Background

Deep transverse friction massage, one of several physical therapy interventions suggested for the management of tendinitis pain, was first demonstrated in the 1930s by Dr James Cyriax, a renowned orthopedic surgeon in England. Its goal is to prevent abnormal fibrous adhesions and abnormal scarring. This is an update of a Cochrane review first published in 2001.

Objectives

To assess the benefits and harms of deep transverse friction massage for treating lateral elbow or lateral knee tendinitis.

Search methods

We searched the following electronic databases: the specialized central registry of the Cochrane Field of Physical and Related Therapies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, and the Physiotherapy Evidence Database (PEDro), up until July 2014. The reference lists of these trials were consulted for additional studies.

Selection criteria

All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing deep transverse friction massage with control or other active interventions for study participants with two eligible types of tendinitis (ie, extensor carpi radialis tendinitis (lateral elbow tendinitis, tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri) and iliotibial band friction syndrome (lateral knee tendinitis)) were selected. Only studies published in English and French languages were included.

Data collection and analysis

Two review authors independently assessed the studies on the basis of inclusion and exclusion criteria. Results of individual trials were extracted from the included study using extraction forms prepared by two independent review authors before the review was begun. Data were cross‐checked by a third review author. Risk of bias of the included studies was assessed using the "Risk of bias" tool of The Cochrane Collaboration. A pooled analysis was performed using mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CIs).

Main results

Two RCTs (no new additional studies in this update) with 57 participants met the inclusion criteria. These studies demonstrated high risk of performance and detection bias, and the risk of selection, attrition, and reporting bias was unclear.

The first study included 40 participants with lateral elbow tendinitis and compared (1) deep transverse friction massage combined with therapeutic ultrasound and placebo ointment (n = 11) versus therapeutic ultrasound and placebo ointment only (n = 9) and (2) deep transverse friction massage combined with phonophoresis (n = 10) versus phonophoresis only (n = 10). No statistically significant differences were reported within five weeks for mean change in pain on a 0 to 100 visual analog scale (VAS) (MD ‐6.60, 95% CI ‐28.60 to 15.40; 7% absolute improvement), grip strength measured in kilograms of force (MD 0.10, 95% CI ‐0.16 to 0.36) and function on a 0 to 100 VAS (MD ‐1.80, 95% CI ‐0.18.64 to 15.04; 2% improvement), pain‐free function index measured as the number of pain‐free items (MD 1.10, 95% CI ‐1.00 to 3.20) and functional status (RR 3.3, 95% CI 0.4 to 24.3) for deep transverse friction massage, and therapeutic ultrasound and placebo ointment compared with therapeutic ultrasound and placebo ointment only. Likewise for deep transverse friction massage and phonophoresis compared with phonophoresis alone, no statistically significant differences were found for pain (MD ‐1.2, 95% CI ‐20.24 to 17.84; 1% improvement), grip strength (MD ‐0.20, 95% CI ‐0.46 to 0.06) and function (MD 3.70, 95% CI ‐14.13 to 21.53; 4% improvement). In addition, the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the quality of evidence for the pain outcome, which received a score of "very low". Pain relief of 30% or greater, quality of life, patient global assessment, adverse events, and withdrawals due to adverse events were not assessed or reported.

The second study included 17 participants with iliotibial band friction syndrome (knee tendinitis) and compared deep transverse friction massage with physical therapy intervention versus physical therapy intervention alone, at two weeks. Deep transverse friction massage with physical therapy intervention showed no statistically significant differences in the three measures of pain relief on a 0 to 10 VAS when compared with physical therapy alone: daily pain (MD ‐0.40, 95% CI ‐0.80 to ‐0.00; absolute improvement 4%), pain while running (scale from 0 to 150) (MD ‐3.00, 95% CI ‐11.08 to 5.08), and percentage of maximum pain while running (MD ‐0.10, 95% CI ‐3.97 to 3.77). For the pain outcome, absolute improvement showed a 4% reduction in pain. However, the quality of the body of evidence received a grade of “very low.” Pain relief of 30% or greater, function, quality of life, patient global assessment of success, adverse events, and withdrawals due to adverse events were not assessed or reported.

