Tennis Elbow, Anyone?

Abstract & Commentary

By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips serves on the speakers bureau for PotomaCME.

Synopsis: Neither physical therapy nor steroid injection improved primary outcomes of tennis elbow at 1 year; in fact, steroid injection was associated with worse outcome. Physical therapy was associated with some improvement in short-term outcomes and secondary measures.

Source: Coombes BK, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA 2013;309:461-469.

The primary aim of this study was to assess the long-term effects of corticosteroid therapy and physical therapy, singly and in combination, for the treatment of epicondylalgia (a.k.a., tennis elbow). This report is the result of a randomized, blinded, placebo-controlled trial with a 1-year follow-up. Recruited patients were randomized to one of four treatment groups: 1) corticosteroid injection, 2) placebo injection, 3) corticosteroid injection plus physiotherapy, and 4) placebo injection plus physiotherapy.

Participants had pain over the lateral humeral epicondyle that was provoked by at least two of the following: gripping, palpation, resisted wrist or middle finger extension, or stretching of forearm extensor muscles with reduced pain-free grip. Those who had already had injections or physical therapy were excluded.

The researcher who assessed outcomes and analyses was blinded to both injection and physiotherapy assignment. Patients were masked to injection type (corticosteroid or placebo), but could not be masked as to whether they received physiotherapy. Those who were randomized to receive an injection received a single injection of either placebo (0.5 mL of 0.9% isotonic saline) or corticosteroid and local anesthetic medication (10 mg/mL of triamcinolone acetonide in a 1 mL injection plus 1 mL of 1% lidocaine). The injection was applied to the site of greatest palpable tenderness at the common extensor origin.

The physiotherapy groups had eight 30-minute sessions in 8 weeks with the first session scheduled prior to the injection. (For the inquiring reader, the specific elbow manipulation techniques are described by Vicenzino1). In addition, there was twice-daily sensorimotor retraining at home. The outcome measures at 4, 8, 12, 26, and 52 weeks were global ratings using a 6-point Likert scale, ranging from “complete recovery” to “much worse.” The primary outcomes were 1-year global scores of complete recovery/much improvement and 1-year recurrence (defined as global rating scores of complete recovery/much improvement at 4 or 8 weeks, but worse after that).

All patients received standardized advice to avoid activities that caused or provoked pain and to refrain from performing strenuous activity for 2 weeks after injection. Following this 2-week rest period, they were encouraged to return to normal activities. Use of analgesics, anti-inflammatories, heat, cold pack, or braces was allowed but not encouraged.

The authors recruited 165 patients with unilateral lateral epicondylalgia over about a 2-year period. Only two patients were lost to follow-up, but four patients missed injections and several missed physiotherapy sessions.

With regard to primary outcomes at 1 year, corticosteroid injection demonstrated lower complete recovery/much improvement (83% vs 96%, P = 0.01) and greater recurrence (54% vs 12%, P < 0.001) than placebo injection. Patient-rated worst pain remained significantly higher for the corticosteroid injection compared with the placebo injection at 1 year. There were no differences between physiotherapy and no physiotherapy at 1 year for complete recovery/much improvement or recurrence. Use of an analgesic or anti-inflammatory medication did not differ between injection of corticosteroid or placebo (31% vs 28%) but was less frequent in patients allocated to physiotherapy compared with those not allocated to physiotherapy (20% vs 39%).

The short-term (secondary) outcomes were strikingly different from the primary outomes. At the 1-month follow-up, in the absence of physiotherapy, complete recovery/much improvement was greater following corticosteroid injection compared with the placebo injection. But when physiotherapy was present, there were no differences between the corticosteroid injection and placebo injection groups for the outcomes of complete recovery/much improvement at 4 weeks (although there was a medium-sized benefit for pain and disability when physiotherapy was combined with corticosteroid injection). Physiotherapy plus corticosteroid (vs corticosteroid alone) had no effect on the outcomes of complete recovery/much improvement at 4 weeks. Patients who received the placebo injection plus physiotherapy had greater complete recovery/much improvement compared with the no physiotherapy group in the short run.

By the 26th week, the corticosteroid injection groups demonstrated lower complete recovery/much improvement compared with the placebo injection. Physiotherapy compared with no physiotherapy demonstrated no effects on the outcomes of complete recovery or much improvement.

Adverse events overall were minor, transient, and not significantly different between injection or physiotherapy factors. Skin depigmentation (5%) and subcutaneous atrophy (4%) occurred exclusively in patients receiving corticosteroid injection, but resolved by 26 weeks.

Commentary

Tennis elbow is common, affecting as many as 3% of the general population, with a peak prevalence between ages 30 and 50 years. Most people with this condition do not play tennis, but do engage in repetitive movements of the forearm in activities like throwing, cutting meat, swimming, gardening, typing, and brick laying.

The finding that corticosteroid injections for tennis elbow are ineffective is not new. A randomized controlled trial previously demonstrated that recurrence occurs within a year in 72% of patients receiving corticosteroid injection compared with 8% after physiotherapy,2 and other reports have failed to find efficacy for steroid injections.3,4 What is new about this study are the findings that steroid injection is actually associated with worse long-term outcomes. The short-term effects of steroid injections are impressive in this study and in clinical experience, but these long-term data are compelling. As the authors put it, “This evidence does not support the clinical practice of using corticosteroid injection to facilitate active rehabilitation.” Why might steroid injections actually make things worse? They could damage the tendon by impairing fibroblasts, which are important for collagen and extracellular matrix protein production.5 Or, because they do provide short-term, immediate pain relief, they could enable excessive or inappropriate early activity.6

The authors set out to determine if physiotherapy combined with steroid injection could enhance the effects of the injections. Disappointingly, they found that physiotherapy (with injection or alone) provided no beneficial long-term effect on complete recovery/much improvement, recurrence, pain, disability, or quality of life. However, in the absence of steroid injection, physiotherapy resulted in short-term benefit across all outcomes and lowest recurrence rates (4.9%) and 100% complete recovery/much improvement at 1 year. In fact, most patients (about 90%) in this study got better by the end of the year. I think the take-home message is that physiotherapy results in reduced pain, is associated with reduced intake of analgesics in the long run, and doesn’t appear to make things worse (which is more than you can say for steroid injections).

References

1. Vicenzino B. Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Man Ther 2003;8:66-79.

2. Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomised trial. BMJ 2006;333:939.

3. Coombes BK, et al. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet 2010;376:1751-1767.

4. Smidt N, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359:657-662.

5. Paavola M, et al. Treatment of tendon disorders: Is there a role for corticosteroid injection? Foot Ankle Clin 2002;7:501-513.

6. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 2008;18:3-15.