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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 1 Pain (VAS 0‐100, 0 = worst) (change from baseline).
Figuras y tablas -
Analysis 1.1

Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 1 Pain (VAS 0‐100, 0 = worst) (change from baseline).

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Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 2 Grip strength (ratio index, higher is better).
Figuras y tablas -
Analysis 1.2

Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 2 Grip strength (ratio index, higher is better).

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Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 3 Function (VAS 0‐100, 0 = worst).
Figuras y tablas -
Analysis 1.3

Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 3 Function (VAS 0‐100, 0 = worst).

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Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 4 Function (pain‐free function; average number of pain‐free items; higher is better).
Figuras y tablas -
Analysis 1.4

Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 4 Function (pain‐free function; average number of pain‐free items; higher is better).

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Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 5 Functional status (number of successes to perform strengthening program).
Figuras y tablas -
Analysis 1.5

Comparison 1 Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only, Outcome 5 Functional status (number of successes to perform strengthening program).

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Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 1 Pain (VAS 0‐100, 0 = worst).
Figuras y tablas -
Analysis 2.1

Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 1 Pain (VAS 0‐100, 0 = worst).

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Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 2 Grip strength (ratio index, higher is better).
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Analysis 2.2

Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 2 Grip strength (ratio index, higher is better).

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Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 3 Function (VAS 0‐100, 0 = worst).
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Analysis 2.3

Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 3 Function (VAS 0‐100, 0 = worst).

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Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 4 Function (pain‐free function; average number of pain‐free items; higher is better).
Figuras y tablas -
Analysis 2.4

Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 4 Function (pain‐free function; average number of pain‐free items; higher is better).

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Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 5 Functional status (number of successes to perform strengthening program).
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Analysis 2.5

Comparison 2 Massage + phonophoresis vs phonophoresis only, Outcome 5 Functional status (number of successes to perform strengthening program).

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Comparison 3 Massage + physical therapy vs physical therapy only, Outcome 1 Pain.
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Analysis 3.1

Comparison 3 Massage + physical therapy vs physical therapy only, Outcome 1 Pain.

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Summary of findings for the main comparison. Massage + ultrasound and placebo ointment compared with ultrasound + placebo ointment only for treating lateral elbow tendinitis (tennis elbow)

Massage + therapeutic ultrasound and placebo ointment compared with ultrasound + placebo ointment only (follow‐up 2 weeks) for treating tendinitis

Patient or population: patients with extensor carpi radialis tendinitis
Settings: community sports injuries clinic in Canada
Intervention: massage + therapeutic ultrasound and placebo ointment
Comparison: therapeutic ultrasound + placebo ointment only

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control (US + placebo ointment only)

Massage + US and placebo ointment

Pain
Visual analog scale

Scale from 0 to 100 (lower is better)
Follow‐up: mean 2 weeks

Mean change in pain in the control groups was
4.6 mm

Mean change in pain in the intervention groups was
6.6 lower
(15.40 lower to 28.60 higher)

20
(1 study)

⊕⊝⊝⊝
Very lowa,b,c

MD = ‐6.60 (‐28.60 to 15.40)

Absolute improvement = ‐7% (‐29% to ‐15%)

Relative percentage change = 8% (‐24% to 37%)

Not statistically significant

Proportion reporting pain relief of 30% or greater not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Function
Visual analog function index

Scale from 0 to 100 (higher is better)
Follow‐up: mean 2 weeks

Mean function (vas 0 to 100, 0 = worst) in the control groups was
78.1 mm

Mean function (VAS 0‐100, 0 = worst) in the intervention groups was
1.8 lower
(18.64 lower to 15.04 higher)

20
(1 study)

⊕⊝⊝⊝
Very lowa,b,c

MD = ‐1.80 (‐18.64 to 15.04)

Absolute improvement = 2% (‐19% to 15%)

Relative percentage change = ‐3% (‐28% to 23%)

Not statistically significant

Quality of life—not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Patient global assessment of success not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Adverse events not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Withdrawals due to adverse events not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; ECRT: Extensor carpi radialis tendinitis; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aAllocation concealment was unclear. Only assessors were blinded. Baseline imbalance was reported.
bVery few participants.
cWide confidence intervals.

