Photomedicine and Laser Surgery

Volume 28, Number 1, 2010 Reviews

ª Mary Ann Liebert, Inc.
Pp. 3–16
DOI: 10.1089=pho.2008.2470

Low Level Laser Treatment of Tendinopathy:

A Systematic Review with Meta-analysis

Steve Tumilty, MPhty,1 Joanne Munn, Ph.D.,1 Suzanne McDonough, Ph.D.,2 Deirdre A. Hurley, Ph.D.,3
Jeffrey R Basford, Ph.D.,4 and G. David Baxter, DPhil1

Abstract

Objectives: To assess the clinical effectiveness of Low Level Laser Therapy (LLLT) in the treatment of
tendinopathy. Secondary objectives were to determine the relevance of irradiation parameters to outcomes, and
the validity of current dosage recommendations for the treatment of tendinopathy. Background: LLLT is pro-
posed as a possible treatment for tendon injuries. However, the clinical effectiveness of this modality remains
controversial, with limited agreement on the most efficacious dosage and parameter choices. Method: The
following databases were searched from inception to 1st August 2008: MEDLINE, PubMed, CINAHL, AMED,
EMBASE, All EBM reviews, PEDro (Physiotherapy Evidence Database), SCOPUS. Controlled clinical trials
evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological
quality was classified as: high (
6 out of 10 on the PEDro scale) or low (<6) to grade the strength of evidence.
Accuracy and clinical appropriateness of treatment parameters were assessed using established recommenda-
tions and guidelines. Results: Twenty-five controlled clinical trials met the inclusion criteria. There were con-
flicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect.
Dosages used in the 12 positive studies would support the existence of an effective dosage window that closely
resembled current recommended guidelines. In two instances where pooling of data was possible, LLLT showed
a positive effect size; in studies of lateral epicondylitis that scored
6 on the PEDro scale, participants’ grip
strength was 9.59 kg higher than that of the control group; for participants with Achilles tendinopathy, the effect
was 13.6 mm less pain on a 100 mm visual analogue scale. Conclusion: LLLT can potentially be effective in
treating tendinopathy when recommended dosages are used. The 12 positive studies provide strong evidence
that positive outcomes are associated with the use of current dosage recommendations for the treatment of
tendinopathy.

Introduction Perhaps because of the multifactorial nature of the path-

ogenesis of tendinopathy,5,6 there is a plethora of treatment

I n recent times, the term ‘‘Tendinopathy’’ has been used as

a general clinical descriptor to indicate pain in the region of
the tendon without any indication of the underlying cause.1
modalities available to reduce symptoms and to attempt to
control or enhance the tendon healing response. These mo-
dalities, which include various electrotherapy modalities,
However, the prevalence of tendinopathies is apparently in- eccentric exercise, a variety of injection techniques, and cross-
creasing. For example, in New Zealand the incidence of fiber massage, provide mixed or uneven benefit across pa-
Achilles tendon ruptures more than doubled between the tient populations.7–9
years 1998 to 2003, from 4.7=100,000 to 10.3=100,000, a phe- Low level laser therapy (LLLT) or the use of laser sources
nomenon that follows international trends.2 Patella tendino- at powers too low to cause measurable temperature in-
pathy accounted for 20% of all knee injuries reported over a creases, has been used to treat soft tissue injuries and in-
six month period at a sports injury clinic,3 while tennis elbow flammation since the 1960s, and studies from as early as the
affects approximately 1%–2% of the population.4 Other 1980s reported benefits in a variety of tendon and sports
common sites of tendinopathy are golfer’s elbow at the medial injuries.10,11 More recently, the term LLLT has been used to
side of the elbow, and the rotator cuff tendons in the shoulder. describe not only the use of low power laser sources, but also

1
Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
2
University of Ulster, Newtownabbey, Co Antrim, Northern Ireland.
3
University College Dublin, Belfield, Dublin, Republic of Ireland.
4
Mayo Clinic, Rochester, Minnesota.

3
4 TUMILTY ET AL.

