The U.S. Food and Drug Administration officially recognized high-intensity laser therapy (HILT) in 2002, allowing it to be used for evaluating its potential positive effects on tissue regeneration and pain relief (Monici et al., 2008). Among HILT’s various applications, the most substantial body of case studies has focused on pain recovery in tendinopathy (Elsodany et al., 2018). Tendinopathy involves changes that lead to damaged tendons, causing pain, swelling, loss of tissue integrity, and restricted muscle function. This condition is accompanied by structural and cellular malfunctions within the tendon. During sports-related activities, repetitive movements and increased speed create substantial mechanical forces on the tendons, leading to greater demands on tendon capacity (Millar et al., 2021). Tendon injuries can result from overuse or excessive strain, especially in older adults, which can lead to lower extremity tendinopathy, resulting in swelling, pain, and a decrease in tissue integrity and function (Riel et al., 2019). The most common tendinopathies affect the Achilles tendon, shoulder (rotator cuff tendon), elbow (medial and lateral epicondyles), ankle (tibialis posterior tendon), and knee (patellar tendon) (Riel et al., 2019; Millar et al., 2021).The frequency and incidence of tendinopathy have increased globally since the 2000s, often resulting in long-term or permanent deficiencies, particularly in athletes (Hopkins et al., 2016). Additionally, the prevalence of tendinopathy varies by age, sex, sport, physical activity level, underlying health conditions, and body region affected. The likelihood of tendinopathy increases with age, and females may have a higher predisposition than males (Riel et al., 2019). Causes of tendinopathy pain include muscle tissue damage, trauma, postural strain, repetitive movement, overuse, and prolonged immobilization. Laser therapy, specifically HILT, has emerged as a non-invasive treatment option for managing musculoskeletal disorders (Song et al., 2018). Studies have also affirmed HILT’s advantages over low-intensity laser therapy (LILT), as high-intensity laser beams treat larger surface areas and penetrate deeper tissues. The primary difference between HILT and LILT is the high-power beam of HILT (power > 500 mW), which delivers a significant amount of energy in a short timeframe. The protocols for HILT and LILT differ in terms of application methods, costs, and exposure times (Kheshie et al., 2014).

HILT has been shown to alleviate pain and improve functional capacity in patients with musculoskeletal conditions. Studies have demonstrated that HILT provides better pain relief and functional improvement than control groups (Song et al., 2018; Verma et al., 2022; Chen et al., 2020). Previous medical studies have highlighted HILT’s complementary effects on tendon recovery and pain reduction (Evangelos et al., 2018; Haslerud et al., 2015). For example, Kaydok et al. (2020) evaluated 60 patients with lateral epicondylitis (tennis elbow) and found that both HILT and lower-intensity laser treatments were effective. However, HILT provided greater improvements in handgrip strength, the Pain Catastrophizing Scale (PCS), and Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QDASH) scores (p < 0.05). These findings strongly indicate that HILT is highly effective for various types of pain management. Figure 1 illustrates the significant benefits of HILT in patient treatment, as confirmed by multiple studies.

Fig. 1: Benefits of high-intensity laser treatment in humans (illustrated by the author)

An assessment of grade I tendinopathy (mild discomfort with minimal pain) confirmed that HILT is a highly effective therapeutic approach for reducing pain and enhancing the quality of life in patients with persistent symptoms of lateral epicondylitis (Elmelgie et al., 2023).

Systematic reviews and meta-analyses are available on the effectiveness of low-level laser-based treatments for patients with tendinopathy (Haslerud et al., 2015; Eslamian et al., 2012). While fewer studies have focused specifically on the efficacy of HILT for pain recovery in tendinopathy patients, this review has gathered the most relevant and accurate data aligned with our research objectives. The goal was to identify further opportunities to optimize HILT for treating different types of tendinopathies and addressing challenges faced by both patients and practitioners.

Given HILT’s high efficacy and the limited treatment options available to many practitioners and surgeons, HILT represents a promising option for patients with severe pain, providing relief with minimal disruption to overall health. HILT focuses on effective pain management and clinical efficacy, potentially reducing the need for frequent clinical visits.

