Many physicians are skep-tical about using corticosteroid injection to manage treatment for workers and other patients suffering from lateral epicondyle tendinopathy (tennis elbow). These doubts are well founded, based on com-pelling evidence regarding the long-term outcomes for tennis elbow sufferers who are being treated with corticoster-oids.
Manual therapy versus injections
In February 2013 the results of a clinical trial by Coombes and colleagues entitled, “Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial,” were published in the Journal of the American Medical Association.
In this trial, 43 patients with chronic tendinopathy randomly received corticosteroid injection, 41 received placebo injection, 40 received corticosteroid injection plus physiotherapy, and 41 received placebo injection plus physiothera-py. Patients receiving corticosteroid injection—with or without physiotherapy treatment—were found to have a greater rate of recurrence of their condition at 1 year (54% versus 12% in the placebo injection group).
The key finding of the study was that although corticosteroids reduced pain for these patients as early as 4 weeks, they were 4 to 5 times more likely to be worse off in the long run. By contrast, the group that received placebo injec-tions combined with physiotherapy experienced a substantial improvement in pain after 4 weeks, with no worsening in the rate of recurrence, compared with those receiving the placebo injection alone. In this clinical trial, physiotherapy treatment consisted of a previously described combination of specific exercises and manual therapy.
The dramatic results of this study are not unique. They are, in fact, consistent with a substantial body of evidence summarized in a 2010 Lancet meta-analysis, which highlighted the worst long-term outcomes associated with cortico-steroids from a number of clinical trials.
A toolkit of treatment options
Despite the research findings, it may not be sufficient to reassure patients with lateral epicondyle tendinopathy that their condition is usually self-limiting within 8 to 12 months, and that ongoing symptoms do not necessarily signify ongoing tissue damage. Most patients would prefer to receive a list of treatment options that will hasten their recovery without increasing the risk of recurrence.
To learn more about treatment options for tennis elbow, physicians can access free online resources on the topic. A group of BC-based researchers and clinicians developed an online toolkit which can be found at http://physicaltherapy.med.ubc.ca/research/physical-therapy-knowledge-br.... The site was designed by physiotherapists primarily for the use of the profession. However, general practitioners can also use the toolkit to guide their patients through a variety of treatment options.
The Lateral Epicondyle Tendin-opathy Toolkit includes the following components:
• A summary of evidence for physical therapy interventions that include phy-siotherapist-applied manual thera-py, exercise, orthotic devices, and taping.
• Details of individual articles summarizing published evidence for commonly used physiotherapy interventions, and emphasizing the findings of systematic review and randomized controlled trials where applicable.
• Treatment algorithms designed to manage patients’ and clinicians’ expectations about the time frame for recovery, and to determine the best forms of early intervention—namely active rehabilitation, with or without manual therapy.
The online toolkit also includes a series of appendices. Each of these provides detailed treatment information, such as the clinical evidence supporting each treatment, descriptions and images of recommended manual therapy techniques, specific exercises and types of braces, taping techniques, and an overview of common medical and surgical interventions. In particular, physicians may appreciate viewing Appendix C, which provides photos and descriptions of standardized exercise protocols deem-ed effective for treating tennis elbow. These can be downloaded and printed as patient handouts.
In short, physicians should feel justified in avoiding corticosteroid injections for the treatment of lateral epicondyle tendinopathy, and should alternatively consider a proven rehabilitation regime that incorporates specific exercises and manual therapy techniques.
—J. Robinson, MD
WorkSafeBC Medical Advisor
—A. Hoens, BScPT, MSc
Clinical Professor, Department of Physical Therapy, UBC Faculty of Medicine
—A. Scott, RPT, PhD
Assistant Professor, Department of Physical Therapy, UBC Faculty of Medicine
This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.
1. Coombes BK, Bisset L, Brooks P. 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.
2. Vicenzino B. Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Manual Therapy 2003;8:66-79.
3. Coombes BK, Bisset L, Brooks P. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomized controlled trials. Lancet 2010;376(9754):1751-1767.
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