Sports Medicine Research: In the Lab & In the Field: The Questionable Long-Term Effectiveness of Physiotherapy and Corticosteroid Injections for Tennis Elbow (Sports Med Res)


Friday, March 29, 2013

The Questionable Long-Term Effectiveness of Physiotherapy and Corticosteroid Injections for Tennis Elbow

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia

Coombes BK, Bisset L, Brooks P, Khan A, and Vicenzino B. JAMA. 2013; 309(5):461-469.

Take Home Message: Corticosteroid injections and structured physiotherapy are not associated with improved patient-reported measures of pain and disability following one year of treatment.

With epicondylalgia, or tennis elbow, the patient experiences pain along the lateral epicondyle during gripping and wrist extension. This condition is usually treated with a combination of corticosteroid injection and physiotherapy. While the short-term effects of this treatment strategy appears favorable, there is a lack of evidence to support its long-term efficacy. Therefore, Coombes and colleagues completed a randomized, blinded, placebo-controlled trial to evaluate the clinical efficacy of corticosteroid injection and physiotherapy at a one year follow-up in patients suffering from unilateral lateral epicondylalgia. A total of 165 patients were randomly assigned into 4 treatment groups (corticosteroid injection = 43 patients, placebo injection = 40 patients, corticosteroid injection plus physiotherapy = 39 patients, and placebo injection plus physiotherapy = 41 patients). The authors included patients 18 years or older who experienced unilateral lateral epicondylalgia for longer than 6 weeks. Additionally, the authors excluded patients who received a corticosteroid injection in the preceding 6 months, received physiotherapy in the preceding 3 months, had concomitant neck or other arm pain, had symptoms suggesting radicular, neurological, or systemic arthritic conditions, were pregnant or breastfeeding, or had contradictions to injections. The injection groups received either a placebo of 0.5mL of 0.9% isotonic saline or 10mg/mL of triamcinolone acetonide plus 1mL of 1% lignocaine. Physiotherapy groups underwent 8, 30-minute sessions during an 8-week period. All physiotherapy was supervised by an experienced physiotherapy practitioner. At 4, 8, 12, 26, and 52 weeks post-treatment, patients recorded their global rating of change on a 6-point Likert-like scale, a 100 mm visual analog scale, and Patient-Rated Tennis Elbow Evaluation score range. Overall, physiotherapy had no effect on outcome measures, though engaging in physiotherapy was associated with decreased use of analgesic and anti-inflammatory medications. At one year follow-up, patients receiving a corticosteroid injection reported less improvement than placebo injections.

Corticosteroid injections and physiotherapy are traditional treatments for epicondylalgia; however, these results suggest that these options have little impact at one-year follow-up. The clinical applicability of these results is difficult to determine as patients were allowed to use analgesic or anti-inflammatory medication; making a true assessment of change in pain and/or disability difficult. At one-year post-treatment, patients who completed physiotherapy reported using less analgesic and anti-inflammatory medications. While use of these medications is not as drastic of a treatment, as a corticosteroid injection, their purpose is similar: decrease inflammation and thus, perceived pain level. This may provide some evidence, although not definitive, that physiotherapy may be beneficial in the treatment of epicondylalgia. Tell us what you think. Even though physiotherapy showed little influence on the subjective measures of patients with epicondylalgia, do you believe there is still benefit from having patients undergo a physiotherapy program? Why or why not?

Written by: Kyle Harris
Reviewed by: Laura McDonald

Related Posts:
Coombes BK, Bisset L, Brooks P, Khan A, & Vicenzino B (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA, 309 (5), 461-9 PMID: 23385272


Anonymous said...

In reading the actual study from JAMA, it is still unclear what interventions were actually applied, how they were applied (were patients told to stop if they had pain). I would also say that it seems a larger issue of concurrent proximal shoulder/scap stabilizer weakness was not addressed. In my experience, a large majority of patients that have lateral epicondyilits and especially those that have recurrences, have proximal weakness that contributes to their distal symptoms. I would like to see research done on the effectiveness of this tretament long-term.

Kyle said...

Thanks for the comment. I think you bring up a few excellent points. Firstly, yes I agree. there were some important points of the study that could be clarified. Your other point concerning the shoulder/scap stabilizers is also interesting. First we should be careful as to the objective of the study. This study was focus primarily on the treatment of the lateral epicondylalgia rather than the causation. With that being said, I agree that as clinicians it is critical that we focus on the cause of a condition, especially in cases where the patient has a recurrence of that condition. I think this is an excellent focus for future research in this area.

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