monochromatic superluminous diodes. Both types of system Selection criteria for this review: types of studies
have been used in the treatment of various musculoskeletal
Fully reported randomized controlled trials (RCTs) and
conditions, including tendon injuries, each apparently with
controlled clinical trials (CCTs) from peer reviewed journals
success. Such applications are supported by experimental
were included. No language restrictions were made.
evidence of the biological effects of LLLT, including in-
creased ATP production, enhanced cell function, and in-
Selection criteria for this review: types of participants
creased protein synthesis.12 LLLT has also been shown to
have positive effects on the reduction of inflammation,13 in- Human participants who had been diagnosed with ten-
crease of collagen synthesis,14 and angiogenesis.15 dinopathy and exhibited pain and=or functional disability
While LLLT is promoted as a safe and effective form of were included. There was no distinction made with regards
treatment for a variety of conditions, in today’s healthcare to age, gender, level of activity or chronicity of the injury.
climate there is a necessity to practice evidence-based med-
icine, and a need to provide high level evidence to support Selection criteria for this review:
the use of any treatment modality. Whether previous re- types of interventions
search into the effectiveness of LLLT has accomplished this is
One group in the controlled trial must have involved
debatable due to the varying quality of the available re-
participants treated with active LLLT. Comparisons were
search.
made with at least one of the following: placebo, no treat-
With this in mind, a systematic review with a meta-
ment, or other treatments such as medication, exercise ther-
analysis of the data was undertaken to answer the question:
apy or other electrotherapy modalities. Interventions based
‘‘Is Low Level Laser Therapy effective in the treatment of tendi-
upon combinations of LLLT and other modalities were not
nopathy?’’ Three main objectives were set:
considered for the review.
a) to determine the clinical effectiveness of LLLT in the
treatment of tendinopathy when compared to placebo, Selection criteria for this review:
no treatment, or other types of intervention; types of outcome measure
b) to determine the relevance of irradiation parameters to
Trials which assessed pain or function for at least one of
reported positive outcomes;
the outcome measures were considered for inclusion.
c) to determine the validity of current dosage recom-
mendations for the treatment of tendinopathy.
Retrieval of relevant articles
Materials and Methods Two independent reviewers (ST and JM) applied the se-
lection criteria to the titles and abstracts of articles retrieved
Search strategy
by the electronic search. All trials classified as relevant by
The MEDLINE (1966-1st Aug 2008), PubMed (1950-1st Aug either of the reviewers were retrieved. When there was in-
2008), CINAHL (1982-1st Aug 2008), AMED (1985-1st Aug sufficient information in the title or abstract to determine
2008), EMBASE (1988-1st Aug 2008), All EBM (Evidence eligibility, the full text of the article was retrieved. Where
Based Medicine) reviews, PEDro (Physiotherapy Evidence there was disagreement between the two reviewers about a
Database), and SCOPUS (1960-1st Aug 2008) databases were trial’s eligibility, the retrieved trial was re-examined against
searched (Table 1). the selection criteria, and disagreement resolved by consen-

Table 1. Search Strategy

Phase 1 Phase 2 Phase 3

1. Tend$.mp. 18. randomized control [Link]. 27. clinical [Link].

2. Tendinopathy 19. controlled clinical [Link]. 28. exp Clinical Trials=
3. Soft Tissue Injuries= 20. Randomized Controlled Trials= 29. (clinic adj25 trial$).tw.
4. Tendon Injuries= 21. Random Allocation= 30. ((singl$ or doubl$ or trebl$
or tripl$) adj (mask$
or blind$)).tw.
5. Achill$.mp. 22. Double-Blind Method= 31. Placebos=
6. Patell$.mp. 23. Single-Blind Method= 32. placebo$.tw.
7. Epicondyl$.mp. 24. or=18–23 33. random$.tw
8. Tennis [Link]. 25. Animal=not Human= 34. Research Design=
9. Golfers [Link] 26. 24 not 25 35. or=27–34
10. Rotator [Link]. 36. 35 not 25
11. (jumper$ adj knee).mp. 37. 35 not 26
12. or=1–11 38. and=17,26
13. [Link]. 39. and=17,37
14. low level laser [Link].
15. [Link]. 40. or=38–39
16. or=13–15
17. and=12,16
A SYSTEMATIC REVIEW OF LLLT FOR TENDINOPATHY 5