Figuras y tablas -
Summary of findings for the main comparison. Massage + ultrasound and placebo ointment compared with ultrasound + placebo ointment only for treating lateral elbow tendinitis (tennis elbow)
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Summary of findings 2. Massage + phonophoresis compared with phonophoresis alone for treating lateral elbow tendinitis (tennis elbow)

Massage + phonophoresis compared with control (phonophoresis only) (follow‐up 2 weeks) for treating tendinitis

Patient or population: patients with extensor carpi radialis tendinitis
Settings: community sports injuries clinic in Canada
Intervention: massage + phonophoresis
Comparison: phonophoresis only

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control (phonophoresis only) (follow‐up 2 weeks)

Massage + phonophoresis

Pain
Visual analog scale

Scale from 0 to 100 (lower is better)
Follow‐up: mean 2 weeks

Mean change in pain in the control groups was
1 mm

Mean change in pain in the intervention groups was
1.2 lower
(17.84 lower to 20.24 higher)

20
(1 study)

⊕⊝⊝⊝
Very lowa,b,c

MD = ‐1.2 (‐20.24 to 17.84)

Absolute improvement = ‐1%
(‐20% to 18%)

Relative percentage change = 6% (‐86% to 97%)

Not statistically significant

Proportion reporting pain relief of 30% or greater not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Function
Visual analog scale

Scale from 0 to 100 (higher is better)
Follow‐up: mean 2 weeks

Mean function in the control groups was
78.8 mm

Mean function in the intervention groups was
3.7 higher
(14.13 lower to 21.53 higher)

‐

20
(1 study)

⊕⊝⊝⊝
Very lowa,b,c

MD = 3.70 (‐14.13 to 21.53)

Absolute improvement = 4% (‐14% to 22%)

Relative percentage change = 5% (‐18% to 28%)

Not statistically significant

Quality of life not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Patient global assessment of success not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Adverse events not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Withdrawals due to adverse events not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; ECRT: extensor carpi radialis tendinitis; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aAllocation concealment was unclear. Only assessors were blinded. Baseline imbalance was reported.
bVery few participants.
cWide confidence interval.

Figuras y tablas -
Summary of findings 2. Massage + phonophoresis compared with phonophoresis alone for treating lateral elbow tendinitis (tennis elbow)
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Summary of findings 3. Deep transverse massage + physical therapy compared with physical therapy alone for treating lateral knee tendinitis

Deep transverse friction massage + physical therapy compared with physical therapy alone

Patient or population: patients with iliotibial band friction syndrome (knee tendinitis)

Settings: community sports injury clinic in South Africa

Intervention: deep transverse massage and physical therapy

Comparison: physical therapy alone

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Deep transverse massage

Daily pain
Visual
analog scale (VAS)
Scale from 0 to
10 (lower is better)

Follow‐up mean 2
weeks

Mean daily pain
in the control groups was
1 point

Mean daily pain in

the intervention groups was
0.4 lower
(0.8 lower to 0.00 higher)

17
(1 study)

⊕⊝⊝⊝
very lowa,b

MD = ‐0.4 (‐0.8 to 0)

Absolute improvement = ‐4% (‐8% to 0%)

Relative percentage change = ‐40% (‐80% to 0%)

Not statistically significant

Proportion reporting pain relief of 30% or greater not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Function not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Quality of life not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Patient global assessment not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Adverse events not measured

See comment

See comment

Not estimable

‐

See comment

Not measured

Withdrawals due to adverse events

See comment

See comment

Not estimable

‐

See comment

Not measured

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; ITBF: Iliotibial band friction syndrome (knee tendinitis); RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aRandomization and allocation concealment were unclear. Only assessors were blinded. No intention‐to‐treat analysis was done, and baseline imbalance was reported.
bVery few participants.

