Which One of the Phototherapy Approaches Could be an Effective Supplement to the Exercise Program for Patients with Chronic Lateral Elbow Tendinopathy

The Lateral Elbow Tendinopathy (LET) is the most common tendinopathy in the elbow area. Physiotherapy as a conservative approach is usually advocated by clinicians. Heavy-slow resistance exercise, soft tissue manipulation, physical agents. external support and manual techniques are recommended physiotherapy treatments to manage chronic LET. A progressive loading supervised or clinical placement exercise programme is the most effective physiotherapy approach for chronic LET management [1]. All the other recommended physiotherapy approaches are used as a supplement to an exercise program and not as a substitute for exercise [2].

One of the recommended physiotherapy treatments used as a supplement to the exercise programme is phototherapy [3- 5]. Research has shown low evidence for the effectiveness of phototherapy as monotherapy in managing chronic LET [3-5]. Phototherapy can be applied in one of the three ways below:
1. Low Level Laser Therapy (LLLT) (photo modulation called in America)
2. High Intensity Laser Therapy (HILT)
3. Polarised Polychromatic non-Coherent Light (Bioptron Light)

LLLT is primarily used in practice for assisting tissue healing at the cellular level. pain alleviation, and improving function by inference [3,6,7]. HILT is also used in practice for pain reduction, accelerating the cellular metabolic response, which may increase the blood flow and vascular permeability [4]. Finally, Bioptron Light could induce bio stimulative effects in living cells, improving cell metabolism and triggering specific biological and cellular reactions [5,8,9]. I wondered which one of the above phototherapy approaches could be an effective supplement to the exercise program for patients with chronic LET. Therefore, the literature was searched.

An electronic search for clinical studies was carried out in four databases: Medline (from 1966 to June 2025), Embase (from 1988 to March 2025), Cinahl (from 1982 to June 2025), and Sport Discus (from 1990 to June 2025). The following key words were used individually or in various combinations: ‘‘lateral elbow tendinopathy,’’ ‘‘tennis elbow,’’ ‘‘lateral epicondylitis,’’ ‘‘lateral epicondylalgia,’’ ‘‘extensor tendinopathy,’’ ‘‘extensor tendonitis,’’ ‘‘extensor tendinosis,’’ ‘‘light therapy,’’ ‘‘low level laser therapy,’’ ‘‘low power laser therapy’’, “low intensity laser therapy”, “high intensity laser therapy”, “high power laser therapy”, “Bioptron Light”. “Clinical trials” and “randomised clinical trials”. Only English language publications were considered. Other references were attempted to identify from books, other papers cited in and the publications searched existing reviews. Additional reports were sought from contacting experts in the field and from the reference sections of papers that were retrieved. Unpublished reports and abstracts were included in the review.

Three published clinical studies were found [10-12]. Two studies compared the effectiveness of LLLT and HILT [10,11], and one trial compared the effectiveness of LLLT and Bioptron Light [12]. No studies were found to compare HILT and Bioptron Light. Both studies found that the HILT treatment was more effective (pain, function, and strength) than the LLLT treatment in the short term [10,11]. The third study showed that LLLT or Bioptron Light are adequate treatment modalities for patients with chronic LET in the intermediate term [12].

The superiority of HILT over LLLT is that HILT can reach and stimulate the larger and/or deeper areas; accordingly, during HILT therapy, significantly greater energy might be transferred into tissue compared to LLLT [13]. A large amount of HILT irradiation can be delivered to deep tissues because HILT has a longer laser emission interval (low duty cycle) and a shorter laser emission time [14]. Therefore, someone can recommend the HILT treatment as a supplement to the exercise programme for LET patients in the short term. On the other hand, the LLLT cannot be ruled out from the list of chronic LET treatments. The reason is that LLLT is a doseresponse modality and the optimal treatment dose has obviously not yet been identified [15]. Moreover, neither study followed WALT recommendations [10,11]. Finally, the current literature suggests no superiority of both types (HILT & LLLT) of phototherapy in musculoskeletal disorders such as chronic LET [16], but this systematic review’s issues may affect the evidence assessment and the study’s conclusions [17]. No differences were found between LLLT and Bioptron Light for LET patients in the intermediate term [12]. LLLT and Bioptron Light differ in their characteristics of radiation [8]. We recommend the Bioptron light in clinical practice based on personal experience [5] because
• Its usage is easy
• It can be used for all patients (no side effects and contraindications)
• It can radiate a large surface of the body
• is cheaper than LPLL

According to the above, it is impossible to recommend a specific type of phototherapy as a supplement to the exercise programme in the management of chronic LET. More research is needed to optimize the design and delivery of phototherapy studies by focusing on application methods (for delivery of phototherapy and control interventions), assessment methods (of clinical outcomes and follow-ups) and allocation methods (of participants to intervention groups). Furthermore, phototherapy research must be funded, and this is probably to have contributed to trials with adequate sample sizes. Finally, factors beyond ‘efficacy/ effectiveness’ should be considered when making evidence-based decisions, including utility, cost, acceptability, safety, clinical experience, etc., and this should be compared with other available treatment approaches. Overall, it is believed that the issues discussed in this editorial can help physicians in their practice and provide avenues of further investigation for researchers.

None.

No conflict of interest.

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