Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;94:2068-74

ORIGINAL ARTICLE

Muscle Energy Technique Versus Corticosteroid

Injection for Management of Chronic Lateral Epicondylitis:
Randomized Controlled Trial With 1-Year Follow-up
Sami Kucuksen, MD,a Halim Yilmaz, MD,b Ali Sall, MD,a Hatice Ugurlu, MDa
From the aDepartment of Physical Medicine and Rehabilitation, Faculty of Medicine, Necmettin Erbakan University, Konya; and bDepartment of
Physical Medicine and Rehabilitation, Konya Education and Research Hospital, Konya, Turkey.

Abstract
Objective: To determine the short- and long-term effectiveness of the muscle energy technique (MET) compared with corticosteroid injections
(CSIs) for chronic lateral epicondylitis (LE).
Design: Randomized controlled trial with 1 year of follow-up.
Setting: Outpatient clinic of a universitys department of physical medicine and rehabilitation.
Participants: Patients with chronic LE (NZ82; 45 women, 37 men).
Interventions: Eight sessions of MET, or a single CSI was applied.
Main Outcome Measures: Grip strength, pain intensity, and functional status were assessed using the pain-free grip strength (PFGS), a visual
analog scale (VAS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, respectively. Measurements were performed
before beginning treatment and at 6, 26, and 52 weeks afterward.
Results: When the baseline PFGS, VAS, and DASH scores were compared with the scores at the 52-week follow-up, statistically significant
improvements were observed in both groups over time. The patients who received a CSI showed significantly better effects at 6 weeks according
to the PFGS and VAS scores, but declined thereafter. At the 26- and 52-week follow-ups, the patients who received the MET were statistically
significantly better in terms of grip strength and pain scores. At 52 weeks, the mean PFGS score in the MET group was significantly higher
(75.08
26.19 vs 62.24
21.83; PZ.007) and the mean VAS score was significantly lower (3.28
2.86 vs 4.95
2.36; PZ.001) than those of the
CSI group. Although improvements in the DASH scores were more pronounced in the MET group, the differences in DASH scores between the
groups were not statistically significant.
Conclusions: This study showed that while both MET and CSI improved measures of strength, pain, and function compared with baseline,
subjects receiving MET had better scores at 52 weeks for PFGS and the VAS for pain. We conclude that MET appears to be an effective
intervention in the treatment of LE.
Archives of Physical Medicine and Rehabilitation 2013;94:2068-74
2013 by the American Congress of Rehabilitation Medicine

Lateral epicondylitis (LE) is the most commonly diagnosed
condition of the elbow, affecting approximately 1% to 3% of the
population and 15% of workers in at-risk industries.1-3 The
condition occurs most often in patients whose activities require
strong gripping or repetitive wrist movements and is characterized
by tenderness or pain at the lateral epicondyle of the humerus and
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
by pain and weakness with gripping activities. Individuals
between the ages of 35 and 50 years are at particularly high risk.
In spite of extensive research on this ailment, there is no general
agreement on the precise etiology and pathophysiology. It is thought
that lesions occur in the common origin of the wrist and finger
extensors on the lateral epicondyle because of the combination of
mechanical overloading and abnormal microvascular responses.4,5
Numerous methods have been advocated for treating LE
including rest, nonsteroidal anti-inflammatory medication,
bracing, physical therapy, corticosteroid injection (CSI), exercise,