However, further investigation is needed to clarify the duration of pain relief, quality of life improvements, and long-term effectiveness. This review emphasizes the positive impacts of HILT therapies in delivering effective pain relief for tendinopathy.

This assessment was completed following the protocol of Preferred Reporting Items in Systematic Reviews and Meta-analyses (PRISMA), along with revised PRISMA guidelines (PRISMA-P) (Page et al., 2021). A comprehensive and in-depth investigation of existing literature proceeded using the following steps.

This comprehensive study examines the outcomes of High-Intensity Laser Therapy (HILT) for pain management, presenting several valuable insights. The research focused on the treatment of various body parts, including the shoulder, knee, and foot. Ahi and Sirzai (2023) evaluated the short-term effects of HILT in patients with de Quervain tenosynovitis, characterized by pain in the thumb area, which ultimately affects the hand tendons. They engaged with over 64 patients and conducted follow-up assessments. The results indicated that after three treatments per week for four to five weeks, there was a significant improvement in handgrip strength and Visual Analog Scale (VAS) scores. Consequently, HILT was recommended for the recovery of patients with de Quervain tenosynovitis. HILT is regarded as a non-invasive, effective, and reliable approach for addressing pain related to muscular activities. Similarly, Dundar et al. (2015) studied three groups: a brace group, a sham therapy (placebo HILT treatment) group, and an HILT group, all aimed at treating lateral epicondylitis pain in 93 patients. Their findings demonstrated that HILT outperformed the other two methods across various evaluation parameters. Significant improvements were observed in the Disability Index, Quality of Life, General Health Survey, and VAS pain scores for patients receiving HILT compared to those in the other groups, underscoring the effectiveness and reliability of HILT therapies. In another study by Ali et al. (2021), lateral epicondylitis was treated using both individual and combined applications of HILT and ultrasound therapies on 45 patients. The results revealed significant improvements in VAS pain scores, the Disabilities of the Arm, Shoulder, and Hand (DASH) scale, and grip strength across all three groups after the treatment sessions (p < 0.0001). The combined HILT and ultrasound group demonstrated superior outcomes compared to each treatment used alone, with statistically significant differences in VAS (p < 0.0001) and DASH scores (p < 0.001). Verma et al. (2022) investigated the effects of HILT therapy on athletes with proximal hamstring tendinopathy and concluded that HILT is an effective method for reducing pain. However, they emphasized the need for an integrated approach to enhance pain management. The benefits of HILT therapies are apparent across all regions of the body, including the upper, lower, and middle sections. In a study by Chen et al. (2020), the immediate effects of HILT treatments were assessed in twenty patients with Subacromial Impingement Syndrome (SAIS) in the shoulder. Comparative results from VAS, Range of Motion (ROM), and Constant-Murley Scale (CMS) assessments before and after treatment showed a significant reduction in pain levels, allowing for improved shoulder movement during various activities. Therefore, patients and athletes experiencing flexion issues or tendon-related pain are advised to consider optimized HILT therapies for enhanced results and improved quality of life. Pain associated with the shoulder and elbow joints is common among athletes and individuals engaged in heavy physical work. Atan and Bahar (2021) demonstrated that HILT therapies, when compared with therapeutic sessions, resulted in significant differences in VAS pain, the Shoulder Pain and Disability Index (SPADI), and SF-36 scores (subgroups of energy/fatigue, pain, and general health). Furthermore, patients with shoulder joint pain (adhesive capsulitis) experienced a notable reduction in pain. Tendinopathy can also be effectively managed using innovative approaches involving the same equipment, such as varying wavelengths, exposure times, and other parameters. Notarnicola et al. (2023) analyzed thirty patients diagnosed with rotator cuff tendinopathy using a combination of wavelengths (650, 810, 980, and 1064 nm) compared to a single wavelength (1064 nm). Pain-related indices were assessed before the intervention and at two follow-up periods, one month and six months later. Group A received a HILT therapy protocol using a single wavelength (1064 nm), while Group B was treated with four wavelengths (650, 810, 980, and 1064 nm). Both protocols resulted in improvements in pain (VAS), function (ASES), and disability (DASH) over time, with no statistically significant differences between the two groups. However, Group B, which received the four-wavelength treatment, showed a trend towards greater pain reduction that approached statistical significance. Beyrami et al. (2023) investigated the combined effects of Transcutaneous Electrical Nerve Stimulation (TENS), ultrasound, hot packs, and exercises in a control group (n=16) and a treatment group (n=16) that received routine physiotherapy alongside HILT in the painful area of the shoulder over twelve sessions. The combination of HILT and routine physiotherapy improved both clinical outcomes and sonographic findings, including supraspinatus tendon thickness and the accumulation of sub-acromial fluid in patients with rotator cuff tendinopathy, compared to the control group. Brandl et al. (2023) examined microcirculatory changes in the patellar tendon and skin temperature as a result of HILT therapies. This investigation involved 21 healthy volunteers, and microcirculation was measured non-invasively using laser Doppler and white light spectroscopy before and after HILT treatment, as well as ten minutes post-treatment. The results indicated significant improvements in blood flow and oxygen saturation following HILT, effects that were still measurable ten minutes later. Conversely, there was a notable decrease in the relative amount of hemoglobin, suggesting an acceleration of blood flow. Salli et al. (2016) explored the effects of HILT therapies combined with a lateral epicondylitis bandage in 65 patients, reporting considerable improvements in disability, quality of life parameters, and handgrip strength following four sessions (75 seconds at 4W, 6J/cm²) followed by six sessions (12 minutes and 30 seconds at 6W, 100-150J/cm²). In another study, Mardh and Lund (2016) examined the effects of HILT therapies on Achilles tendon pain over six sessions during a three to four-week period, with follow-up assessments conducted eight to ten weeks later. The results indicated significant improvements within groups, with the HILT group demonstrating a more pronounced reduction in pain levels compared to the placebo HILT group. Therefore, HILT can be considered a promising treatment for tendinosis-related pain issues. Further studies investigating the long-term effects of HILT could enhance our understanding of this treatment modality. Table 3 provides a brief summary of the studies included in this research.