Authors' conclusions

We do not have sufficient evidence to determine the effects of deep transverse friction on pain, improvement in grip strength, and functional status for patients with lateral elbow tendinitis or knee tendinitis, as no evidence of clinically important benefits was found. The confidence intervals of the estimate of effects overlapped the null value for deep transverse friction massage in combination with physical therapy compared with physical therapy alone in the treatment of lateral elbow tendinitis and knee tendinitis. These conclusions are limited by the small sample size of the included randomized controlled trials. Future trials, utilizing specific methods and adequate sample sizes, are needed before conclusions can be drawn regarding the specific effects of deep transverse friction massage on lateral elbow tendinitis.

Keywords: Humans, Combined Modality Therapy, Cryotherapy, Iliotibial Band Syndrome, Iliotibial Band Syndrome/therapy, Massage, Massage/methods, Ointments, Ointments/administration & dosage, Phonophoresis, Randomized Controlled Trials as Topic, Rest, Tennis Elbow, Tennis Elbow/therapy, Ultrasonic Therapy

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).

Summary of findings 2. Massage + phonophoresis compared with phonophoresis alone for treating lateral elbow tendinitis (tennis elbow).

Summary of findings 3. Deep transverse massage + physical therapy compared with physical therapy alone for treating lateral knee tendinitis.

Description of the condition

Extensor carpi radialis tendinitis (ECRT) (ie, lateral elbow tendinitis, tennis elbow or lateral epicondylitis, or lateralis epicondylitis humeri) is a local inflammation near the proximal (upper) attachments of wrist extensor muscles, characterized by pain on palpation of the lateral epicondyle of the humerus and in resisted movements against wrist extension (Struijs 2002). The prevalence of lateral elbow tendinitis (tennis elbow) varies between 1% and 10% of the population; it commonly occurs between the ages of 34 and 74 years (Allander 1974; Roquelaure 2006; Shiri 2006;Walker‐Bone 2004).Stratford 1989 reported that lateral elbow tendinitis (tennis elbow) does not seem to be a degenerative condition, as its prevalence declines after the age of 42 (Allander 1974). It is a syndrome of overuse (eg, use of computer mouse, racquet sports) that can result in considerable socioeconomic costs resulting from prolonged leave of absence from work (Struijs 2002).

Iliotibial band friction syndrome (ITBFS) (lateral knee tendinitis) is an overuse musculoskeletal injury that causes lateral knee pain and is frequently observed in long distance runners, cyclists, football players, and military personnel. The incidence of lateral knee tendinitis varies between 1.6% and 52%, depending upon the population studied (Jordaan 1994;Kirk 2000;Lavine 2010;Pinshaw 1984;Strauss 2011). The mechanism of lateral knee tendinitis appears to be repetitive friction of the iliotibial band moving over the lateral femoral condyle during knee flexion/extension (Schwellnus 1991). The cause of ITBFS (lateral knee tendinitis) is multifactorial (Messier 1988). Three main risk factors play a large role in the development of lateral knee tendinitis, according to the current literature: (1) biomechanical factors such as muscle imbalance causing maximal braking forces required to control body movements depending on velocity and angle of inclination (Messier 1995), (2) anthropometric factors such as abnormalities in leg and/or feet anatomy (Messier 1988), and (3) training factors such as inadequate warm‐up and cool‐down training (Messier 1988;Messier 1995).

Description of the intervention

Treatment of tendinitis consists of medical, physiotherapeutic, and surgical approaches. The medical approach encompasses rest and the prescription of anti‐inflammatory agents combined with anti‐inflammatory or analgesic medication to control pain and inflammation (Kirk 2000). Goals of the physiotherapeutic approach in the treatment of tendinitis include (1) control of pain and inflammation (Cyriax 1975a;Cyriax 1975b;Thaunton 1987;Wilk 2004); (2) correction of biomechanical deficiencies (Johnson 2007;Thaunton 1987); (3) restoration of motion (Hart 1994); (4) increase in strength, endurance, and function (Hart 1994;Reinold 2002;Thaunton 1987;Wilk 2004); (5) prevention of reinjury (Hart 1994;Reinold 2002); and (6) gradual return to training (Reinold 2002;Thaunton 1987). The surgical approach includes resection of the impinging portion of the extensor carpi radialis brevis tendon release (Grewal 2009) or the iliotibial band (Kirk 2000;Martens 1989).