sus. For studies published in languages other than English, a reasons, including: they were review articles; they involved
translation was obtained. surgery or did not involve LLLT; they did not address ten-
dinopathy; they included inappropriate LLLT intervention=
Quality assessment application techniques; they were not an RCT=CCT; they
were not full reports; or they did not appear in peer-
Three independent reviewers (ST, SM & DH) assessed the
reviewed journals. Twenty-five articles were included in the
included articles for methodological quality against the
review (Table 2 and Table 3).
PEDro scale.16
Assessing the level of evidence for the effectiveness of
LLLT in the treatment of tendinopathy based upon van
Data extraction
Tulder’s recommendations (see Table 3),18 the evidence for
Three reviewers (ST, JB & GDB) independently extracted the effectiveness of LLLT in the treatment of tendinopathy is
and recorded the necessary details about diagnosis, inter- inconclusive, as there are conflicting findings among multi-
ventions, and LLLT parameters, in line with recommenda- ple RCTs: twelve studies reported a positive effect (Table 4),
tions by the World Association for Laser Therapy (WALT)17 and thirteen studies reported no effect or inconclusive results
to determine the parameters and method of delivery of laser (Table 5).
therapy. Twelve studies provided sufficient detailed data to input
into RevMan 4.2 (Cochrane Collaboration, Copenhagen,
Analysis Denmark20) to calculate effect sizes for the outcome
measures of final pain scores and pain change scores mea-
The recommendations of Van Tulder et al.18 regarding
sured on a VAS (Fig. 2), or, for lateral epicondylitis, grip
levels of evidence were used to interpret the results:
strength (Fig. 3). These twelve studies are indicated by** in
Strong evidence: consistent findings among multiple higher
Tables 4 and 5.
quality RCTs;
Attempts to pool data from multiple studies were not
Moderate evidence: consistent findings among multiple
valid as the test for heterogeneity was significant (p < 0.05)
lower quality RCTs and=or one higher quality RCT;
for most of the analyses. However, to show the effect of
Limited evidence: one lower quality RCT;
individual comparisons, for studies that compared LLLT
Conflicting evidence: inconsistent findings among multiple
against more than one other group, data comparing LLLT
RCTs;
against all other modalities were included in the analy-
No evidence: no RCTs.
sis (Fig. 2). For example, in a poorly powered study by
Hernandez-Herrero et al.24 in which LLLT was compared
Pooling of data
against four other modalities of treatment for elbow tendi-
Where available, data were pooled as follows: nosis, it can be seen that there was very little difference be-
Pain: used a visual analogue scale (VAS) for both final tween LLLT and the other forms of treatment. Of the studies
scores and change in scores; that showed a positive result of LLLT for pain, the effects
Site of injury: i.e., for lateral epicondylitis, Achilles tendi- ranged from 2.1-28 mm on a 100 mm VAS (Fig. 2).
nopathies, rotator cuff injuries; Grip strength. It was valid to pool data in two instances: the first for
To investigate the relevance of parameters to reported participants’ grip strength in studies of lateral epicondylitis
benefits, studies were also grouped into those reporting that scored
6 on the PEDro scale (Fig. 3); in the second
positive effects and those reporting inconclusive or no ef- instance, for pain scores in Achilles tendinopathy (Fig. 4).
fects. Effect sizes corresponded to grip strength values of 9.59 kg
greater than the control group for participants with lateral
Statistical analysis epicondylitis, and 13.6 mm less pain on a 100 mm VAS for
participants with Achilles tendinopathy.
Where pooling of data was justified, results were ex-
Results for pain scores categorized by site of injury are
pressed as relative risks (RR) and 95% confidence intervals
displayed in Figure 4. Three studies reported pain change
(CI) for dichotomous outcomes, and weighted mean differ-
scores for rotator cuff injuries treated with LLLT.35–37 Of these,
ence (WMD) and 95% confidence intervals calculated for
two compared LLLT to placebo,35,37 while Saunders et al.36
continuous outcomes. Testing for heterogeneity was done
included three groups: LLLT, placebo, and ultrasound. As-
using the chi-square test. Test results for heterogeneity de-
sessment by change in pain between initial and final assess-
termined whether a random or fixed effects model was used.
ments all showed a positive effect in favor of LLLT.
Disagreements between reviewers were settled by con-
Of the two studies which investigated Achilles tendino-
sensus. Where insufficient data was provided in the pub-
pathy,39,40 both showed positive effects in terms of pain
lished article, every attempt was made to contact the authors
scores at the final assessment, with a pooled effect size of
to obtain the relevant information.
13.64 mm in favor of the LLLT groups.
Final pain scores were analyzed for participants with lat-
Results
eral epicondylitis. Figure 4 shows multiple comparisons from
The Quality of Reporting of Meta-Analysis (QUOROM) single studies, so that determination of a pooled effect size
statement flow diagram19 (Fig. 1) displays the results of the was not possible. Of the five studies, two showed no effect of
search conducted on 1st August 2008. As shown, 663 inves- LLLT on participants’ pain,21,24 and three resulted in a pos-
tigations were identified as being potentially relevant ac- itive effect on pain.27,29,31
cording to the initial search criteria. Of these, 638 reports Table 4 displays those studies reporting positive effects of
were excluded at various stages of the process for a variety of LLLT, as concluded by the authors of the individual studies,
6 TUMILTY ET AL.

FIG. 1. Search Strategy Flow Diagram Search strategy used to screen articles against the inclusion=exclusion criteria to
generate the final list of articles for analysis.

along with the parameters used. Five studies (marked**) densities are allowed to go as high as 600 mW=cm2, with an
provided data that were used in the RevMan analysis. Table 5 energy dose range of 3–9 J.
displays studies reporting inconclusive results or no effect
from LLLT. It should be noted that even though three
Epicondylitis
studies29,37,40 reported no significant differences between
groups, in the RevMan analysis the effect sizes of these Of thirteen studies investigating the effectiveness of LLLT
studies favored the group treated with laser. for epicondylitis, six showed positive results.22,25,27,28,31,32
Using the parameters reported in Table 4, a range of ef- Ten out of the thirteen scored six points or more on the
fective dosages can be calculated for each injury site. These PEDro scale and would be considered of high quality. The
can then be compared to the current recommendations from positive studies used a wavelength of 904 nm and power
WALT17 and from Bjordal et al.45 (Table 6). These guidelines densities that lay between 2–100 mW=cm2 as recommended
state that power densities below 100 mW=cm2 should be by the WALT=Bjordal et al. guidelines.13 However, one
used for superficial tendons with an energy dose range of study32 used a dosage slightly higher then the recommended
1–8 J. For the deeper tendons of the rotator cuff, power value (3.5 J=cm2 instead of 3 J=cm2) while another28 used a
A SYSTEMATIC REVIEW OF LLLT FOR TENDINOPATHY 7

