Am Fam Physician. 2007 Apr 15;75(8):1246-1248.
Background: Treatment strategies for tennis elbow include physical therapy, corticosteroid injection, and a wait-and-see approach (including analgesics as needed). Studies have reported that corticosteroid injections provide the best results in the short term (i.e., three to six weeks); but in the longer term (i.e., three to 12 months), no significant differences can be demonstrated among the three treatment strategies. Poor study quality has been a significant problem in assessing tennis elbow treatment and has impeded the ability of systematic reviews to provide guidance on treatment strategies. Bisset and colleagues conducted a long-term trial evaluating the three treatment strategies in 198 Australian patients with tennis elbow.
The Study: The authors of this randomized controlled trial recruited volunteers by advertising for persons 18 to 65 years of age who had been experiencing pain and tenderness over the lateral epicondyle for at least six weeks. After being screened to confirm the diagnosis and having baseline data collected, 198 participants were randomly allocated to one of three treatment groups.
The patients assigned to the wait-and-see group were provided with information, reassurance, and instructions on modifying daily activities to avoid aggravating pain. These patients could use analgesics, braces, and local heat or cold as needed. The participants assigned to injection received corticosteroid in their most painful joint area and were advised to gradually return to normal activities. After two weeks, a second injection was permitted if necessary. Participants in the physical therapy group were offered eight 30-minute treatments with elbow manipulation and exercise over six weeks. In addition, these patients were encouraged to do exercises and manipulation at home.
The primary outcomes measured were global improvement, pain-free grip force, and the assessor's rating of severity. Secondary outcomes included elbow disability and reported pain during the preceding seven days. The assessors were blinded to the treatment allocation. Patients were assessed at three, six, 12, 26, and 52 weeks after randomization. The groups were comparable demographically and clinically.
Results: At six weeks, injection was significantly more successful than the two other strategies. In the injection group, 51 patients (78 percent) reported success compared with 16 (27 percent) in the wait-and-see group and 41 (65 percent) in the physical therapy group. Conversely at 52 weeks, patients in the injection group were significantly worse on all outcome measures compared with the physical therapy group (number needed to treat = 4) and on two of the three outcome measures compared with the wait-and-see group.
At six weeks, patients in the physical therapy group reported significantly better success on all measures than the wait-and-see group. By 52 weeks, almost all patients in both of these groups had recovered or were much improved. Overall, 47 patients (72 percent) treated with injections experienced recurrence after three to six weeks compared with 8 percent of the physical therapy group and 9 percent of the wait-and-see group.
Conclusion: The authors conclude that although corticosteroid injection provided superior short-term relief, the outcomes from this treatment over time were inferior to physical therapy or wait-and-see strategies. They advise that most patients with tennis elbow, when given general ergonomic advice, can be reassured that symptoms will improve over time. Physical therapy is associated with better results than a wait-and-see strategy in the short term and is superior to corticosteroid injection in the longer term.
Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. November 4, 2006;333:939–41.
Copyright © 2007 by the American Academy of Family Physicians.
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