High recurrence rates of steroid injection for tennis elbow not relieved by physiotherapy

The addition of physiotherapy to corticosteroid treatment for chronic unilateral lateral epicondylalgia does not significantly improve patient outcome, according to a study published in JAMA.

“Prior to our current study we knew from other clinical trials, case series and expert opinion that corticosteroid injections for tennis elbow produce a characteristic effect: high success rates early within 6 weeks to 8 weeks but with high recurrence rates and protracted recovery there afterwards,” Bill Vicenzino, PhD, Chair in Sports Physiotherapy at The University of Queensland in St. Lucia, Australia, told Orthopedics Today. “One of the often-recommended solutions to the problem of high recurrence rates and protracted recovery is to add physiotherapy to the injection.”

Bill Vicenzino

Vicenzino and colleagues evaluated 165 patients between July 2008 and May 2010. The patients were randomly placed into groups where they received corticosteroid treatment alone, placebo, corticosteroid therapy with physiotherapy or placebo with physiotherapy.

Physiotherapy in each group consisted of weekly 30-minute sessions during an 8 week period, with the first session occurring prior to injection. Patient elbow therapy included mobilization with movement in combination with gripping techniques.

“In our study, we evaluated the effect of combining injection and physiotherapy, as well as including a placebo injection comparison and found that adding physiotherapy to corticosteroid injection does not solve the problem,” Vicenzino told Orthopedics Today.

At 1 year, patients who received corticosteroid injections showed 83% recovery compared to 96% recovery in patients who received placebo. Additionally, there was no significant difference among recurrence, complete recovery or partial recovery between the patients who received physiotherapy and the patients who did not. There were similar associations between the groups at 26 weeks and at 4 weeks.

“The corticosteroid medication appears to be responsible for the recurrence and delayed recovery (as it was much less in the placebo injection),” Vicenzino said. “The effect of physiotherapy is compromised when combined with steroid injection, and those undertaking physiotherapy take significantly less analgesic or anti-inflammatory medication (half as much).”

The authors cautioned that, while the study shows physiotherapy showed no benefit in a combined approach, it was effective in reducing recurrence rates and showed significantly improved outcomes without corticosteroid injections at 1 year.

Reference:

Coombes BK. JAMA. 2013;doi:10.1001/jama.2013.129.

Disclosure: One or more of the authors received grants from the Australian National Health and Medical Research Council to conduct this study.