Deep transverse friction massage (DTFM) is a technique popularized by Dr James Cyriax (Cyriax 1975a;Cyriax 1975b) for relief of pain and inflammation in musculoskeletal conditions. Deep friction is given transverse to the fiber direction of involved tissue, and friction massage must be sufficiently deep to impact the affected structure.

How the intervention might work

Deep transverse friction massage is offered in the treatment of various musculoskeletal conditions. This technique attempts to prevent or destroy abnormal fibrous adhesions (cross‐links or cross‐bridges) by imposing stress transversely to the remodeling collagen of the tissue to soften the adhesion. Thus, DTFM also optimizes the quality of the scar tissue by realigning the collagen of normal soft tissue fibers in a longitudinal way (Walker 1984). It has been indicated that DTFM enhances normal healing conditions and prevents abnormal scarring. Its mechanical action causes hyperemia (ie, an increase in blood flow to the affected area).

Why it is important to do this review

No meta‐analyses or literature reviews have reported the efficacy of this type of massage for lateral elbow or knee tendinitis. Clinicians and patients must be provided with evidence that will enable them to make informed decisions regarding treatment options.

Criteria for considering studies for this review

Search methods for identification of studies

Data collection and analysis

Description of studies

Risk of bias in included studies

We assessed the risk of bias for each included study using the "Risk of bias" tool of The Cochrane Collaboration. The risk of bias graph and summary are presented inFigure 2 andFigure 3, respectively.

Effects of interventions

See:Table 1;Table 2;Table 3

No studies were pooled; therefore assessment of heterogeneity and subgroup analyses were not possible. (SeeData and analyses section for additional details.)

Summary of main results

Evidence was insufficient to demonstrate a consistent clinically important benefit of deep transverse friction massage combined with additional physical therapy modalities when compared with a control in the treatment of extensor carpi radialis tendinitis (lateral elbow tendinitis) (Stratford 1989) and of iliotibial band friction syndrome (knee tendinitis) (Schwellnus 1992). The additional benefit of deep transverse friction massage was not confirmed, as combined interventions were used. The included studies did not report on adverse events.

Overall completeness and applicability of evidence

Only two clinical trials met the inclusion criteria of this review update. Moreover, these two trials were at high risk of bias. Therefore evidence on the specific benefits of deep transverse friction massage is sparse. Further, results of the intervention looking at deep transverse friction massage and physical therapy versus physical therapy alone may not be applicable to general populations, as participants in the trial were experienced runners. The Philadelphia Panel recommends that evidence is insufficient (level 1, grade C for pain) to include or exclude deep transverse friction massage alone as a therapeutic intervention for treating tendinitis (Philadelphia 2001). Evaluation of deep transverse friction massage as a single treatment in comparison with other techniques has not been undertaken, so its efficacy has not yet been demonstrated (Joseph 2012).

Quality of the evidence

For both included RCTs, the two major outcomes (pain and function) received a GRADE score of “very low” for the quality of the body of evidence.

The two RCTs included in this systematic review highlight a common problem among trials of rehabilitation interventions: difficulty or inability to blind participants and personnel, which contributes to the high risk of bias. Although outcome assessors were blinded in both studies, lack of blinding of participants may have an impact on patient‐reported outcomes such as pain, leading to overestimation. Both presented baseline imbalance (mean age and duration of symptoms were different across groups). One of the studies (Schwellnus 1992) demonstrated high risk of incomplete outcome data, as investigators reported a 15% dropout rate, and no intention‐to‐treat analysis was performed. The small sample sizes and wide confidence intervals also contribute to the very low quality rating of the body of evidence for reported outcomes.

Confounding variables such as characteristics of the device, characteristics of the therapeutic application, characteristics of the population, characteristics of the disease, and methodological considerations might have contributed to the lack of effect (Morin 1996). Characteristics of the technique described by Cyriax (Cyriax 1975a;Cyriax 1975b) such as years of experience of the therapist, characteristics of the application (pressure, rhythm and progression, and frequency), duration of treatment sessions and the treatment schedule, characteristics of the population (age, gender), characteristics of the disease (chronic vs acute conditions), and weakness of methodological considerations (comparison groups, sample size, study duration, nonvalidated outcome measures) in both studies (Schwellnus 1992;Stratford 1989) may have contributed to inconclusive results on the effectiveness of deep transverse friction massage for tendinitis. FInally, larger and better powered studies are required to confirm findings because of the small number of studies included in this update of the review and the small sample sizes presented by the included trials.