0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.05.022
Muscle energy technique in lateral epicondylitis
extracorporeal shock wave therapy, platelet-rich plasma injection,
prolotherapy, botulinum toxin injection, and surgery; however,
there is not enough scientific evidence to favor any particular type
of treatment.6-8 The Cochrane Library has several reviews9-13 of
treatments for LE. These reviews all determine that there is
insufficient evidence to draw firm conclusions as to which
methods of treatment are the most effective.
While providing pain relief in the acute setting, CSIs may be
detrimental to recovery in the long-term.14-16 A meta-analysis on
the effects of CSIs by Smidt et al17 found evidence of short-term
pain relief but no effect beyond the initial 6 weeks. CSI has also
been associated with adverse effects such as tendon rupture,
postinjection pain, local skin atrophy, facial flushing, postinjection
flare, hyperglycemia, and hypersensitivity reactions.18,19
In view of this evidence, an effective treatment strategy that
provides a safe, rapid, and long-term recovery from LE is needed.
In recent years, muscle energy techniques (METs) have been used
increasingly to treat some musculoskeletal disorders,20-21 with
claimed effectiveness for a variety of purposes including length-
ening a shortened or contractured muscle, and increasing the range
of motion of a restricted joint. MET is a gentle manual therapy
intervention directed at the joints or muscles involving voluntary
contraction by the patient against a counterforce applied by the
operator. During the procedure, the affected muscle is gently
stretched to its longest pain-free range. The patient then performs
a series of 3 to 5 submaximal muscle contractions of about 5
seconds each. The procedure encourages the muscle to naturally
relax and results in an improved range of motion.22,23
The effects of MET intervention have been investigated in
recent studies,24-26 and these studies suggest that MET results in
an improvement in pain and function. Although the use of MET
for LE has been described previously,27 no investigation has thus
far been conducted regarding its effects on LE. The aim of our
randomized controlled trial was to compare the short-term and
long-term efficacy of MET when compared with that of CSI for
the treatment of chronic LE.
Methods
Participants
The study was designed as a randomized controlled trial with
a follow-up of 1 year. Between April 2011 and October 2011, 105
consecutive patients with chronic unilateral LE (duration 3mo)
who were referred to the physical medicine and rehabilitation
outpatient clinic of Necmettin Erbakan University Hospital were
assessed for their suitability for inclusion in this study.
The patients were screened by the same physician (A.S.) for the
proper diagnosis of LE and to rule out other disorders that could
possibly contribute to lateral elbow pain. The participants were
eligible for inclusion in the study if they had tenderness on or near
the lateral epicondyle and if the pain was elicited with at least 2 of 3
pain provocation tests (gripping, resisted wrist extension performed
List of abbreviations:
CSI corticosteroid injection
DASH Disabilities of the Arm, Shoulder and Hand
LE lateral epicondylitis
MET muscle energy technique
PFGS pain-free grip strength
VAS visual analog scale
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2069
with the elbow in extension, and stretching of the forearm extensor
muscles).28 The other inclusion criteria were as follows: unilateral
elbow pain for >3 months, pain severity 50mm on a 100-mm
visual analog scale (VAS), age between 18 and 70 years, and will-
ingness to comply with treatment and follow-up assessments.
Exclusion criteria were as follows: treatment of elbow complaints
with surgical intervention; physiotherapy or CSIs in the past 6
months; bilateral elbow symptoms; duration of <3 months; severe
neck or shoulder problems likely to cause or maintain the elbow
complaints, as determined by the investigator; posterior interosseous
nerve compression; congenital or acquired deformities of the elbow;
systemic musculoskeletal or neurologic disorders; age <18 years; and
contraindications for corticosteroids (pregnancy or breast-feeding).
Sociodemographic information regarding age, sex, duration of
symptoms, hand dominance, employment, and history of previous
treatment was collected at the baseline. The nature of employment
was considered to be manual if participants used their upper
extremity for 25h/wk.29
After a detailed explanation of the study protocol, written
informed consent was obtained from each eligible participant. The
study was approved by the local research ethics committees of
Selcuk Universitys Medical Faculty, and all procedures were
conducted according to the Declaration of Helsinki.
Randomization
Patients were allocated sequentially into 2 parallel groups, MET and
CSI, of 41 cases each. Equal randomization (1:1 allocation ratio) was
undertaken according to a computer-generated randomization table.
Outcome measures and assessments
The primary outcome measure was pain-free grip strength
(PFGS). Secondary outcome measures included a VAS for the
severity of pain during the hand-gripping task, and the Disabilities
of the Arm, Shoulder and Hand (DASH) questionnaire for the
function of the arm and disability.
The same assessor (A.S.), who was blinded to the group allo-
cation, made all of the measurements for each participant before the
randomization and at 6, 26, and 52 weeks. The 6-week time point
was used primarily to investigate the short-term effects of the
interventions. The 26-week time point was used to derive indices for
the recurrence rates. These time points had been chosen on the basis
of a previous study15 that noted deterioration in the corticosteroid-
injected group during this period. The 52-week time point provided
a primary endpoint for the study of all long-term effects.
Pain-free grip strength
PFGS has been reported to be the most sensitive and useful
outcome measure of physical impairment in tracking the changes
in LE, and it should be at least 1 of the outcome measures used in