Table 2. Characteristics of the Included Studies

Author Year Diagnosis n Interventions Outcomes reported

21
Basford 2000 Lateral epicondylitis 47 Laser vs. placebo VAS for pain,
VAS for tenderness
to palpation,
VAS for patient’s
perception of
change (benefit).
Grip strength;
pinch strength
Haker22 May 91 Lateral epicondylalgia 49 Laser vs. placebo Grip strength
Haker23 Nov 91 Lateral epicondylalgia 58 Laser vs. placebo Patient satisfaction
(5 point scale)
Grip strength
Hernandez-Herrero24 2006 Elbow tendinosis 46 Laser vs. other VAS for pain
electrotherapy VAS for function
modalities DASH questionnaire
Konstantinovic25 1997 Radiohumeral 32 Laser vs. corticosteroid McGill pain questionnaire
epicondylitis injection vs.
combination of both
Krasheninnikoff 26 1994 Lateral epicondylitis 36 Laser vs. placebo Pain
Dynamic muscle test
Number of tender points
Lam27 2007 Lateral epicondylitis 39 Laser vs. placebo Mechanical pain threshold
Grip strength
VAS for pain
DASH questionnaire
Melagati28 1994 Humeral epicondylitis 32 Laser vs. cryotherapy & VAS for pain
Iontophoresis Telethermography
Oken29 2008 Lateral epicondylitis 58 Laser vs. ultrasound VAS for pain
V brace Grip strength
Global assessment
of improvement
Papadopoulos30 1996 Tennis elbow 29 Laser vs. placebo VAS for pain
Strength & endurance score
Stergioulas31 2007 Lateral epicondylitis 50 Laser vs. placebo VAS for pain
Grip strength
ROM
Wrist extension strength
Vasseljen32 1992 Tennis elbow 30 Laser vs. placebo Strength measures
Goniometric measure
of wrist flex
VAS for pain
Verbal rating scale
Vasseljen33 May 92 Tennis elbow 30 Laser vs. deep Strength measures
friction massage Goniometric measure
& pulsed ultrasound of wrist flex
VAS for pain
Verbal rating scale
England34 1989 Shoulder tendinitis 30 Laser vs. placebo Goniometry of flex,
vs. drug treatment ext, abd
VAS of pain, stiffness,
function
Saunders35 1995 Supraspinatus 24 Laser vs. placebo Pain
tendinitis Isometric strength
Saunders36 2003 Supraspinatus 36 Laser vs. ultrasound vs. Pain
tendinitis placebo Isometric strength
Vecchio37 1993 Rotator cuff tendinitis 35 Laser vs. placebo ROM score
Painful arc score
Resisted movement score
VAS for pain
VAS for function
Bjordal13 2006 Achilles tendinitis 14 Laser vs. placebo Inflammatory
markers (PGE2)
Pressure pain threshold
(continued)
8 TUMILTY ET AL.

Table 2. (Continued)

Author Year Diagnosis n Interventions Outcomes reported

38
Darre 1994 Achilles tendinitis 89 Laser vs. placebo VAS for pain
Morning stiffness
Swelling
Tenderness
Crepitation
Number of treatments
Stergioulas39 2008 Achilles tendinopathy 52 Laser vs. placebo VAS for pain
Crepitation
Morning stiffness
Tenderness during palpation
Active dorsiflexion
Tumilty40 2008 Achilles tendinopathy 20 Laser vs. placebo VISA-A questionnaire
VAS for pain
Concentric strength
Eccentric strength
Costantino41 2005 Achilles tendinitis 45 Cryoultrasound vs. VAS for pain
Patella tendinitis epicondylitis laser vs. T.e.c.a.r. therapy Patient satisfaction
Muller42 1993 Various tendinopathies 48 Laser vs. placebo VAS for pain
Siebert43 1987 Med. & lat. epicondylitis, 64 Laser vs. placebo 4 point verbal rating
other tendinopathies scale for resting pain,
movement pain and
pressure pain
Sharma44 2002 De Quervains tenosynovitis 30 Laser vs. placebo VAS for pain
Grip strength

Table 3. Itemized Methodology Scores of the Included Studies

PEDro criteria*

Author 1 2 3 4 5 6 7 8 9 10 11 Score

Basford21 (ü) ü  ü ü ü  ü  ü ü 7
Haker22 (ü) ü  ü ü ü ü ü  ü  7
Haker23 (x) ü  ü ü ü ü ü  ü  7
Hernandez-Herrero24 (ü) ü ü ü   ü    ü 5
Konstantinovic25 (ü) ü          1
Krasheninnikoff26 (ü) ü  ü ü ü    ü ü 6
Lam27 (ü) ü  ü ü   ü  ü ü 7
Melegati28 (ü)   ü   ü ü  ü  4
Oken29 (ü) ü  ü   ü ü  ü ü 6
Papadopoulos30 (ü) ü   ü ü  ü ü ü  6
Stergioulas31 (ü) ü  ü ü  ü   ü ü 6
Vasseljen32 (ü) ü  ü ü ü  ü ü ü ü 8
Vasseljen33 (ü) ü  ü    ü ü ü ü 6
England34 (ü) ü   ü  ü ü  ü ü 6
Saunders35 (ü) ü  ü ü ü ü ü ü ü ü 9
Saunders36 (ü) ü  ü   ü ü ü ü  6
Vecchio37 (ü) ü  ü ü ü ü ü ü ü ü 9
Bjordal13 (ü) ü ü ü ü ü ü ü ü ü ü 10
Darre38 (ü) ü   ü ü  ü  ü  5
Stergioulas39 (ü) ü  ü ü  ü  ü ü ü 7
Tumilty40 (ü) ü ü ü ü ü ü ü ü ü ü 10
Costantino41 (x)   ü   ü ü ü ü ü 6
Muller42 (x) ü ü  ü ü  ü ü   6
Siebert43 (ü) ü   ü  ü    ü 4
Sharma44 (ü)    ü ü ü ü ü  ü 6

*PEDro criteria: 4 - Baseline comparability? 8 - Adequate follow-up?

1 - Eligibility criteria? 5 - Blind subjects? 9 - Intention-to-treat analysis?
2 - Random allocation? 6 - Blind therapists? 10 - Between-group comparisons?
3 - Concealed allocation? 7 - Blind assessors? 11 - Point estimates and variability?

