Cortiocosteroid injection may not help tennis elbow

A single corticosteroid injection to treat unilateral lateral epicondylalgia-tennis elbow-is linked to poorer outcomes after 1 year, according to a study published February 6 in JAMA.

Australian researchers conducted a 2 x 2 factorial, randomized, injection-blinded, placebo-controlled trial at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia lasting longer than 6 weeks’ duration were enrolled between July 2008 and May 2010. One-year follow-up was done in May 2011.

“Prior to our current study we knew that corticosteroid injections for tennis elbow produce a characteristic effect: high success rates early within 6 to 8 weeks but with high recurrence rates and protracted recovery thereafter. One of the often recommended solutions to the problem of high recurrence rates and protracted recovery is to add physiotherapy to the injection,” said corresponding author Bill Vicenzino, PhD, professor, and chair in sports physiotherapy and head of division of physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St. Lucia, Australia.

In the study, the researchers evaluated the effect of combining injection and physiotherapy and found that (1) adding physiotherapy to corticosteroid injection does not solve the problem; (2) the corticosteroid medication appears to be responsible for 50% recurrence and delayed recovery (as was much less in the placebo injection); (3) the effect of physiotherapy is compromised when combined with steroid injection; and (4) those undertaking physiotherapy take significantly less analgesic or anti-inflammatory medication (half as much).

“We know from a previous study that the physiotherapy we studied is superior in regard to recurrence rates and longer-term recovery than injection, and almost as successful in the short term,” Vicenzino said. “Physiotherapy was shown to double the rate of recovery compared to taking a wait and see approach in that previous study.”

According to Vicenzino, previous studies showed high recurrence rates with corticosteroid injection (and protracted/delayed recovery) compared to physiotherapy and adoption of a wait-and-see approach.

“Conventional advice is that if recurrence and delayed recovery is of concern, then physiotherapy following injection should overcome this,” he said. “Be informed, that corticosteroid injections are associated with a high recurrence rate-twice plus as likely to recur compared to doing nothing or having physiotherapy.”