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What Is the Optimal Treatment
for Tennis Elbow?
American Family Physician
March 15, 2000
Author/s: Anne D. Walling
Every year approximately four of every 1,000 adults has a problem with
tennis elbow, or painful lateral epicondylitis. While more than 40 treatments
for tennis elbow have been proposed, the two leading strategies are
local injections of corticosteroids and courses of oral nonsteroidal
anti-inflammatory drugs (NSAIDs). Because previous clinical studies
were complicated by methodologic problems, Hay and colleagues conducted
a randomized controlled trial in 23 general practices to compare treatment
with local corticosteroid injections and NSAIDs for tennis elbow.
All patients 18 to 70 years of age who consulted their general practitioner
because of symptoms consistent with tennis elbow were considered for
the study. Exclusion criteria included structural abnormalities of the
elbow and contraindications to either of the study treatments. After
baseline assessment by research nurses, patients were randomly assigned
to one of three treatment groups. Local injection of 20 mg of methylprednisolone
plus 0.5 mL of 1 percent lidocaine was given to 51 patients. Enteric-coated
naproxen in a dosage of 500 mg twice daily for two weeks was prescribed
for 49 patients. The remaining 56 patients were given placebo (unmarked
vitamin C tablets) and the same advice and instructions as the patients
who received naproxen. All patients were given an information leaflet
and provided with analgesia. Patients were reassessed four weeks, six
months and one year after treatment. All of the assessments were conducted
by a research nurse who was not aware of the treatment used. Patient
assessment of symptoms, functional impairment and change of symptoms
over time were included in the reassessments. Grip strength and physical
examination findings were also documented.
Although the groups were comparable at randomization, by four weeks
after treatment 92 percent of patients who received injections reported
improvement or recovery compared with 57 percent of those who were treated
with naproxen and 50 percent of patients who received placebo. Five
patients discontinued use of naproxen because of side effects. Most
injected patients reported a minor increase in pain following treatment,
but no serious side effects of treatment were noted. Local skin atrophy
occurred in three patients in the naproxen and placebo groups. At one
year, 84 percent of injected patients, 85 percent of naproxen-treated
patients and 82 percent of placebo-treated patients recorded no or low
The authors conclude that early local injection of a corticosteroid
is an effective, safe treatment for lateral epicondylitis. A two-week
course of NSAIDs was found to be no more effective than placebo in this
study, and the long-term outcome was good regardless of initial treatment.
Anne D. Walling, M.D.
Hay EM, et al. Pragmatic randomised controlled trial of local corticosteroid
injection and naproxen for treatment of lateral epicondylitis of elbow
in primary care. BMJ October 9, 1999;319:964-8.
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