Table 1: Eligibility considerations for the current systematic review

Fig. 2: Flow chart indicating the scrutiny research strategy following PRISMA guidelines

Laser therapy, which stands for light amplification by stimulated emission of radiation, has been recommended for treating a wide variety of conditions, such as wound healing, bone repair, spinal cord injury, tendinopathy, postoperative recovery, and peripheral nerve regeneration (Notarnicola et al., 2023).

Recent studies have shown that both low-energy and high-intensity laser therapy (HILT) are effective for clinical and functional recovery in various tendon pathologies; HILT, however, demonstrates superior results due to its greater ability to reach and stimulate deeper and wider areas (Notarnicola et al., 2023). The analgesic effect of HILT is based on multiple mechanisms, including its ability to slow the transmission of pain stimuli and increase the production of morphine-mimetic substances in the body (Dundar et al., 2015).

The pain-relieving effects of HILT lasers are related to delays in pain signal transmission along pain-related nerve fibers and to an increase in the release of enkephalins and endorphins.

Additionally, HILT directly affects nerve structures, accelerating nerve recovery and improving blood circulation, thereby aiding nerve repair (Beyrami et al., 2023). Tendinopathy is a complex pain condition often accompanied by swelling and is challenging to manage, as most patients seek rapid pain relief. Recently, laser therapies, including HILT, have been used in the treatment of tendinopathy. HILT therapies are widely recognized for their ability to provide quick pain relief without affecting surrounding tissues, using a precise and targeted approach to address pain points. Significant changes in blood flow have been observed following HILT treatments, exceeding minimal detectable changes, suggesting effects beyond simple vasodilation by enhancing the flow properties of erythrocytes and platelets. Consequently, HILT may be a valuable option for clinicians managing tendinopathy with impaired microcirculation and may help prevent sports-related tendon overload associated with reduced blood flow (Brandl et al., 2023).