ü ¼ Criterion met; ¼ Criterion not met; ( ) ¼ Eligibility criteria item does not contribute to total score.
A SYSTEMATIC REVIEW OF LLLT FOR TENDINOPATHY 9

Table 4. Studies Reporting Positive Effect of Low Level Laser Therapy

Study Diagnosis Power density mW=cm2 Dose J=cm2 Wavelength nm PEDro

22
Haker (May 91) Lateral epicondylalgia 60 1.8 904 7
Konstantinovic25 Radiohumeral epicondylitis * * 904 1
Lam27** Lateral epicondylitis 218 2.4 904 7
Melagati28 Humeral epicondylitis * 150 1064 4
Stergioulas (2007)31** Lateral epicondylitis 80 2.4 904 6
Vasseljen (92)32 Tennis elbow * 3.5 904 8
England34 Shoulder tendinitis * * 904 6
Saunders (95)35** Supraspinatus tendinitis 320 19.2 820 9
Saunders (2003)36** Supraspinatus tendinitis 320 19.2 820 6
Bjordal13 Achilles tendinitis 20 3.6 904 10
Stergioulas (2008)39** Achilles tendinopathy 60 1.8 820 7
Sharma44 De Quervains tenosynovitis 32 4 830 6

*Parameters not provided or insufficient information given to calculate missing parameter.

**These studies are included in the RevMan analysis.

wavelength (1064 nm) and energy density (150 J=cm2) that do did not.38,40 One of the negative studies was deemed of low
not appear in any of the guidelines. Those studies demon- methodology (less than 6 on the PEDro scale).38
strating no effect21,23,24,26,29,30,33 all used power densities and
dosage parameters outside of the guidelines, regardless of De Quervain’s tenosynovitis
wavelength employed.
One high quality study44 used LLLT to treat tendinopathy
at the wrist (Table 6); however, there are no recommended
Rotator cuff
guidelines published for that condition. The parameters used
Four high quality studies examined the effects of LLLT on are provided in the table.
tendinopathy around the shoulder region,34–37 with three
studies35–37 using parameters that lay within the guidelines Discussion
(30–600 mW=cm2 & 4.2-42 J=cm2). However, these three
This systematic review and meta-analysis was designed to
provided conflicting results (two positive35,36 and one neg-
assess the evidence for the clinical effectiveness of LLLT for
ative37). The study by England et al.34 failed to provide en-
the treatment of tendinopathy, the currently accepted ter-
ough detail on irradiation parameters.
minology used clinically to encompass tendonitis, tendinosis,
and insertional tendinopathy. Its secondary objectives were
Achilles tendinopathy
to determine the relationship between irradiation parameters
Four studies investigated LLLT for Achilles tendino- and outcomes and to compare them with the dosage rec-
pathy.13,38–40 Two proved beneficial,13,39 and two were in- ommendations provided by WALT17 and from Bjordal et al.45
conclusive.38,40 The two positive studies used parameters The findings provided conflicting evidence regarding the
that lay within recommended guidelines,13,39 but the others effectiveness of LLLT for the treatment of tendinopathies.

Table 5. Studies Reporting Inconclusive Results or no Effect of Low Level Laser Therapy
(no Statistically Significant Effect)

Study Diagnosis Power density mW=cm2 Dose J=cm2 Wavelength nm PEDro

Basford21** Lateral epicondylitis 204 12.24 1060 7

Haker (Nov 91)23 Lateral epicondylalgia * * 904 and 632.8 7
Hernandez-Herrero24** Elbow tendinosis * * * 5
Krasheninnikoff 26 Lateral epicondylitis 114 13.68 830 6
Oken29** Lateral epicondylitis * * 632.8 6
Papadopoulos30** Tennis elbow 400 24 820 6
Vasseljen (May 92)33 Tennis elbow * 3.5 904 6
Vecchio37** Rotator cuff tendinitis 422 14 830 9
Darre38 Achilles tendinitis 150 20.1 830 5
Tumilty40** Achilles tendinopathy 2375 82.4 810 10
Costantino41** Various tendinopathies * * * 6
Muller42 Various tendinopathies * * 904 6
Siebert43 Medial & lateral epicondylitis, 7500 * 904 4
other tendinopathies

*Parameters not provided or insufficient information given to calculate missing parameter.

**These studies are included in the RevMan analysis.
10 TUMILTY ET AL.

FIG. 2. Pain analysis with all groups in all studies. When studies included more than two groups or an active control group,
the non-laser treatments are shown after the author’s name. US, ultrasound; Sono, sonophoresis; Electro, electrophoresis;
Cryo, cryotherapy; Cryo=us cryoultrasound; TECAR, capacitive-resistive electric transfer therapy; Brace, tennis elbow brace;
Pl, placebo.

