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QUESTION: In patients with lateral epicondylitis, what is the effectiveness of a wait and see policy, physiotherapy, or corticosteroid injections?
Practices of 85 family doctors in the Netherlands.
185 patients who were 18 to 70 years of age (median age 47 y) with pain at the lateral side of the elbow that increased with pressure on the lateral epicondyle and with resisted dorsiflexion of the wrist. Exclusion criteria included physiotherapy or corticosteroid injections for elbow pain in the previous 6 months; bilateral elbow symptoms; duration of pain for <6 weeks; dislocation, tendon ruptures, or fractures near the elbow in the preceding year; and systemic musculoskeletal or neurological disorders. Follow up was 99%.
Patients were allocated to corticosteroid injections (up to 3 injections of 1 ml of triamcinoloneacetonide and 1 ml of lidocaine 2%) (n=62) by their family doctors, physiotherapy (9 treatments of pulsed ultrasonography, deep friction massage, and an exercise programme) (n=64), or a wait and see policy (patients visited their family doctors once during the 6 wk intervention period to discuss activities that provoked pain and to receive advice) (n=59).
Main outcome measures
Change from baseline in self reported success rates (6 point scale ranging from completely recovered to much worse; complete recovery and much improved were considered successes), severity of the main symptom, pain during the day, inconvenience, overall severity of elbow symptoms, pain-free grip strength, maximum grip strength, and elbow disability.
Analysis was by intention to treat. At 6 weeks, more patients in the injection group than in the physiotherapy and wait and see groups reported success (table). Other outcomes were also more improved in the injection group. However, at 1 year, more patients who received physiotherapy rather than corticosteroids reported success. The physiotherapy and wait and see groups did not differ (table).
In patients with lateral epicondylitis, physiotherapy or a wait and see policy were the best long term treatment options.
Lateral epicondylitis (tennis elbow) is commonly treated with activity modification, physiotherapy, non-steroidal anti-inflammatory drugs (NSAIDs), and steroid injections. Acupuncture, orthotic devices, and surgery have also been used, albeit without much evidence to support them. The benefit associated with steroid injection is only short term, and long term detrimental effects may exist.1
In this study by Smidt et al, more than 50% of patients treated with physiotherapy or injections reported such adverse effects as temporary increase in pain, pain radiating into the forearm, and swelling. Topical and oral NSAIDs have been shown to provide short term symptom relief for lateral epicondylitis.2 Several patients in the physiotherapy and the wait and see groups in the study by Smidt et al received NSAIDs, which may have influenced the results.
Activity modification to minimise repetitive stress is generally the first step in treating lateral epicondylitis. Better evidence is required before definitive statements can be made about additional treatment. However, a simple wait and see approach combined with NSAIDs as required is probably the most cost effective long term strategy with the fewest adverse effects, although physiotherapy may also be useful.
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