Tennis elbow: injections, PT, or wait-and-see?

Journal of Family Practice, Feb, 2007

* Clinical question

Is steroid injection or physical therapy more effective than wait-and-see for patients with tennis elbow?

* Bottom line

At 6 weeks, steroid injection had better results than physical therapy or wait-and-see.

At 1 year, physical therapy resulted in better function and greater improvement than corticosteroid injection, primarily because of frequent recurrences after the injection. (LOE: 1b)

Study design Randomized controlled trial (single-blinded)

Funding Government

Allocation Concealed

Setting Outpatient (any)

* Synopsis

A total of 198 adults with tennis elbow symptoms were enrolled for an average of 22 weeks in this Australian study. Patients were, on average, in their mid-40s. About one third were women. Approximately 57% had symptoms due to unknown causes and not due to overuse or trauma. The average pain score was 57 out of a possible 100.

The treatment choices

The patients were randomly assigned, using concealed allocation, to 1 of 3 treatments:

* 10 mg triamcinolone (Aristocort) with 1% lidocaine injected to painful elbow points, repeated after 2 weeks as necessary.

* 8 physical therapy treatments of 30 minutes in duration, consisting of elbow manipulation and exercises done during the session and at home

* General nonspecific treatment (analgesics, heat, cold, braces), as desired.

3 outcomes were evaluated

Primary outcomes were evaluated, using an intention-to treat analysis, at 6 weeks and at 52 weeks:

* global improvement was measured on a 6-point Likert-type scale from "completely recovered" to "much worse"

* pain-free grip strength

* overall assessment of severity was measured by an assessor who was unaware of treatment.

Results at 6 weeks

Global improvement: 78% of patients receiving an injection were "much improved" or "completely recovered," as were 65% of those receiving physical therapy, and 27% of those receiving no specific treatment.

However, 72% of patients receiving injections reported recurrences. Pain-free grip strength was significantly better at this time in the injection group than in the other 2 groups.

Overall assessment was likewise significantly better at this time in the injection group than in the other 2 groups.

Results at 1 year

Patients receiving a steroid injection had significantly lower score s on all 3 outcomes than did those with either physical therapy or nonspecific treatment.

FAST TRACK

Injections had significantly lower outcome scores than PT or no specific treatment, after 1 year

Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333:939.