However, there was a clear relationship between positive expected to accumulate from an ever increasing number of
findings and the use of recommended dosages. studies; this is seen in the therapeutic ultrasound litera-
Studies reporting benefits (n ¼ 12) were similar in number ture.46,47 Under these circumstances, it becomes important to
to those that found no benefit (n ¼ 13). These conflicting re- look at the available evidence using methods other than van
sults did not appear to be due to methodological quality, Tulder’s best evidence synthesis, which does not take into
however; the studies’ methodological scores were generally account the validity of the intervention used.18
good (6 or higher on the PEDro scale), with only two positive Twelve studies provided sufficient data to undertake a
studies scoring low,25,28 compared with three inconclusive meta-analysis of effects. Unfortunately, given the variation in
studies.24,38,43 Perhaps the most important finding of this interventions used (including different manufacturers, de-
review is that 12 RCTs (ten high quality and two low quality) vices, variations in delivery, and calculations of dosages)
demonstrate that LLLT is potentially effective in the treat- there was clinical heterogeneity between studies. This can
ment of tendinopathy when the recommended irradiation result in misleading conclusions, as differences in treatment
parameters are used. parameters and application are important,48 and can lead in
This finding is perhaps not surprising as a dosage- turn to statistical heterogeneity. Indeed, only two of the
dependent effect should not be unexpected for any effective meta-analyses (the effect on Achilles tendon pain and the
therapeutic modality. Furthermore, as the body of research effect on grip strength for lateral epicondylitis) resulted in
grows for a new modality and researchers seek to establish studies that were homogenous (see Figs. 2–4) and thus al-
an effective dosage window, conflicting evidence would be lowed calculation of pooled effect results. Other meta-
A SYSTEMATIC REVIEW OF LLLT FOR TENDINOPATHY 11

FIG. 3. Lateral epicondylitis grip strength. The upper graph includes both comparisons from Oken et al.29 (2008) and
therefore pooling of data is not shown.

analyses resulted in statistical heterogeneity, thus limiting Some studies used a true placebo group and others used
any conclusions from these data.49 Given such clinical and an active control group that received a potentially beneficial
statistical heterogeneity from the studies included in this therapy. This of course dilutes the effect of the treatment
review, we made no attempt to report these combined data. under investigation as the potential difference between a
However, useful information can still be derived from the treatment and no-treatment would be greater than compar-
RevMan analysis by calculating effect sizes from individual ing the effect of a new treatment against a known beneficial
studies and making multiple comparisons when studies in- treatment. In fact, the two experimental designs are attempts
clude more than one other intervention or control group. For to answer two different questions; does it work; or is it better
this reason, results displayed in Figures 2–4 include effect than the other? It is beyond the scope of this article to enter
size calculations for all studies comparing LLLT to all other the debate over the ethics of placebo,55 but the Declaration of
groups. Sensitivity analyses were attempted using only two Helsinki advocates for the active control orthodoxy.56
groups per study (LLLT versus placebo; or LLLT versus most The present study also aimed to assess the relevance of
commonly used modality from the other groups), and also treatment=irradiation parameters to reported effectiveness.
using only studies scoring
6 on the PEDro scale. In both Assessment of results from positive studies provided inter-
instances, outcomes changed very little in magnitude or in esting insights: Table 6 summarizes current results by ana-
the direction of effect (pro or contra LLLT) which also re- tomical site in comparison to guidelines from WALT17 and
mained constant. Bjordal et al.45
When interpreting these results it should be borne in mind
that what is important is whether the effect size is greater
Epicondylitis
than the relevant minimal clinically important difference
(MCID) for the outcome measure. For pain scales, both a two Four high quality studies provided enough information to
point reduction on a ten point scale50,51,52 and a 13 mm re- allow comparison with guidelines; whereas power densities
duction on a 100 mm scale53 have been reported as MCIDs.54 were within recommendations, dosages ( J=cm2) used in
From Figs. 2–4, several instances of effect sizes for LLLT these studies suggest that for epicondylitis the effective
treatments which meet or exceed this MCID can be seen, dosage window could be widened. Interestingly, of the in-
even though pooling of effect sizes was not always possible: conclusive studies, Oken et al.29 actually shows a WMD in
e.g. for participants with rotator cuff injury (Fig. 4). favor of laser for both pain and grip strength (Figs. 2–4).
12 TUMILTY ET AL.

FIG. 4. Low Level Laser Therapy Effects on Pain Scores Categorized by Site of Injury. Pooling of data was only valid for
Achilles Tendinopathy Pain. When studies included more than two groups or an active control group, the non-laser treat-
ments are shown after the author’s name. US, ultrasound; Sono, sonophoresis; Electro, electrophoresis; Cryo, cryotherapy;
Cryo=us cryoultrasound; TECAR, capacitive-resistive electric transfer therapy; Brace, tennis elbow brace; Pl, placebo.

However, this study scored only five on the methodology As with many trials exploring the treatment of tendon pa-
scale and would be classified as low quality. While the thologies, the authors of the included trials have not made
wavelength used by Oken et al.29 was not one identified in definitive differential diagnoses. Indeed, it is very difficult to
the guidelines, nevertheless it would be potentially beneficial distinguish between tendinosis, tendonitis, and insertional
for the treatment of epicondylitis. tendinopathy with lateral epicondylitis. Furthermore, ele-
One point to consider when analyzing the effects of any ments of all three may well be present.
treatment for lateral epicondylalgia is that the pathology of
this condition does not always originate from the tendons.
Rotator cuff
The bony insertion may alternatively be the source of the
symptoms; this would represent a totally different patho- A range of dosages and methods of application was used
logical problem which may respond differently to treatment. for treatment of rotator cuff injuries. This may explain the
A SYSTEMATIC REVIEW OF LLLT FOR TENDINOPATHY 13

Table 6. Effective Parameters

Injury site Number of studies Parameters World association for laser therapy Bjordal et al. 2001

