Authors' Response to a Letter to the Editor on Radial Extracorporeal Shockwave in the Management of Lateral Epicondylitis

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To the Editor:
The authors would like to thank the authors for their insightful comments and the opportunity to clarify a number of points from our article “Radial Extracorporeal Shockwave Therapy Is No More Effective Than Placebo in the Management of Lateral Epicondylitis: A Double-Blind, Randomized, Placebo-Controlled Trial.”1
To clarify regarding the suggestion of the use of magnetic resonance imaging (MRI) for identifying the severity of the lateral epicondylitis, it was also cited in our article, the authors followed the method of Southampton diagnostic criteria of epicondylar pain and epicondylar tenderness and pain on resisted extension of the wrist and not the MRI to diagnose lateral epicondylitis.2 In support of this approach number of studies had used the diagnostic tests and not any radiological evaluation.3–5
Although our study could have been enhanced by diagnostic use of MRI as mentioned, MRI is not the only imaging technique, which could be used in diagnosing lateral epicondylitis for which there is no gold standard criteria as indicated in a systematic review by Dones et al.6 Musculoskeletal ultrasonography (USG) is a reliable, noninvasive, and inexpensive technique that can be used instead of MRI.6 In addition, the specificity of USG is as good as MRI (the specificity of USG is 90%–100% and MRI is 83%–100%).7
Furthermore, real-time sonoelastography is an effective method of identifying the intratendinous and peritendinous pathologies.8
However, the authors agree the notion that shoulder assessment is important in lateral epicondylitis. Although the association between restricted internal rotation and aggravation of lateral epicondylitis has been shown by LaBan et al,9 it seems that this association is more evident in older ages due to viscoelastic stiffness. It should be noted that our population' mean age is lower than their study. Furthermore, the authors also evaluated the shoulder range of motions of the control and the study group; there were no limitations of internal rotation.
Herewith, the authors can also speculate that not only the shoulder internal rotation but also the scapular muscle performance are also important in the assessment of the lateral epicondylitis.10
In the end again, the authors would like to express our gratitude to the authors for their invaluable comments and providing us with the opportunity to discuss our research.
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