For both studies, 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. In other words, we obtained very low grades for the main outcomes, principally because of unclear allocation concealment and randomization, single‐blind processes, wide confidence intervals, and small sample size.

Potential biases in the review process

It is important to consider whether all relevant trials were identified (whether or not all pertinent data could be obtained) and if the methods used (search strategy, selection of studies, data collection, analysis) could have introduced potential bias. When selecting studies for inclusion, we did not consider languages other than French and English. This could have limited the number of potentially eligible studies found.

Agreements and disagreements with other studies or reviews

This systematic review of deep transverse friction massage for tendinitis was initially conducted as part of a guideline development project entitled the Philadelphia Panel Guidelines on Rehabilitation Interventions for knee pain (Philadelphia 2001). Other guidelines such asACR 1996,ACR 2000,Godlee 2000, andManal 1996 did not evaluate any type of massage as a treatment intervention for knee conditions. To our knowledge, no guidelines on massage for extensor carpi radialis tendinitis are available. The American Physical Therapy Association (APTA) guidelines (APTA 2001) recommend massage for musculoskeletal conditions, although the APTA guidelines do not differentiate between types of massage. However, these guidelines are not based on evidence from comparative controlled trials.

No meta‐analysis or literature reviews have reported the efficacy of this type of massage (Chapman 1991;Furlan 2008;Green 1998;van der Heijden 1997). Evaluation of deep transverse friction massage as a single treatment in comparison with other techniques has not been undertaken, so its efficacy has not been yet demonstrated. Comparison of different studies is difficult to perform because of heterogeneity in terms of (1) types of tendinitis, (2) confounding approaches, and (3) varied outcome measures selected (Joseph 2012).

In the included RCT (Stratford 1989), deep transverse friction massage was performed to reduce symptoms of tendinitis. The inflammation and pain observed in tendinitis are frequently due to three main factors: (1) biomechanical factors), (2) anthropometric factors, and (3) training factors. Pain is an indirect symptom. Based on identified factors, pain could be controlled more effectively through other physical therapy interventions such as strengthening and postural exercises, or changes in functional and sporting activities that correct biomechanical deficiencies (Thaunton 1987), restore motion (Hart 1994), increase strength, endurance, and function (Hart 1994;Thaunton 1987), and permit gradual return to training (Thaunton 1987). One included study (Stratford 1989) found that phonophoresis is not superior to ultrasound and placebo ointment, where similar results were obtained. Antich et al (Antich 1986) mentioned that phonophoresis is as good as ice and ultrasound. Halle and colleagues (Halle 1986) confirmed that ultrasound, transcutaneous electrical nerve stimulation (TENS), and cortisone injections represent comparative therapies in terms of efficacy. The second included RCT (Schwellnus 1992) suggested that the addition of deep transverse friction massage might not appear to aggravate clinical outcomes in iliotibial band friction syndrome (knee tendinitis). Therefore, the included study rejected the findings of the first study author, who examined the biologic rationale of this therapy (Griffin 1963) and reported that the success rate was significantly greater in the phonophoresis group compared with the group given ultrasound therapy. Similar success rates for the phonophoresis groups were shown in the work of Kleinkort et al (Griffin 62% vs Kleinkort 66%) (Stratford 1989). However, it is important to note that those study authors did not consider the presence of potential confounding variables, and neither of them reported their diagnostic criteria and the power of their statistical test (Stratford 1989).

Additional well‐designed RCTs are needed before this specific type of massage can be excluded for treatment of this condition. Clinicians and patients need to be presented with evidence that will enable them to make informed decisions regarding treatment options.

Implications for practice.

Implications for research.

