Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial

Morten Olaussen, Øystein Holmedal, Ibrahimu Mdala, Søren Brage, Morten Lindbæk, Morten Olaussen, Øystein Holmedal, Ibrahimu Mdala, Søren Brage, Morten Lindbæk

Abstract

Background: Lateral 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.

Methods: A 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.

Results: One 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.

Conclusions: Acute 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 registration: ClinicalTrials.gov Identifier: NCT00826462.

Figures

Fig. 1
Fig. 1
Study flow diagram showing recruitment, randomisation to treatment groups, and follow up rates
Fig. 2
Fig. 2
Unadjusted percentage of success at each follow up, defined as participants rating themselves much improved or completely recovered on a six-point scale

References

    1. Bot SD, van der Waal JM, Terwee CB, van der Windt DA, Schellevis FG, Bouter LM, et al. Incidence and prevalence of complaints of the neck and upper extremity in general practice. Ann Rheum Dis. 2005;64(1):118–123. doi: 10.1136/ard.2003.019349.
    1. Hudak PL, Cole DC, Haines AT. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys Med Rehabil. 1996;77(6):586–593. doi: 10.1016/S0003-9993(96)90300-7.
    1. Chard MD, Hazleman BL. Tennis elbow–a reappraisal. Br J Rheumatol. 1989;28(3):186–190. doi: 10.1093/rheumatology/28.3.186.
    1. Murtagh J. Tennis elbow. Aust Fam Physician. 1984;13(1):51.
    1. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259–278. doi: 10.1302/0301-620X.81B2.9154.
    1. Scott A, Docking S, Vicenzino B, Alfredson H, Murphy RJ, Carr AJ, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013;47(9):536–544. doi: 10.1136/bjsports-2013-092329.
    1. Alfredson H, Lorentzon R. Chronic tendon pain: no signs of chemical inflammation but high concentrations of the neurotransmitter glutamate. Implications for treatment? Curr Drug Targets. 2002;3(1):43–54. doi: 10.2174/1389450023348028.
    1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333:939. doi: 10.1136/.
    1. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767. doi: 10.1016/S0140-6736(10)61160-9.
    1. Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open. 2013;3(10):e003564. doi: 10.1136/bmjopen-2013-003564.
    1. 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;309(5):461–469. doi: 10.1001/jama.2013.129.
    1. Newcomer KL, Laskowski ER, Idank DM, McLean TJ, Egan KS. Corticosteroid injection in early treatment of lateral epicondylitis. Clin J Sport Med. 2001;11:214–222. doi: 10.1097/00042752-200110000-00002.
    1. Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. 2007;61(2):240–246. doi: 10.1111/j.1742-1241.2006.01140.x.
    1. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–416. doi: 10.1136/bjsm.2008.051193.
    1. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39(7):411–422. doi: 10.1136/bjsm.2004.016170.
    1. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319(7215):964–968. doi: 10.1136/bmj.319.7215.964.
    1. Smidt N, Van Der Windt DAWM, Assendelft WJJ, Deville WLJM, Korthals-De Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet. 2002;359(9307):657–662. doi: 10.1016/S0140-6736(02)07811-X.
    1. Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther. 2005;18:411–419. doi: 10.1197/j.jht.2005.07.007.
    1. Olaussen M, Holmedal O, Lindbaek M, Brage S. Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: a protocol for a randomised, placebo-controlled study. BMC Musculoskelet Disord. 2009;10:152. doi: 10.1186/1471-2474-10-152.
    1. Cyriax JH. Textbook of Orthopedic Medicine, Volume 1. Diagnosis of soft tissue lesions. Edition seven. London: Bailliere Tindall, 1978.
    1. Ombregt L. A system of orthopedic medicine. London: W B Saunders; 1995.
    1. Mills GP. The Treatment of “Tennis Elbow.”. Br Med J. 1928;1(3496):12–13. doi: 10.1136/bmj.1.3496.12.
    1. Pienimaki T, Tarvainen T, Siira P, Malmivaara A, Vanharanta H. Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow. Clin J Pain. 2002;18(3):164–170. doi: 10.1097/00002508-200205000-00005.
    1. Smidt N, Van der Windt DA, Assendelft WJ, Mourits AJ, Devillé WL, de Winter AF, et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil. 2002;83(8):1145–1150. doi: 10.1053/apmr.2002.33728.
    1. Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group. Arch Fam Med. 1997;6:257–262. doi: 10.1001/archfami.6.3.257.
    1. Stratford PL, Gauldie D, Levy S, Miseferi D. Extensor carpi radialis tendonitis: a validation of selected outcome measures. Physiother Can. 1987;39(4):250–255.
    1. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42(1):121–130. doi: 10.2307/2531248.

Source: PubMed

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