Epicondylitis 6 904 nm 1064 nm 780–860 nm: 4 J 830 nm; 5–100 mW=cm2

60 mW=cm2 904 nm: 1 J 0.7–7 J=cm2
1.8–3.5 J=cm2 < 100 mW=cm2 904 nm; 2–100 mW=cm2
0.3–3 J=cm2
Rotator cuff 3 820 nm 904 nm 780–860 nm: 9 J 830 nm; 30–600 mW=cm2
320 mW=cm2 904 nm: 3 J 4.2–42 J=cm2
19.2 J=cm2 904 nm; 12–600 mW=cm2
0.4–4 J=cm2
Achilles 2 820 nm 904 nm 780–860 nm: 8 J 830 nm; 5–100 mW=cm2
20–60 mW=cm2 904 nm: 2 J 0.7–7 J=cm2
1.8–3.6 J=cm2 < 100 mW=cm2 904 nm; 2–100 mW=cm2
0.3–3 J=cm2
Wrist 1 830 nm 32 mW=cm2 780–860 nm: 8 J No guideline
4 J=cm2 904 nm: 2 J

conflicting results of two different research groups: two Three other studies reported negative outcomes,41,42,43 but
studies by Saunders et al.35,36 used standardized treatment the design of these studies, namely the grouping of different
points and applied laser three times per week for three tendinopathies together and the lack of adequate reporting
weeks; Vecchio et al.37 treated up to five tender points per of parameters or outcome data, precluded comparison of
session and gave two sessions per week for eight weeks. these findings with other work.
Once again, even though Vecchio et al.37 reported no benefit There have been few reviews focusing on the evaluation of
from the laser treatment, the effect size expressed as WMD the evidence for LLLT in the treatment of tendinopathies. Two
(Fig. 4) for pain change scores favored the LLLT group. The Cochrane reviews have looked at interventions for rotator cuff
mean change in pain for the laser group over the time period tears and shoulder pain,57,58 and made no or weak recom-
studied was twice that of the control group, which would mendations as to the effectiveness of LLLT. The rotator cuff
suggest that that analysis of results in the original paper was study57 evaluated physiotherapy interventions but did not
flawed. On the whole, the effective dose for rotator cuff adequately define what was included in such an intervention;
tendinopathies was found to lie within that recommended by therefore, no comparison could be made with the current
Bjordal et al.45 work. The shoulder pain study7 came to the conclusion that
LLLT was more effective than placebo for adhesive capsulitis
but not for rotator cuff tendinopathy. This conclusion was
Achilles tendinopathy
based on the finding of only one study for each condition,
Three high quality studies13,39,40 and one of low quality38 apparently due to an inability to determine sufficient detail
were included in the review. Bjordal et al.13 measured from two of the other included studies. Another Cochrane
prostaglandin E2 (PGE2) over the first two hours following review on interventions for treating acute and chronic
treatment using parameters within his own recommended Achilles tendonitis8 concluded that there was insufficient
guidelines.45 Results showed that LLLT was effective in re- evidence for effectiveness of LLLT, based on one study.
ducing this proxy for inflammation over that time period. Two reviews looked at lateral epicondylitis;58,59 both re-
Stergioulas et al.39 also used parameters from within the ported weak or negative conclusions for the effectiveness of
recommended guidelines. Darre et al.38 studied treatment of LLLT to treat this condition. In the first review,58 the authors
Achilles tendinopathy in Danish Army recruits, however, the acknowledged many methodological weaknesses, but they
number of treatments given was not standardized, detail on still recommended that LLLT should not be used as a sole
participants was insufficient, and no criteria were given for treatment for lateral epicondylitis. However, they did ac-
making the decision to end treatment. The power density knowledge that LLLT is a dose-response modality and that
and the dose delivered were significantly above what would the optimum dose has yet to be found. The second article59
be considered appropriate by Bjordal45 and may explain the was a synthesis of other reviews, as well as clinical and
lack of reported differences between treatment and control randomized controlled trials. Again, and as noted else-
groups. Studies by Stergioulas et al.39 and Tumilty et al.40 where,60 the review methodology had many shortcomings
were very similar in design, in that both looked at LLLT as (inadequate coverage of relevant databases; studies rejected
an adjunct therapy to heavy load eccentric exercise; both because they were ‘‘old’’; and insufficient analysis of dosage
used similar wavelengths (810 nm & 820 nm) but the power and knowledge of dosage recommendations). The final
and energy densities differed. The pilot study40 was under- conclusion that LLLT was ineffective seemed to be based on
powered as the aim was to gather data to inform a larger the evidence from only two studies, and relied strongly on
RCT in the future; therefore, these results need to be the results of one study with a good methodology score.
interpreted with this in mind. Once again, the studies re- In contrast, a recent review by Bjordal et al.61 evaluated
porting beneficial effects support the already published the evidence from 18 RCTs of LLLT to treat lateral epi-
guidelines. condylitis and assessed the validity of treatment procedures
14 TUMILTY ET AL.

