Tennis Elbow: Cortisone Bad! PT so-so!

Reference:Coombes BK, et al Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9.

“Tennis elbow” has to be one of the more clinically frustrating conditions seen by PTs.
Who would assume that something as a localized as lateral elbow pain could be so challenging to treat?

So which one is better for lateral epicondylalgia, physiotherapy or cortizone injection or a combination of both?

This 2013 Australian study put 165 patients with persistent lateral epicondylalgia into 4 groups:

i) Corticosteroid injection
ii) Placebo injection
iii) Corticosteroid injection + physiotherapy
iv) Placebo injection + physiotherapy

The physiotherapy involved 30 minute treatment sessions at once a week for 8 weeks. The treatments included mobilization with movements (MWMs) and progressive concentric and eccentric exercises.

Result #1: At 4 weeks post injection, the corticosteroid demonstated to be effective at reducing pain. Therefore crticosteroid injection appeared to be benficial in the short term.

However when compared to the patients who received the placebo injections, those who received the corticosteroid injections had significantly poorer recovery, greater pain levels and greater recurrence at 6 months and at 1 year.

One-year recurrence rate was 55% for the corticosteroid injection group and only 5% for the physiotherapy group.

Result #2: At 4 weeks, 40% of the patients who received the placebo injection plus physiotherapy had fully recovered versus 5% of those who did not receive physiotherapy.

Result #3: Significantly fewer patients receiving physiotherapy took analgesic or NSAIDs.

Result #4: The physio and no physio groups did not differ after 1-year with respect to recovery or recurrence.

Result #5: There was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone.

It is as if the corticosteroid injection negated the potential benefits physiotherapy may have had.

In a Nutshell: Patients with chronic lateral epicondylalgia had actually worse outcomes post corticosteroid injection after 1 year.

Although physiotherapy was effective in the first 4 weeks, after one year it was no better than the no physiotherapy group.

Personal Comment: After reading the abstract of the study one can easily conclude with the following 2 conclusions…

Corticosteroid injections = bad
Physiotherapy = useless!

When reading the full article one realizes that in the absence of the corticosteroid, physiotherapy provided short-term benefit across all outcomes, as well as the lowest recurrence rates (5%) and the highest recovery rate at 1 year (100%).

Think about it: if it was your elbow, you would not want to wait one year to get better, you would want to get better in the first 4 weeks; that is precisely what physiotherapy provided.

Sure, a corticosteroid injection gave similar pain relief in the short term, but the short term relief comes with a 50% recurrence rate in the long term.

A description of how to perform the Lateral Glide MWM for lateral epincodylalgia is available on this “Clinical Library”.
Simply search for “Tennis Elbow”.

Posted on: March 10, 2014

Categories: Elbow

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