapy is dynamic, the main challenge for the therapist is to synchronize the manipulation of the tool with his or her own gestures and technique. We indicate that there are no known conflicts of interest associated with this publication.
25
TREATMENT TOOLS FOR MUSCLE INJURIES
Explore the Chattanooga and Lightforce product range that can support the treatment of conditions such as ACL and Lateral Epicondylitis
LightForce Therapy Lasers
LightForce XLI Therapy Laser | 40W
LightForce XPI Therapy Laser | 25W
LightForce FXI Therapy Laser | 15W
Chattanooga Shockwave Devices
Intelect® RPW2
Intelect® Mobile 2 RPW
Intelect® Focus Shockwave
Electrical Stimulation & Ultrasound
Chattanooga® Intelect® Mobile 2
Chattanooga® Intelect® Transport 2
Chattanooga® Wireless Pro
DISCOVER CHATTANOOGA® PORTFOLIO OF REHABILITATIVE TECHNOLOGY learn.chattanoogarehab.com/request-a-quote-ebook
26
BETTER IS
CREATING THE NEXT GENERATION OF POSSIBLE. TOGETHER.
ABOUT ENOVIS™ Enovis™ (NYSE: ENOV) is a medical technology company focused on developing clinically differentiated solutions that generate measurably better patient outcomes and transform workflows.
Powered by a culture of continuous improvement, extraordinary talent and innovation, we ‘create better together’ by partnering with healthcare professionals. Our extensive range of products, services and integrated technologies fuel active lifestyles.
EGX is our unique business system that guides the way we operate. It provides the tools, techniques, and values that ensure we are continuously improving our ability to meet or exceed customer requirements each and every day.
ASSOCIATES 7,000+
MEDICAL DEVICES 1,000+
2022 REVENUE $1.6B
WE ARE UNIQUELY POSITIONED ACROSS THE ORTHOPEDIC CARE CONTINUUM
PREVENTION
REPAIR
RECOVERY
PERFORMAMCE • Athletic Braces • Muscle Stimulation
PREVENTION • Off-loading Braces
SURGICAL • Shoulder • Knees • Hips • Foot / Ankle
RECOVERY • Post-op Braces • Walker Boots • Cold Therapy
REHAB • Electrotherapy • Laser Therapy • Heat / Cold Therapy • Traction Devices
• Back Braces • Cold Therapy
27
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29Made with FlippingBook - PDF hosting