clinical practice.30,31 PFGS was measured using a calibrated
hydraulic grip dynamometer.a The participant was placed in the
supine position with the tested elbow in relaxed extension and
pronation and was then instructed to maximally squeeze the
dynamometer on the unaffected side. On the affected side, the
participant was asked to grip the dynamometer at the same rate as
on the unaffected side, but to stop the instant that pain was
experienced. Three attempts with 20-second intervals in between
were recorded, and the mean value in kilograms was calculated.
The grip strength of the affected side was presented as a ratio of
the maximum grip strength of the unaffected side.
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VAS for pain during the hand-gripping task
The elbow pain during the hand-gripping task was registered on
a VAS. The VAS consists of a 10-cm line marked at one end with
no pain and at the other end with worst imaginable pain. The
participants were asked to indicate where on the line they rated
their pain during the hand-gripping task on the day of the
presentation. The VAS is considered to be the most sensitive of all
pain rating scales and has been specifically evaluated in the LE
population, with high test-retest reliability and moderate correla-
tion with the pain-free grip.32
DASH questionnaire
The DASH questionnaire was designed to assess the physical
function and symptoms in patients with any or several musculo-
skeletal disorders of the upper limb. It is a self-reporting ques-
tionnaire consisting of 30 questions, 5 of which are related to the
symptoms and 25 of which are related to functional tasks. The
questionnaire also allows assessment of changes in symptoms and
function over time. The total DASH score ranges from 0 (no
disability) to 100 (severest disability).33-35
Interventions
Muscle energy technique
MET was applied immediately after informed consent and
randomization for 4 consecutive weeks as described by Sucher and
Glassman.27 While stabilizing the patients humerus distally with
1 hand, the subjects forearm was supinated with the operators
other hand until resistance or discomfort was detected. While the
position was held, the patient briefly pronated the forearm
(isometric contraction approximately 75% of maximal) against
resistance for a period of 5 seconds, followed immediately by
slightly increased supination until resistance was met once again.
After periods of 5 seconds of relaxation, the procedure was
repeated 5 times during a single treatment session (fig 1). This
technique was applied in 2 sessions per week for 4 weeks. All
intervention sessions were conducted by the same investi-
gator (S.K.).
Corticosteroid injection
The CSI was performed with the patients arm resting flexed on
a firm surface, and the anatomic bony landmarks were identified.
Under aseptic precautions, 1mL of triamcinolone acetonide
(40mg/mL) plus 1mL of 1% lidocaine (10mg/mL) were injected
deep into the subcutaneous tissues and muscles, 1cm distal to the
lateral epicondyle and aiming toward the area of maximum
tenderness. Patients were informed of the possible adverse effects
from the injection and were advised to avoid pain-provoking
activities for 1 to 2 weeks after the injection.
If necessary, patients were allowed to use acetaminophen
(except within 24h before the measurements), but the use of
nonsteroidal anti-inflammatory medication was prohibited. The
subjects were allowed to use the affected elbow in daily living
activities.
Statistical analysis
Statistical analysis was performed using the SPSS (version 15.0)
statistical software.b Descriptive statistics were used, providing
the numbers and percentages for the categorical variables and the
means, SDs, minimum and maximum values for the numeric
S. Kucuksen et al
Fig 1 MET for lateral epicondylitis. The patients elbow is stabilized
with 1 hand (star). The forearm is supinated with the operators other
hand until resistance or discomfort is detected. The patient performs
an isometric effort of forearm pronation against the unyielding
counterforce of the therapist for 5 seconds. Immediately afterward,
the forearm supination is increased until resistance is met once again.
After a period of 5 seconds of relaxation, the procedure is repeated 3
to 5 times during a single treatment session.
variables. Independent group comparisons were conducted using
the Mann-Whitney U test when the data were assumed not to be
normally distributed. The Friedman test was used for the
repeated-measures analysis because the variables did not present
a normal distribution. The subgroup analysis was performed
using the Wilcoxon signed-rank test with the Bonferroni
correction. The statistical significance was defined as a P value
of <.05.
Results
Between April 2011 and October 2011, 105 patients with chronic
LE were referred to our outpatient clinic. Of these, 82 patients
met all the selection criteria and were randomly assigned to either
the MET group or the CSI group. Figure 2 illustrates the flow of
participants through the trial.
The MET group was composed of 18 men and 23 women with
a mean age of 46.17
7.56 years, while the CSI group was
composed of 19 men and 22 women with a mean age of
43.78
9.16 years. In the MET group, 1 patient at 6 weeks, 1
patient at 26 weeks, and 2 patients at 52 weeks were lost to follow-
up. In the CSI group, 1 patient at 6 weeks, 2 patients at 26 weeks,
and 1 patient at 52 weeks were lost to follow-up.
The MET group and the CSI group did not differ in demo-
graphic (table 1) or clinical (tables 2e4) characteristics at base-
line (P>.05).
Pain-free grip strength
In the MET group, the mean PFGS score was significantly lower
at 6 weeks, but significantly higher at 52 weeks than that of the
CSI group (PZ.005 and PZ.007, respectively) (see table 2).
Within both groups, statistically significant differences were
observed in the mean PFGS scores over time (P<.001 and P<.001,
respectively) (fig 3). In the MET group, the increase in the PFGS
scores at 6 weeks compared with the baseline, at 26 weeks
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Muscle energy technique in lateral epicondylitis 2071

