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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 the study.

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 therapy.

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.






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