Abstract
BackgroundLateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis.MethodsA randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale.ResultsOne hundred fifty-seven patients (89 %) completed the trial. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success.ConclusionsAcute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend.Trial registrationClinicalTrials.gov Identifier: NCT00826462
Highlights
Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms
One patient in the placebo injection with physiotherapy group withdrew from the study before receiving any treatment. 103 (89 %) of the remaining 116 patients concluded the treatment in accordance with the physiotherapy protocol as assessed by the treating physiotherapist, 53 (91 %) in the placebo injection with physiotherapy group and 50 (85 %) in the corticosteroid injection (CI) with physiotherapy group
Our results suggest that acute lateral epicondylitis is a self-limiting condition where 3/4 of the patients recover within 52 weeks without active treatment, but 1/4 had long-lasting symptoms and the use of sick-leave and additional treatments was high
Summary
Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Lateral epicondylitis of the elbow (tennis elbow) is frequently encountered in general practice with an incidence of 5.5 per 1000 person-years [1] It is characterised by pain and tenderness over the lateral humeral epicondyle and pain on resisted dorsiflexion and radial deviation of the wrist. The effect of combining physiotherapy with corticosteroid injection has been investigated in three studies with different duration of symptoms and length of follow-up [11,12,13]. None of these studies showed any additional benefit of physiotherapy compared with corticosteroid injection alone.
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