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DOCTORS should forget about using a corticosteroid injection for the treatment of tennis elbow in all but the most painful cases, according to a physiotherapy and pain management expert.
Professor Darren Rivett, of the School of Health Sciences at the University of Newcastle, NSW, said a new study published in the JAMA reported that even placebo injections showed lower recurrence rates for lateral epicondylalgia after a year than corticosteroids. (1)
The randomised, placebo-controlled trial involved 165 Brisbane adults with unilateral lateral epicondylalgia of longer than 6 weeks’ duration, split between four groups — corticosteroid injection with and without physiotherapy, or placebo injection with and without physiotherapy.
Patients estimated their global rating of change at 4, 8, 12, 26 and 52 weeks, using a 6-point Likert scale, ranging from “complete recovery” to “much worse”.
At 1-year follow-up, corticosteroid injection resulted in lower rates of complete recovery or much improvement compared with placebo injection (83% v 96% respectively) and greater recurrence rates (54% v 12%). The physiotherapy and no-physiotherapy groups did not differ after 1 year, with ratings of complete recovery or much improvement of 91% and 88% respectively, or recurrence, at 29% and 38% respectively.
However, Professor Rivett did not believe the news was not all bad for physiotherapy.
“Results showed that the recurrence rate 1 year after corticosteroid injection with no physiotherapy was 55%, while the addition of a course of physiotherapy interventions made almost no difference, at 54%”, Professor Rivett said.
“But physio with the placebo injection had a recurrence rate of just 5% after 52 weeks. That suggests that the physiotherapy intervention is compromised by the corticosteroid”, he said
The researchers said the high recurrence rate with injection may occur because “corticosteroids do not address key features of tendinopathy”, or that they may be deleterious to the tendon “through an effect on fibroblasts’ role in collagen and extracellular matrix protein production”.
“Physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates and 100% complete recovery or much improvement at 1 year”, the researchers wrote.
Professor Rivett said the results showed that “physiotherapy following a placebo injection was the most successful strategy, with a recurrence rate of just 5% after a year”.
“Placebo injection alone had a recurrence rate of 20% after the same period”, he said.
There was additional benefit to physiotherapy intervention because of a lesser need for analgesic treatments in the long-term.
“Those who had the placebo injection and physiotherapy needed analgesics in 17% of cases”, Professor Rivett said. “Those who did not have the physiotherapy used analgesics in 39% of cases.
“My take-home message from this study is that unless there is severe pain or dysfunction that would benefit from the short-term effect, there is no great benefit in a corticosteroid injection”, he said.
– Cate Swannell
Posted 11 February 2013
The studies showing positive response to topical nitric oxide indicate that the main issue is stimulating local blood flow. This can best be done by frequent but gentle wrist extensor muscle strengthening exercises, together with avoidance of provocative activities at work and in sport. Good compliance with this regimen over a few months almost always gives excellent results.
We need to analyse the paper in more details. We need to look at the protocol of physiotherapy treatment. I read the abstract of the article which involved recruitment from 16 primary care centres so if physiotherapy treatment was not standardised then the study is invalid. More importantly working on the elbow alone is insufficient and an assessment of the upper limb biomechanics should be part of the physiotherapy treatment.
When I treat a patient for tennis elbow, I am less guided by whether it will return twelve months hence or not. Nor is this particularly uppermost in my patient’s mind. He presents for more immediate relief of a condition that has become increasingly troublesome to him. And direct experience has shown me that intra-lesional Depo-Medrol plus local anaesthetic has generally yielded the quick and usually very effective and lasting relief that he seeks. True, on some occasions, albeit very few, a second injection may be required a week or two later; Physiotherapy, which the patient has already had before he has presented, is too slow. I have never resorted to placebo injections and have only used steroid/anaesthetic when the patient’s pain and tenderness have been sufficiently severe to warrant intervention at all.
Say what these latest pundits will, the end-point of the presenting consultation is relief in the quickest way possible. If the tennis elbow recurs, my patient and I will deal with it then. Meanwhile, overall, the outcomes have been gratifying, recurrences relatively few, not one patient has yet come to any harm from ths approach, and I have been given any adequate, clear or persuasive reason to cease the practice that has served the bulk of my patients (and my own singular episode and other localised pains of a similar kind so well).
There have been a couple of RCTs that have utilised an ‘adopt a wait and see policy’ arm, which might relate to the post on no active treatment and physiotherapy only arms. [e.g., Bisett et al BMJ 10.1136/bmj.38961.584653.AE; and Smidt et al Lancet 10.1016/S0140-6736(02)07811-X].
This study fails as many do in the treatment of tennis elbow as there is no standardisation of the appropriate dose of corticosteroid to inject. The appropriate dose is 2 ampoules of Celestone Chronodose together with 3mls of 1-2% Lignocaine injected into the periosteal/bone interface. This large volume tracks along the periosteum &settles the inflammatory process. Neither Rheumatology trainees nor Radiologigts are aware of how to administer appropriately. Ignore the study.
This interesting and illuminating study would have been even more interesting if it had included a ‘no active treatment at all’ arm and a ‘physiotherapy only’ arm. In the future, studies of treatments should inlcude a ‘no active treatment at all’ or ‘usual care’ arm, because even the taking or administering of a placebo medicine probably alters outcomes, whether by direct physical or biochemical means or through psychological or emotional means.