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Evidence summaries

Corticosteroid Injections for Lateral Epicondylitis

A corticosteroid injection is an effective treatment for lateral epicondylitis in the short-term pain relief, but the results are paradoxically reversed after six weeks, with high recurrence rates of epicondylitis with corticosteroid injections. Level of evidence: "A"

A topic in Clinical Evidence 2 summarizes the results of one systematic review (search date 1999) and two subsequent RCTs. One RCT in the systematic review found evidence of benefit in the short term, another RCT did not. The first subsequent RCT (n=39) found that a corticosteroid injection improved pain compared with control (saline) injection from 8 weeks to 6 months (improvement on VAS scale 24.3 vs 8.9, p=0.04). The second subsequent RCT (n=59) found that a corticosteroid injection improved mean "main complaint" and functional disability at 3 weeks and 6 weeks compared to no treatment (6 weeks, mean difference in "main complaint" 24%, 95% CI 14% to 35%). It found no significant difference at 12, 26 and 52 weeks. 2 out of 3 small RCTs comparing corticosteroid injections to local anaesthetica alone found greater global improvement with corticosteroid in the short term. Two RCTs compared corticosteroid injection with physiotherapy. One RCT found that friction massage and a manipulation technique reducend the chance of overall improvement compared with steroid injection (Rr 0.45, 95% CI 0.29 to 0.69). The second RCT found that physiotherapy consisting of nine sessions of ultrasound, deep friction massage and an exercise programme was inferior to corticosteroid injection at 3 and 6 weeks, but superior to conrticosteroid injection at 26 and 52 weeks (mean difference in "main complaint" 15%, 95% CI 5% to 25%). Two RCTs comparing corticosteroid injection with NSAIDs found greater benefit of a corticosteroid injection in the short term, but greater benefit for the NSAID in the long-term. Clinical Evidence category: Trade-off between benefits and harms.

In addition, there is evidence from two other RCTs. The first one (n=185) allocated eligible patients to 6 weeks of treatment with corticosteroid injections, physiotherapy, or a wait-and-see policy 3. At 6 weeks, corticosteroid injections were significantly better than all other therapy options for all outcome measures. Success rates were 92% (57) compared with 47% (30) for physiotherapy and 32% (19) for wait-and-see policy. However, recurrence rate in the injection group was high. Long-term differences between injections and physiotherapy were significantly in favour of physiotherapy. Success rates at 52 weeks were 69% (43) for injections, 91% (58) for physiotherapy, and 83% (49) for a wait-and-see policy. Physiotherapy had better results than a wait-and-see policy, but differences were not significant.

The second RCT (n=198) allocated patients with epicondylitis of at least six weeks furation to eight sessions of physiotherapy; corticosteroid injections; or wait and see 4. Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections.

    References

    • Assendelft W, Green S, Buchbinder R, Struijs P, Smidt N. What are the effects of treatments? Tennis elbow. Clinical Evidence 2005;13:1573-1581.
    • Smidt N, Assendelft WJ, van der Windt DA, Hay EM, Buchbinder R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002 Mar;96(1-2):23-40. [PubMed]
    • Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002 Feb 23;359(9307):657-62. [PubMed]
    • 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 Nov 4;333(7575):939. [PubMed]

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