Tennis Elbow: The Good & Bad News!! 2013 RCT
Reference:Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. 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 lateral elbow pain could be so challenging to treat?
So which one is better for lateral epicondylalgia, phsyiotherapy or cortizone injection or a combination of both?
This 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 and progressive concentric and eccentric exercises.
Result #1: At 4 weeks post injection, the corticosteroid demonstrated to be effective at reducing pain. Therefore corticosteroid injection appeared to be beneficial 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 anti-inflammatory medications. Whereas there was no difference between the placebo and the corticosteroid injection groups with respect to use of analgesic or anti-inflammatory medications.
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 benfits 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, and 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.
Posted on: February 18, 2014