Table 2 PFGS measures (affected side/unaffected side  100)

Measurement Time MET (nZ37) CSI (nZ37) P*
Baseline 40.46
17.26 44.00
18.64 .495
6wk 60.95
19.07 72.48
19.54 .005
26wk 68.90
19.15 61.45
19.03 .034
52wk 75.08
26.19 62.24
21.83 .007
NOTE. Values are mean
SD or as otherwise indicated.
* Mann-Whitney U.

Visual analog scale

In the MET group, the mean VAS score was significantly higher at
6 weeks but significantly lower at 26 and 52 weeks than that of the
CSI group (PZ.004, PZ.016, and PZ.001, respectively) (see
table 3). Within both groups, statistically significant differences
were observed in the mean VAS pain measurement over time
(P<.001 and P<.001, respectively) (fig 4). In the MET group, the
reduction in the VAS score at 6 weeks compared with the baseline,
and the reduction at 52 weeks compared with 26 weeks were
statistically significant (P<.001 and P<.001, respectively). In the
Fig 2 Flow diagram of participants through each stage of the CSI group, the reduction at 6 weeks compared with the baseline
study. and the increase at 26 weeks compared with 6 weeks were
statistically significant (P<.001 and P<.001, respectively).

compared with 6 weeks, and at 52 weeks compared with 26 weeks

Disabilities of the Arm, Shoulder and Hand
were statistically significant (P<.001, P<.001, and P<.001,
respectively). In the CSI group, the increase at 6 weeks compared
Although the results in the MET group were much better than
with the baseline, and the reduction at 26 weeks compared with 6
those in the CSI group at 26 and 52 weeks, there were no statis-
weeks were statistically significant (P<.001 and P<.001,
tically significant differences observed between the groups in their
respectively).
DASH scores (see table 4). Within both groups, statistically
significant differences were observed in the mean DASH scores
over time (P<.001 and P<.001, respectively) (fig 5). In the MET
Table 1 Sociodemographic and clinical characteristics of the group, improvements in the DASH scores at 6 weeks when
participants compared with the baseline, and at 52 weeks when compared with
Characteristics MET (nZ41) CSI (nZ41) P 26 weeks were statistically significant (P<.001 and P<.001,
respectively). In the CSI group, the improvement at 6 weeks
Age (y) 46.17
7.56 43.78
9.16 .142 compared with the baseline, and the reduction at 26 weeks
Sex compared with 6 weeks were statistically significant (P<.001 and
Women 23 (56.1) 22 (53.7) .824* P<.001, respectively), but the differences at 52 weeks compared
Men 18 (43.9) 19 (46.3) with 6 and 26 weeks were not statistically significant.
Employment
Manual labor 17 (41.5) 18 (43.9) .972*
Nonmanual 6 (14.6) 6 (14.6) Adverse effects
work
Unemployed 18 (43.9) 17 (41.5) In the MET group, there were no significant adverse effects
Affected elbow exhibited throughout the study. A total of 3 participants experi-
Dominant 33 (80.5) 31 (75.6) .594* enced adverse events in the CSI group: 1 participant reported pain
Nondominant 8 (19.5) 10 (24.4)
Duration of 22.73
18.02 26.49
17.53 .158
complaints (wk) (12e78) (12e96) Table 3 VAS scores
PFGSz (kg) 40.46
17.26 44.00
18.64 .495y Measurement Time MET (nZ37) CSI (nZ37) P*
VAS 7.39
1.07 7.17
1.07 .330y
DASH 46.73
11.88 45.63
10.40 .666y Baseline 7.39
1.07 7.17
1.07 .330
6wk 4.38
2.08 2.98
2.49 .004
