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Physicaltherapyscience.com- News - Corticosteroid or placebo injection in combination with deep transverse friction, manipulation of Mills, stretching and eccentric exercises for acute lateral epicondylitis

Corticosteroid or placebo injection in combination with deep transverse friction, manipulation of Mills, stretching and eccentric exercises for acute lateral epicondylitis

22-07-2018
Lateral epicondylitis of the elbow (tennis elbow) is often seen in general practice with an incidence of 5.5 per 1000 persons. It is characterized by pain and sensitivity to the lateral humeral epicondyle and pain in dorsal flexion with lower resistance and radial deviation of the wrist. It is usually a self-limiting condition that disappears within six to twelve months, regardless of treatment, but symptoms can last up to two years or longer.

A randomized, controlled study with a follow-up of one year was performed in a general practice in Sarpsborg, Norway. 177 Men and women aged 18 to 70 years were included with clinically diagnosed lateral epicondylitis from a recent onset (2 weeks to 3 months). They were randomly assigned to one of three groups: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see policy. Physiotherapy consisted of deep transverse friction (DTF), Mills manipulation, stretching technics and eccentric exercises. One used double-blind injection of corticosteroids and single blind reviews. The main outcome measure was treatment success, defined as patients who fully recovered or had a much better judgment on a six-point scale.

One hundred fifty-seven patients (89%) completed the study. Placebo injection with physiotherapy showed no significant difference in comparison with control or with corticosteroid injection with physiotherapy at each follow-up. Corticosteroid injection with physiotherapy had a 10.6-fold greater chance of success after six weeks (odds ratio 10.60, p <0.01) compared to control (NNT = 3, 99% CI 1.5 to 4.2 ). After 12 weeks there was no significant difference between these groups, but after 26 weeks the chance of success was 91% lower (OR 0.09, p <0.01) compared to control, which showed a large negative effect (NNT = 5, 99% CI 2.1 to 67.4). There was no significant difference after 52 weeks. Both control and placebo injection with physiotherapy showed a gradual increase in treatment success.

Acute lateral epicondylitis is a self-limiting condition in which 3/4 of the patients recover within 52 weeks. Physiotherapy with DTF, Mills manipulation, stretching and eccentric exercises showed no clear benefit, and corticosteroid injection did not produce an added effect. Corticosteroid injections in combination with physiotherapy may be considered for patients requiring rapid improvement, but an intermediate (12 to 26 weeks) worsening of symptoms makes treatment difficult to recommend.

BMC Musculoskeletal Disorders (2015). Morten Olaussen et al.

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