and doses. Bjordal et al. concluded that the use of optimal 2. Tumilty, S. (2007). Achilles Tendon Rupture: Rising In-
wavelengths and doses resulted in beneficial effects of LLLT, cidence in New Zealand Follows International Trends. Phys.
either alone or in conjunction with an exercise program. Ther. Rev. 12, 59–65.
Such apparent differences in conclusions are explained in 3. Kannus, P., Aho, H., Jarvinen, M., and Niittymaki, S. (1987).
part by the Bjordal’s approach in scrutinizing application Computerized recording of visits to an outpatient sports
and dosage information included in RCTs. Independent clinic. Am. J. Sports Med. 15, 79–85.
analysis of reported dosages as miscalculations is important, 4. Gabel, G.T. (1999). Acute and chronic tendinopathies at the
since such miscalculated dosages are not uncommon in the elbow. Cur. Opin. Rheumatol. 11, 138–143.
literature. It is noteworthy that negative reviews of laser 5. Riley, G. (2004). The Pathogenesis of Tendinopathy; A Mo-
lecular perspective. Rheumatology. 43, 131–142.
therapy for musculoskeletal conditions can be challenged, at
6. Sharma, P., and Maffulli, N. (2005). Tendon Injury and
least in part, on the basis of inaccurately reported or inap-
Tendinopathy: Healing and Repair. J. Bone Joint Surg. Am.
propriate dosages.62
8, 187–202.
The current review reinforces the validity of this approach, 7. Green, S., Buchbinder, R., and Hetrick, S. (2003). Phy-
as analysis of results from positive studies can provide evi- siotherapy Interventions for Shoulder Pain. Cochrane Data-
dence of a therapeutic window for effective treatment of base Syst. Rev. (2):CD004258.
tendinopathies. 8. McLauchlan, G.J., and Handoll, H.H.G. (2001). Interventions
for Treating Acute and Chronic Achilles Tendinitis. Co-
Limitations of the review chrane Database Syst. Rev. (2):CD000232.
Synthesis of the evidence proved difficult for a number of 9. Andres, B.M., and Murrell, G.A.C. (2008). Treatment of
Tendinopathy: What Works, What Does Not, and What is
reasons: although studies scored well in terms of methodo-
on the Horizon. Clin. Orthop. Relat. Res. 466(7), 1539–1554.
logical quality, the clinical application of LLLT was either
10. Emmanoulidis, O., and Diamantopoulos, C. (1986). CW IR
poorly reported or varied between studies. Poor blinding
Low-Power Laser Application Significantly Accelerates
procedures, lack of randomization, and lack of intention to Chronic Pain Relief Rehabilitation of Professional Athletes.
treat analysis may have increased potential biases and A Double Blind Study. Lasers Surg. Med. 6, 173.
weakened the scientific merit of the works reviewed. Lack of 11. Roumeliotis, D., Emmanoulidis, O., and Diamantopoulos, C.
use of valid and reliable outcome measures, and inadequate (1987). C.W. 820 nm 15 mW, 4 J=cm2, laser diode application,
detail in the reporting of these measures, made it difficult to in: Sports Injuries. A Double Blind Study. Abstracts, Fifth
pool data from numerous studies and thus provide any Annual Congress, 28–30 January 1987. British Medical Laser
measure of estimated overall effect. We did not perform a Association.
hand search of the literature. It might be thought that one 12. Karu, T. (1989). Photobiology of Low Power Laser Therapy.
would have been beneficial, but the databases targeted and New York: Harwood.
the search strategy used (Table 1) were deemed by the au- 13. Bjordal, J.M., Lopes-Martins, R.A.B., and Iversen, V.V.
thors to be robust enough to minimize the possibility of (2006). A Randomised Placebo Controlled Trial of Low Level
missing a significant amount of literature, particularly higher Laser Therapy for Activated Achilles Tendonitis with Mi-
quality trials. crodialysis Measurement of Peritendinous Prostaglandin E2
Concentrations. Br. J. Sports Med. 40, 76–80.
Conclusion 14. Reddy, G.K., Stehno-Bittel, L., and Enwemeka, C.S. (1998).
Laser Photostimulation of Collagen Production in Healing
This study found conflicting evidence as to the effectiveness Rabbit Achilles Tendons. Lasers Surg. Med. 22, 281–287.
of LLLT in the treatment of tendinopathy. Ten high quality 15. Salate, A.C.B., Barbosa, G., Gaspar, P., et al. (2005). Effect of
and two low quality RCTs with positive outcomes, compared In-Ga-Al-P Diode Laser Irradiation on Angiogenesis in
with ten high quality and three low quality RCTs with nega- Partial Ruptures of Achilles Tendons in Rats. Photomed.
tive outcomes, were found. However, there is strong evidence Laser Surg. 23(5), 470–475.
from the 12 positive studies of a correlation between use of 16. Centre for Evidence-based research, U.O.S., Sydney. PEDro.
recommended dosages and a positive outcome. Physiotherapy Evidence Database. (2007). Accessed 29th
The quality of reporting of clinical application techniques March 2007. http:==[Link].
and parameters and results needs to be improved in future 17. World Association of Laser Therapy. Dosage Re-
studies; this would facilitate the pooling of data for a meta- commendations and Scientific Guidelines. Accessed 5th De-
analysis. At present, the heterogeneity of studies often pre- cember 2007. http:==[Link].
cludes the ability to assess the overall effect of LLLT. 18. van Tulder, M., Furlan, A., Bombardier, C., Bouter, L., and
Furthermore, for LLLT as for any electrotherapy modality, Editorial Board of the Cochrane Collaboration Back Review
the application technique and dose must be considered as Group. (2003). Updated method guidelines for systematic
part of any systematic review. reviews in the Cochrane collaboration back review group.
Finally, the quality of systematic reviews needs to follow Spine. 28, 1290–1299.
some guidelines, such as the QUORUM statement,19 to en- 19. Moher, D., Cook, D.J., Eastwood, S., Olkin, I., Rennie, D.,
and Stroup, D.F. (1999). Improving the quality of reports of
sure a fair and robust evaluation of the evidence.
meta-analyses of randomised controlled trials: the QUOR-
OM statement. Quality of Reporting of Meta-analyses.
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