NOTE. Values are mean
SD, n (%), mean
SD (minimumemaximum), 26wk 4.00
2.59 5.29
2.04 .016
or as otherwise indicated. 52wk 3.28
2.86 4.95
2.36 .001
* Pearson chi-square.
y
Mann-Whitney U. NOTE. Values are mean
SD or as otherwise indicated.
z
Affected side/unaffected side  100 * Mann-Whitney U.

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2072 S. Kucuksen et al

Table 4 DASH scores

Measurement Time MET (nZ37) CSI (nZ37) P*
Baseline 46.73
11.88 45.63
10.40 .666
6wk 26.25
15.40 21.10
14.02 .113
26wk 23.78
17.50 27.84
14.91 .079
52wk 22.56
20.29 27.03
15.45 .061
NOTE. Values are mean
SD or as otherwise indicated.
* Mann-Whitney U.

lasting 5 days after the injection, 2 participants reported a loss of

skin pigment, and 1 patient had subcutaneous atrophy.

Discussion
This prospective, randomized controlled study compared the
effectiveness of MET with that of CSI in LE. We observed
statistically significant improvements in pain, grip strength, and
functional status in both groups over time. Initially, the CSI was
superior to the MET, but the significant short-term benefits of the
CSI were decreased after 6 weeks, whereas the outcomes in the
MET group were progressively improved.
Our results regarding CSI are similar to those reported by
many other authors14-16,36 showing that CSI is the best treatment
option in the short-term for patients with LE. Poor results are often
seen after the 12-week follow-up. In a systematic review, Assen-
delft et al37 compared the validity and outcomes of randomized
controlled trials of CSIs for LE. The pooled analysis indicated
short-term effectiveness only (2e6wk). At follow-ups beyond 6
weeks, no difference was found between CSI and other treatments,
including placebo. In another systematic review, Smidt et al17
showed that the effects of CSI (as compared with a placebo
injection, injection with local anesthetics, injection with another
steroid, or another conservative treatment) are not significantly
different in the intermediate- and long-term.
Fig 4 The course of the VAS pain scores across the study.
In recent years, several researchers have examined the effects
of MET in some musculoskeletal disorders. Wilson et al24
examined the outcomes of MET in patients with acute lower
back pain, and they concluded that the MET group showed greater
improvement in the Oswestry Disability Index score than the
control group. Selkow et al25 investigated the short-term effects of
MET on pain in individuals with nonspecific lumbopelvic pain.
They showed that subjects receiving MET demonstrated
a decrease in VAS worst pain over 24 hours. Moore et al26
revealed immediate improvements in both the glenohumeral
joint adduction and internal rotation range of movement in
asymptomatic subjects. However, literature on MET intervention
for the management of LE is nonexistent. Our study showed that
the treatment of LE with MET is a good alternative. In addition to
being more effective than CSI over the long-term, MET is
a noninvasive, painless, safe, and easy treatment option. More
importantly (unlike CSI), MET is a repeatable treatment option
without adverse events. Repeated intervention might be beneficial,
especially in resistant or recurrent cases. In addition, MET is cost-
effective when compared with other treatments.