On a larger scale, most studies reviewed affirm the effectiveness and reliability of HILT for managing pain in tendinopathy. Conditions such as tennis elbow, lateral epicondylitis, and shoulder stiffness respond well to HILT without negatively impacting surrounding tissues or overall physical health (Ali et al., 2021; Kaydok et al., 2020; Dundar et al., 2015). Other body areas, including the hand, knee, ankle, and hamstrings, have also shown positive responses to HILT in a variety of patients and athletes, as documented in the current literature (Ahi & Sirzai, 2023; Mardh & Lund, 2016). Korkmaz et al. (2021) also investigated the effects of HILT on hemiplegic shoulder pain, comparing multiple sessions of HILT combined with therapeutic exercises. The results showed positive changes in the VAS, BRS, PTRCT, SPADI, and other indicators, confirming the benefits of HILT when used alongside therapeutic exercise. Globally, HILT is used to manage pain in the shoulder, knee, elbow, and Achilles tendon. Its physiological effects inhibit pain through various chemical mechanisms at targeted pain points, leading to rapid recovery and pain relief. Nervous paralysis—natural repair of damaged nerve endings—also aids in pain reduction (Ebid et al., 2013).

Table 3: Summary of case studies included

HILT has many clinical benefits, both as a standalone therapy and when combined with strength or range-of-motion (ROM) exercises (Fiore et al., 2013; Chow et al., 2011). Additionally, HILT’s effectiveness depends on wavelength strength, dosage, and penetration depth at the pain site. Dosage profiles show that high-powered wavelengths penetrate more deeply and speed up pain relief (Nussbaum et al., 2007). Pellegrino et al. (2022) compared HILT and hyaluronic acid injections in nearly 80 patients, finding that combining these treatments effectively reduced pain short-term; however, the long-term effects of this approach need further investigation. A randomized trial by Akkurt et al. (2016) on elbow pain found that HILT significantly improved VAS, DASH, and HGST scores over a 6-month follow-up. SF-36 scores also showed significant improvements in mental and physical health, supporting HILT’s effectiveness for both short- and long-term relief of lateral epicondylitis symptoms.

Tendinopathy may be triggered by various factors, including medication and biomedical issues (Miller et al., 2021). HILT is used to treat a range of muscular pain conditions in the knee, neck, and arms, particularly among athletes (Song et al., 2018; Kheshie et al., 2014). Santamato et al. (2009) found that HILT significantly reduced pain and improved ROM and hand-grip strength over 10 sessions. Similarly, Kim et al. (2015) reported both short- and long-term benefits of HILT, including improvements in ROM, VAS, and IR measures in patients treated three times weekly. Yilmaz et al. (2022) evaluated HILT combined with targeted exercises for rotator cuff pain and found that patients who also followed a physical therapy program experienced greater pain relief. Known for its photochemical and mechanical effects, HILT supports recovery by improving blood flow, vascular permeability, and metabolism (Angelova & Ilieva, 2016).

In conclusion, this focused study on high-intensity laser therapy (HILT) demonstrates its significant effectiveness in managing pain across various types of tendinopathy. Its physiological effects, including promoting blood flow and enhancing metabolism, make it a preferred option for both short-term and long-term recovery. Research on different body areas, such as the shoulder, elbow, knee, hamstrings, and foot, shows that HILT consistently improves pain scores, functionality, and quality of life. It has proven to be a reliable, non-invasive method for reducing pain, improving mobility, and supporting recovery in both acute and chronic conditions.

The main limitations of this study are the relatively small sample size and the lack of long-term follow-up data (beyond 3 months and up to 1 year). While HILT demonstrates both short-term and long-term benefits, further large-scale research is needed to fully understand its long-term effects and to optimize treatment protocols. Based on these studies, we recommend HILT as an effective therapy for a range of tendinopathies and tendinosis. Future studies with varied dosages, combinations of different wavelengths, larger participant samples, and extended follow-up periods are needed to provide more robust data.

The author declares no conflicts of interest.

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