Methods

Study design: randomized, assessor‐blinded trial

Sample size at entry: 20
G1: deep transverse friction massage (DTFM) group 10
G2: control group 10
Treatment duration: 10 days
Follow‐up: 14 days

Participants

Setting: visitors to a sports injury clinic with unilateral chronic (> 4 weeks) iliotibial band syndrome causing pain severe enough to restrict running distance or speed (grade 3), or to prevent it altogether (grade 4)

Inclusion criteria:

• Age in years (mean (± SE)): DTFM group 25 (± 6), control group 29 (± 5), P value 0.20 student t‐test

• Weeks injured (mean (± SE)): DTFM group 23 (± 17), control group 74 (± 95)

• Years of running (mean (± SE)): DTFM group 7.7 (± 5.5), control group 5.4 (± 6.2)

• Kilometers run per week (mean (± SE)): DTFM group 45 (± 15), control group 64 (± 30)

• Grade of injury (mean (± SE)): DTFM group 3.4 (± 0.5), control group 3.4 (± 0.5)

Exclusion criteria: < 18 years old, history of previous knee surgery, concomitant medical therapy

Interventions

Deep transverse friction massage: applied on days 3, 5, 7 and 10

Treated anatomical area (most tender area) with constant pressure, such that discomfort was experienced, but not severe pain; 2 minutes of light friction, then 8 minutes of harder friction

Technique: Pressure was applied with the index finger and reinforced with the ring finger, with the thumb acting as a pivot; brisk motion was initiated from the therapist's shoulder, with the wrist flexible and the hand stiff

Concurrent treatment:

• Rest (apart from 3 * 30 min treadmill exercise tests on days 3, 7 and 14)

• Ice 20 minutes twice daily

• Stretch of iliotibial band, daily

• Ultrasound: 1 MHz, 0.5 W/cm/cm (continuous), 5 minutes on days 3, 4, 5 and 6, then 7 minutes on days 7 and 10

• G1 received deep transverse friction massage and concurrent treatment while control group received concurrent treatment only

Outcomes

Mean pain daily recall, total pain while running, % max pain experienced while running (VAS 0 to 10; 0 = no pain) for 3 treatment periods (days 0 to 2, 3 to 6, 7 to 14)

Notes

One participant was excluded for refusal to comply with the treatment group. Two participants were not accounted for in the control group (reasons not provided)

Per‐protocol analysis

Source of funding: "This research project was generously supported financially by Johnson and Johnson Pty Ltd"

Declarations of interest of primary researchers not provided

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: ''patients were divided into two treatment groups on a random basis''

Comments: method not described

Allocation concealment (selection bias)

Unclear risk

Comments: Investigators state that they divided the 17 athletes into 2 groups without explaining the method of allocation

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Comment: Participants and personnel were not blinded

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Quote: ''the efficacy of the treatment was assessed by a different therapist who was blind to the treatment group of the patient''

Comments: Insufficient information available to judge whether not blinding the participants had an impact on patient‐reported outcomes. More likely at 'high risk' for self‐reported subjective outcomes (eg, pain)

Incomplete outcome data (attrition bias)
All outcomes

High risk

Comments: This study had a 15% dropout rate (even across treatment groups). Duration of follow‐up was mentioned, but investigators did not perform an intention‐to‐treat analysis

Selective reporting (reporting bias)

Low risk

 Comments: The trial presented planned outcomes whether or not the result was significant. No selective reporting was found to be present

Other bias

High risk

Comment: Baseline imbalance was reported; mean age and duration of symptoms were different across groups

Methods

Study design: randomized controlled trial, parallel group, combination of interventions

Sample size at entry: 40
Group 1: ultrasound and placebo ointment without frictions—9
Group 2: ultrasound and placebo ointment with frictions—11
Group 3: phonophoresis without frictions—10
Group 4: phonophoresis with frictions—10
# male/# female: 20/20
Group 1: 2/7
Group 2: 5/6
Group 3: 5/5
Group 4: 8/2

Treatment duration: 9 sessions within 5 weeks

Follow‐up: 5 weeks

Participants

Setting: patients attending a community sports injuries clinic

Inclusion criteria: those who complained of discomfort at or about the lateral epicondyle; pain at the lateral aspect of the elbow during resisted wrist extension; radial deviation during complete elbow extension; tenderness in palpation over, or at, one of the following areas: (1) origin of extensor carpi radialis longus tendon, (2) origin of extensor carpi radialis brevis tendon, (3) extensor carpi radialis brevis at tendon body, and (4) extensor carpi radialis brevis tendon with tenderness extending from origin to the tendon body

Age (mean in years (± SD))
Group 1: 43.8 (± 9.8)
Group 2: 44.6 (± 9.8)
Group 3: 40.1 (± 8.3)
Group 4: 44.7 (± 8.7)

Disease duration (months: mean (± SD))
Group 1: 4.3 (± 3.2)
Group 2: 2.1 (± 1.2)
Group 3: 5.2 (± 7.2)
Group 4: 5.4 (± 4.1)

Exclusion criteria: combined lesions; bilateral elbow problems at initial assessment; history of prior surgery; history of an injection to the elbow within the past 6 months

Interventions

Deep transverse friction massage
Treated anatomical area (elbow) with friction massage applied perpendicular to the structure of interest for 10 minutes, 3 times per week, 9 treatment sessions within 5 weeks
Frictions for groups 2 and 4: position of participant: for lesion at origin of the extensor carpi radialis longus or brevis tendon, elbow flexed at 90 degrees with forearm fully supinated; if lesion at or included tendon body or extensor carpi radialis brevis tendon, elbow flexed at 45 degrees with forearm pronated

Concurrent treatment for group 1 and group 2: ultrasound and placebo ointment
Ultrasound: Dosage varied from 1.3 w/cm² continuous output to 0.5 w/cm² pulsed (1:4). Application technique: sound head moved in slow concentric circles, while sound head contact with the participant was maintained at the same time. Duration: 6 minutes

Concurrent treatment for groups 3 and 4: phonophoresis
Phonophoresis: 10% hydrocortisone ointment used with ultrasound treatment

Outcomes

Pain

• Pain‐free function (8 pain‐free item, 8 = better)

• Pain VAS (0 to 100 mm; 0 = worst).

Grip strength

• Ration index of pain‐free grip strength (grip strength: kilograms of force). Ratio is pain‐free grip divided by maximum grip of uninvolved limb

Function

• Function VAS (0 to 100 mm; 0 = worst)

Functional status (success or failure to perform pain‐free strengthening program for the wrist extensor muscles, with the elbow extended, without subsequent regression within 2 weeks of follow‐up)

Notes

We extracted the outcome of pain on VAS (0 to 100), not pain‐free function, for the review

Source of funding: "This work was supported by the Physiotherapy Foundation of Canada"

Declarations of interest of primary researchers not provided

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''The study design was a two by two factorial design. The subjects were randomly assigned using a balanced blocked randomization table''

Allocation concealment (selection bias)

Unclear risk

Comments: Method of allocation concealment was not described

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Comment: Participants and personnel were not blinded to treatment

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Quote: ''Decision was made by the assessor who was blind to both interventions''

Comments: Insufficient information was available on which to base judgement if not blinding participants had an impact on patient‐reported outcomes

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Comments: No description of withdrawals and dropouts was mentioned. However, all randomly assigned participants were accounted for in the results

Selective reporting (reporting bias)

Low risk

Comments: The trial presented all planned outcomes whether or not the result was significant. No selective reporting was found to be present

Other bias

High risk

Comments: Baseline imbalance was reported; the duration of symptoms was different across groups