Motivation: Summer is the time for tennis and tennis elbow. Anyone who has suffered a tennis elbow - known in medial lingo as lateral epicondylalgia - can attest to the frustration and pain that keeps people away from the beautiful sport after waiting all winter. I have often wondered what works. Using an injured elbow hardly seems wise but then again, exercise sounds like a good idea. If all else fails, do steroid injections work? Recently, this idea was tested in a randomized way.
Paper: Coombes, B.K., Bisset, L., Brooks, P. et. al. "Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia." JAMA (2013); 309(5): 461-469.
Methods: 2x2 factorial multi-center randomized blinded placebo controlled trial. Inclusion critera were essentially untreated unilateral lateral elbow pain of greater than six weeks duration provoked by palpation or stretching the region. The two intervention arms were a single corticosteroid (triamcinolone) vs. placebo injection and physiotherapy for eight weeks vs. no physiotherapy. The primary outcomes were one year rating of change score (using Likert scale from "complete recovery" to "much worse") and one year recurrence. Secondary outcomes were rate of complete recovery to much improvement at four and 26 weeks.
Results:
Cohort: A total of 165 patients were randomized with mean age of 49 years and male predominance of 62%. Average duration of symptoms was 16 weeks. On visual analog scale (VAS), resting median pain level was 7.5 out of 100 with worst pain of 61.7 out of 100. In total , 41 patients only got placebo, 41 got placebo plus physiotherapy, 43 got corticosteroids, and 40 got corticosteroids plus physiotherapy.
Primary Outcome (one year): Corticosteroids resulted in lower recovery or improvement at one year compared to placebo (83% with steroids vs. 96% without, p = 0.01). There was increased recurrence of elbow pain at one year with corticosteroids (54% with steroids vs. 12%, p < 0.001). There was no difference between physiotherapy or no physiotherapy in terms of recovery or rate of recurrence. There was no interaction between corticosteroids and physiotherapy.
Four week Outcome: In absence of physiotherapy, complete recovery or much improvement was greater following steroid injection than placebo (RR: 7.32, NNT 1.6, p < 0.001). With physiotherapy, steroids did not significantly improve recovery compared to placebo (RR: 1.73 (95% CI, 0.97 to 3.08)) though combination had some additional benefit on pain scores. Physiotherapy alone in absence of steroids also significantly improved recovery (RR: 4,.0, NNT: 3.4, p = 0.004). There was no major difference between steroids plus physiotherapy versus steroids alone.
Discussion: This paper points out an instance where trials with short term follow-up miss deleterious effects in the long term. Steroids are quite efficacious in four weeks but result in greater recurrence of pain and with lower recovery in one year. In comparison, while physiotherapy does not make a difference in the long term, it is comparable to steroids for recovery at four weeks. Consequently, for someone with a tennis elbow, a reasonable strategy would be to use physiotherapy in the short term and expect spontaneous recovery in the long term (96% recovery naturally) - avoid the steroids.
Paper: Coombes, B.K., Bisset, L., Brooks, P. et. al. "Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia." JAMA (2013); 309(5): 461-469.
Methods: 2x2 factorial multi-center randomized blinded placebo controlled trial. Inclusion critera were essentially untreated unilateral lateral elbow pain of greater than six weeks duration provoked by palpation or stretching the region. The two intervention arms were a single corticosteroid (triamcinolone) vs. placebo injection and physiotherapy for eight weeks vs. no physiotherapy. The primary outcomes were one year rating of change score (using Likert scale from "complete recovery" to "much worse") and one year recurrence. Secondary outcomes were rate of complete recovery to much improvement at four and 26 weeks.
Results:
Cohort: A total of 165 patients were randomized with mean age of 49 years and male predominance of 62%. Average duration of symptoms was 16 weeks. On visual analog scale (VAS), resting median pain level was 7.5 out of 100 with worst pain of 61.7 out of 100. In total , 41 patients only got placebo, 41 got placebo plus physiotherapy, 43 got corticosteroids, and 40 got corticosteroids plus physiotherapy.
Primary Outcome (one year): Corticosteroids resulted in lower recovery or improvement at one year compared to placebo (83% with steroids vs. 96% without, p = 0.01). There was increased recurrence of elbow pain at one year with corticosteroids (54% with steroids vs. 12%, p < 0.001). There was no difference between physiotherapy or no physiotherapy in terms of recovery or rate of recurrence. There was no interaction between corticosteroids and physiotherapy.
Four week Outcome: In absence of physiotherapy, complete recovery or much improvement was greater following steroid injection than placebo (RR: 7.32, NNT 1.6, p < 0.001). With physiotherapy, steroids did not significantly improve recovery compared to placebo (RR: 1.73 (95% CI, 0.97 to 3.08)) though combination had some additional benefit on pain scores. Physiotherapy alone in absence of steroids also significantly improved recovery (RR: 4,.0, NNT: 3.4, p = 0.004). There was no major difference between steroids plus physiotherapy versus steroids alone.
Discussion: This paper points out an instance where trials with short term follow-up miss deleterious effects in the long term. Steroids are quite efficacious in four weeks but result in greater recurrence of pain and with lower recovery in one year. In comparison, while physiotherapy does not make a difference in the long term, it is comparable to steroids for recovery at four weeks. Consequently, for someone with a tennis elbow, a reasonable strategy would be to use physiotherapy in the short term and expect spontaneous recovery in the long term (96% recovery naturally) - avoid the steroids.
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