Treatment Strategy by Anne D. Walling - American Family Physician
American Family Physician
May 1, 2002
Author/s: Anne D. Walling
Up to 3 percent of adults have tennis elbow (lateral epicondylitis),
an overload injury of the extensor muscles of the lateral elbow. Most
patients eventually recover spontaneously, but symptoms can persist
for six to 24 months. The leading treatment strategies are physical
therapy, corticosteroid injection, and use of nonsteroidal anti-inflammatory
drugs (NSAIDs). Choosing among these treatments is difficult because
studies are generally of poor quality and give conflicting results.
Smidt and colleagues studied patients presenting to Dutch general practitioners
to compare treatment options for tennis elbow.
The authors studied patients 18 to 70 years of age who presented to
one of 85 participating family physicians with classic symptoms of tennis
elbow. Patients were examined for confirming signs and to exclude alternative
causes of symptoms. All patients were assessed at baseline by a research
physical therapist. Patients with no exclusionary factors were randomly
assigned to receive corticosteroid injection, physical therapy, or no
intervention. Patients in the last group could take acetaminophen or
NSAIDs for pain if necessary. Patients assigned to injection received
1 mL (10 mg per mL) of triamcinolone acetonide plus 1 mL of lidocaine
(2 percent) into each tender area until resisted dorsiflexion produced
no pain. The physical therapy program consisted of pulsed ultrasonography,
deep friction massage, and an exercise program.
All patients were treated for six weeks and assessed at six, 12, 26,
and 52 weeks. Assessment included recovery as assessed by the patients
on a six-point Likert scale, questionnaires on pain and functional abilities,
and standardized assessments by the research physical therapist. Use
of analgesics and consultations with physicians were also recorded during
At six weeks, success was reported in 57 (92 percent) of the patients
in the injection group, 30 (47 percent) of the patients in the physical
therapy group, and 19 (32 percent) of the patients in the nonintervention
group. At 26 weeks, the significant advantage of injections was no longer
apparent, and the best results were associated with physical therapy.
By 52 weeks, success rates were 69 percent for injection, 91 percent
for physical therapy, and 83 percent for no intervention. Only 24 percent
of the nonintervention group received additional treatment for tennis
elbow during the one-year follow-up period, compared with 63 percent
of those receiving injections and 81 percent of those receiving physical
The authors conclude that each of the treatment strategies offers advantages
and disadvantages. Corticosteroid injection provides the greatest short-term
relief but is associated with high rates of recurrence in the long term.
This may be attributable to damage to the tendon or overuse as soon
as symptoms subsided. The high success rates of physical therapy in
the longer term were offset by the need for intercurrent treatment in
large numbers of patients. The authors recommend that treatment be individualized,
depending on each patient's symptoms, needs, and preferences. In many
patients, the optimal choice may be no intervention, provided that this
includes adequate explanation, advice, and use of analgesics when appropriate.
ANNE D. WALLING, M.D.
Smidt N, et al. Corticosteroid injections, physiotherapy,
or a wait-and-see policy for lateral epicondylitis: a
randomised controlled trial. Lancet February 23, 2002; 359:657-62.