Figuras y tablas -
Summary of findings 3. Deep transverse massage + physical therapy compared with physical therapy alone for treating lateral knee tendinitis
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Table 1. Inclusion and exclusion critieria according to the PICOTS strategy

Inclusion

Exclusion

Participants/Population (P)

  • Outpatients or inpatients

  • Diagnosis: tendinitis pain

  • Chronic versus acute conditions

  • Normal weight (BMI < 25 kg/m2)

  • Age groups ≥ 18 years

  • Medically stable

  • Mentally competent

Participants/Population (P)

  • Cancer (and other oncologic conditions)

  • Dermatologic conditions

  • Healthy normal

  • Mixed population

  • Multiple conditions (presenting other chronic problems additional)

  • Neurologic conditions

  • Pediatric conditions

  • Psychiatric conditions

  • Pulmonary conditions

  • Scoliosis

  • Condition in which rapid weight loss or exercise is contraindicated (angina, frailty, advanced osteoporosis)

  • Obese or overweight patient (BMI ≥ 25 kg/m2)

Interventions (I)

  • Eligible interventions: deep transverse frictions  techniques only, in community or not, and with or without:

    • Concurrent programs (eg, stretching exercises, modalities (ultrasound), phonophoresis)

    • Supervision

  • Eligible control groups: conventional therapy, untreated, waiting list, active physical therapy treatments, educational pamphlets

Interventions (I)

  • Surgery (ie, not the effects of surgery)

  • Medication (eg, phonophoresis with medications)

  • Thermal biofeedback

Comparisons (C)

Studies were included if they compared an intervention group (eg, deep transverse frictions techniques combined with modalities, exercises) with a comparison group (eg, placebo, no treatment, active treatment such as modalities, exercises)

Comparisons (C)

Studies were excluded if they did not compare the intervention group with a comparison group (eg, placebo, no treatment, active treatment such as modalities, exercises)

Outcomes (O)

  • Functional status (self‐care activities)

  • Medication intake (if reported)

  • Muscle strength

  • Pain intensity

  • Participant satisfaction

  • Quality of life

  • Compliance

Outcomes (O)

  • Biochemical measures

  • Participant compliance with medication

  • Psychosocial measures (depression, home and community activities, leisure, social roles, sexual functions)

  • Serum markers (except ESR)

Period of time (P)

Studies were included if the intervention period lasted longer than 1 week or 1 treatment session, with or without a follow‐up period 

Period of time (P)

Studies were excluded if the intervention period lasted less than 1 week or 1 treatment session 

Study designs (S)

  • Randomized controlled trial

  • Controlled clinical trial

*English and French articles only.

Study designs (S)

  • Case series/case report

  • Case control studies

  • Cohort studies

  • Data (graphic) without a mean and SD

  • Sample size of fewer than 5 participants per experimental group

  • Studies with greater than 20% dropout rate

BMI: Body mass index.
ESR: Erythrocyte sedimentation rate.
PICOTS: Populations, interventions, comparators, outcomes, timing, and setting framework.
SD: Standard deviation.

Figuras y tablas -
Table 1. Inclusion and exclusion critieria according to the PICOTS strategy
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Comparison 1. Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain (VAS 0‐100, 0 = worst) (change from baseline) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Grip strength (ratio index, higher is better) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Function (VAS 0‐100, 0 = worst) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Function (pain‐free function; average number of pain‐free items; higher is better) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Functional status (number of successes to perform strengthening program) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only
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Comparison 2. Massage + phonophoresis vs phonophoresis only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain (VAS 0‐100, 0 = worst) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Grip strength (ratio index, higher is better) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Function (VAS 0‐100, 0 = worst) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Function (pain‐free function; average number of pain‐free items; higher is better) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Functional status (number of successes to perform strengthening program) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 2. Massage + phonophoresis vs phonophoresis only
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Comparison 3. Massage + physical therapy vs physical therapy only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.1 Daily pain

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Pain while running

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 % of maximum pain while running

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 3. Massage + physical therapy vs physical therapy only
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