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.
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

placebo injection = 40
corticosteroid injection plus physiotherapy = 39
patients, and placebo injection plus physiotherapy = 41 patients). The authors included patients 18
years or older
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
sessions during an 8
period. All physiotherapy was supervised by an experienced physiotherapy practitioner.
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.

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

Written by: Kyle
Reviewed by: Laura

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