Quick Fix vs Delayed Gratification
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus, Huntsville. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: When compared to physiotherapy and watchful waiting, corticosteroid injection in the treatment of lateral epicondylitis helps in the short term, but had the worst results at one year.
Source: Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333:939-944.
This is a single-blind, randomized controlled trial (RCT), conducted in Australia in 2002 through 2004, that compared corticosteroid injection (CI), physiotherapy (PT), and a wait-and-see (WS) approach of the treatment of lateral epicondylitis (tennis elbow). The authors were following up on their previous studies that indicated a benefit to manipulation of the elbow and exercise. Four hundred ninety-seven (497) subjects where recruited through advertisement. Two hundred ninety-nine (299) were not randomized because they did not meet the inclusion criteria (pain over the lateral elbow of at least six weeks' duration), met exclusion criteria (neck or shoulder problems, bilateral tennis elbow, or treatment in the last six months), or declined to participate. The remaining 198 were randomized to three groups, WS (67), CI (65), and PT (66). Average age was 47.6 years, and 35% of subjects were female. The subjects in the WS group were given reassurance and encouragement and were instructed on changing their daily activity. They were allowed to use analgesics and physical measures. Subjects in the CI group were injected with a mixture of 1% lidocaine (1 mL) and triamcinolone acetonide (10 mg in 1 mL). They were instructed to gradually return to their normal activities and were allowed to receive a second injection after two weeks if necessary. Members of the PT group met with a therapist for eight sessions of 30 minutes duration over 6 weeks for elbow manipulation and exercise. They were also instructed in exercises and manipulations to perform at home. The three groups were evaluated on pain-free grip, self-reported global improvement, and complaints referable to the elbow by a blinded assessor at 3, 6, 12, 26, and 52 weeks.
At six weeks follow-up, subjects in the CI group had greater pain-free grip and greater global improvement and were judged to have less severe elbow complaints when compared to the WS group. The same results held when the CI group was compared to the PT group, except for global improvement, where there was no significant difference. When the PT and WS groups were compared, the PT group scored significantly better across all measures. At follow up at 52 weeks the CI group fared worse than the PT group for all three measures and worse than the WS group in two out of three. There was no difference between the WS and PT groups. An area-under-the-curve analysis that incorporated the findings at all follow-up visits favored the PT group over the CI group for all 3 measures and over the WS group for all but global improvement. The AUC analysis showed that the WS group did better than the CI group for global improvement and assessor judgment. The CI group reported the most recurrences of lateral epicondylitis. Most side effects were mild. However, in the CI group two subjects had loss of skin pigment and one had atrophy of subcutaneous tissue.
I read this study with mixed feelings. My personal and professional experiences with steroid injection have been positive, and there is something magical in providing patients with near-instantaneous pain relief. However, I would be hard-pressed to put together 198 patients for one year to study this objectively. Long follow-up of a large number of subjects is this study's strength.
An editorial published in the same journal notes that the "cost of physiotherapy is much higher than the cost of corticosteroid injections or a wait and see policy." The authors recommend that physicians discuss the various options with their patients. Interestingly, these editorialists co-authored a cost-effectiveness study of treatment for lateral epicondylitis, which showed that a wait-and-see policy was best. These editorialists also published a systematic review of corticosteroid injection for lateral epicondylitis that came to essentially the same conclusions as this article. Before you abandon this procedure entirely, however, a RCT added a fourth group, steroid injection plus physiotherapy. Patients in this study who received a steroid injection did better, whether they received physiotherapy or not. The authors recommend injection for patients "demanding a quick return to daily activities." Other therapies for lateral epicondylitis have been tested, including pulsed low-intensity ultrasound, which was no more effective than placebo, and botulinum toxin, which helped some patients for three months, but was associated with finger paralysis and weakness. Again, it appears that patience is a virtue.