Fig 3 The course of the PFGS scores across the study (affected side
is presented as percentage of the unaffected side). Fig 5 The course of the DASH scores across the study.

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Muscle energy technique in lateral epicondylitis
The proposed mechanisms underlying the possible therapeutic
effects of MET have been largely speculative. The underlying
therapeutic action may involve a variety of neurophysiological and
biomechanical mechanisms, including altered proprioception,
motor programming and control, and changes in tissue fluid.22
The causes of LE can be due to tendinogenic, articular, or
neurogenic reasons. Numerous theories have been put forth, and
one of the most recent theories is that the condition results from
the repeated contraction of the wrist extensor muscles, especially
the extensor carpi radialis brevis, which may compress the
posterior branch of the radial nerve at the elbow during repeated
supination and pronation.38 On the other hand, in a cadaveric
study, Bunata et al39 examined the anatomic factors related to the
causes of LE. They found that the average site of the origin of the
extensor carpi radialis brevis on the humerus is slightly medial and
superior to the outer edge of the capitellum. As the elbow was
extended, the undersurface of the extensor carpi radialis brevis
rubbed against the lateral edge of the capitellum while the
extensor carpi radialis longus compressed the brevis against the
underlying bone. The findings of these aforementioned studies
may help us to understand the pathomechanics of LE, and may
provide an explanation of the mechanism of MET. It is proposed
that MET can release articular restrictions, lengthen muscle fibers,
and increase the range of motion through a combination of creep
and plastic change in the connective tissue.22,40 However, many
studies indicate that passive joint mobilization might also activate
several areas within the central nervous system to produce
a multisystem response that extends beyond the specific joints and
spinal segments stimulated.41 Furthermore, increased tolerance to
stretch may also play a role in the apparent increased flexibility of
muscles after MET.20,42
There are some strengths related to this study. Our study
population was sufficiently large to detect clinically important
differences between the treatment groups. The study adhered to
the CONSORT statement43 for randomized controlled trials. Since
the nature of the MET intervention means that the blinding of the
patients and practitioners is not possible, the assessor was blinded
to the allocation of the treatment group. Validated outcome
measures for LE were used, and the dropout rate was kept
to a minimum.
Nevertheless, when looking at the results, it appears that the
increasing SDs over time on all variables in both groupsdmore in
the MET than CSI group and most at 52 weeksdare remarkable.
This means that the conclusions based on the group level may not
have been reached on an individual level.
Study limitations
A major limitation of the current study is the lack of a control
group not receiving MET or CSI. This could have been resolved
by using a sham MET control group. Such a study design would
allow the calculation of the magnitude of the effect in comparison
to natural history rather than to other groups receiving MET
or CSI.
Another limitation of this study is that we did not measure the
range of motion, especially pronation/supination of the elbow,
before and after intervention. The improvement in the range of
movement after the MET intervention is a potential area for
future research.
Finally, as in many manual therapeutic approaches, we might
not have been able to achieve standard implementation procedures
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2073
in all MET interventions, despite the use of the same number of
repetitions, strength of contraction, and stretch phases.
Conclusions
This study showed that while both MET and CSI improved
measures of strength, pain, and function compared with baseline,
subjects receiving MET had better scores at 52 weeks for PFGS
and the VAS for pain. There were no statistically significant
differences found between the groups in DASH scores at 52
weeks; however, statistically significant differences were observed
in the mean DASH scores over time within both groups. Based on
these findings, MET appears to be an effective intervention in the
treatment of LE.
Further research is needed to replicate these results, to explain
the mechanism of the effects, and to address the therapeutic
effects of repeated MET interventions. Future studies should
explore whether the repeated use of MET over a period produces
any lasting viscoelastic changes, and the effects of varying the
duration of isometric contractions.
Suppliers
a. Jamar; Asimov Engineering, Los Angles, CA 90024.
b. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
Keywords
Corticosteroids; Epicondylitis, lateral humeral; Function; Hand
strength; Pain; Physiology; Rehabilitation
Corresponding author
Sami Kucuksen, MD, Yunus Emre mah, Serinyol sok, Konya,
42080, Turkey. E-mail address: samikucuksen@hotmail.com.
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