Appendix 1. MEDLINE search strategy

Ovid MEDLINE(R) In‐Process & Other Nonindexed Citations, and Ovid MEDLINE(R) (1946 to July 1, 2014)

1 exp Tendinopathy/ (6229)

2 tendinopath$.tw. (1352)

3     tend?nit$.tw. (2331)

4     tend?nos$.tw. (576)

5     ECRT.tw. (11)

6     tennis elbow.tw. (650)

7     lateral$ epicondylitis.tw. (507)

8     ITBFS.tw. (18)

9     Iliotibial band friction syndrome.tw. (55)

10     exp Cumulative Trauma Disorders/ (10274)

11     (repetiti$ adj (motion disorder or strain)).tw. (358)

12     cumulative trauma disorder$.tw. (273)

13     or/1‐12 (18667)

14     exp Musculoskeletal Manipulations/ (11415)

15     physical therapy modalities/ (26485)

16     massag$.tw. (6837)

17     Deep transverse friction.tw. (6)

18     dtfm.tw. (2)

19     Cyriax.tw. (31)

20     or/14‐19 (41129)

21     13 and 20 (534)

Appendix 2. EMBASE search strategy

Database: EMBASE Classic + EMBASE (1947 to July 1, 2014)

1     exp massage/ (10894)

2     therapeutic touch.mp. (429)

3     reflexotherapy.mp. (416)

4     exp ROLFING/ (12)

5     exp SHIATSU/ (65)

6     exp reflexology/ (374)

7     myotherapy.mp. (34)

8     (polarity adj therapy).mp. (13)

9     (myofascial adj release).mp. (114)

10     (craniosacral adj therapy).mp. (87)

11     exp REIKI/ (184)

12     (trager adj psychophysical).mp. (6)

13     (hakomi adj method).mp. (2)

14     (jin adj shin).mp. (4)

15     (neuromuscular adj therapy).mp. (10)

16     (pfrimmer adj25 therapy).mp. (4)

17     (alexander adj technique).mp. (85)

18     exp Alexander Technique/ (35)

19     (feldenkrais adj method).mp. (57)

20     massag$.mp. (18532)

21     or/1‐20 (19890)

22     exp tendon injury/ (15552)

23     tendinitis/ (6184)

24     tenosynovitis/ (4011)

25     tendinopathy/ (5701)

26     (tend#nitis or tend#nosis or tend#nopathy or tenovaginitis or paratend#nitis or peritend#nitis or tenosynovitis).tw. (7635)

27     or/22‐26 (25837)

28     21 and 27 (172)

Appendix 3. CENTRAL search strategy

Wiley Cochrane Library – CENTRAL
Issue 7 of 12, July 2014

#1        MeSH descriptor: [Tendinopathy] explode all trees

#2        MeSH descriptor: [Tendon Injuries] explode all trees

#3        (Tendinitis or Tendinosis or Tendonitis):ti,ab

#4        lateral epicondylitis

#5        Iliotibial band friction syndrome

#6        repetitive motion

#7        repetitive strain

#8        #1 or #2 or #3 or #4 or #5 or #6 or #7

#9        Deep transverse friction

#10      massage

#11      MeSH descriptor: [Massage] explode all trees

#12      MeSH descriptor: [Musculoskeletal Manipulations] explode all trees

#13      dtfm

#14      Cyriax

#15      MeSH descriptor: [Physical Therapy Modalities] explode all trees

#16      #9 or #10 or #11 or #12 or #13 or #14 or #15

#17      #8 and #16

Appendix 4. CINAHL search strategy

EBSCO Host CINAHL
1982‐July 2014

Appendix 5. PEDro search strategy

PEDro

Therapy: stretching, mobilization, manipulation and massage

Problem: pain

Body part: forearm elbow

Appendix 6. Clinicaltrials.gov search strategy

Clinicaltrials.gov

Conditions: tendinitis OR tenosynovitis OR tendinopathy
Interventions: massage

Comparison 1. Massage + therapeutic ultrasound (US) and placebo ointment vs US + placebo ointment only.

Comparison 2. Massage + phonophoresis vs phonophoresis only.

Comparison 3. Massage + physical therapy vs physical therapy only.

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Internal sources

• Institute for Population Health, University of Ottawa, Canada.

• Ottawa Health Research Institute, Canada.

External sources

• Holistic Health Research Foundation of Canada, Canada.

References to studies included in this review

References to studies excluded from this review

Additional references