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Treatment of acute lateral epicondylitis in general practice (completed)

Lateral epicondylitis or tennis elbow is a painful condition responsible for loss of function and sick leave for long periods of time. In many countries, the treatment guidelines recommend a wait-and-see policy, reflecting that no conclusions on the best treatment can be drawn from available research.

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Objectives

The objective of our study was to compare the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute lateral epicondylitis in a primary care setting. Also, to find the short and long term effect of physiotherapy and to ascertain whether this outcome is influenced by corticosteroid injection.

We have also done a systematic review on the efficacy of treatment with non-electrotherapeutic physiotherapy and corticosteroid injections has been done. This provided us with the most current scientific evidence on the use of these treatments.

Results

A systematic review with meta-analysis on the efficacy of non-electrotherapeutic physiotherapy and corticosteroid injections was published in BMJ Open i october 2013. The review finds supports for the use of manipulation and exercise and eccentric exercise with stretching for tennis elbow when patients want treatment. Corticosteroid injections should be used with caution because of the risk of relapse and uncertainty of the long-term effect.

The results of the treatment study was published in May 2015 in BMC Musculoskeletal Disorders. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks compared to control. At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower compared to control, showing a large negative effect. At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success. We conclude that acute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend.

Background

Our main project is a randomised double blind controlled clinical trial conducted in a primary care setting in Sarpsborg, Norway. While earlier trials have either compared corticosteroid injections to physical therapy or to naproxen orally, we compared the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute tennis elbow.

Patients seeing their general practitioner with lateral elbow pain of recent onset was randomised to one of three interventions:

  1. physiotherapy, corticosteroid injection and naproxen or
  2. physiotherapy, placebo injection and naproxen or
  3. wait and see treatment with naproxen alone.

The physiotherapy treatment consists of deep transverse friction massage, Mill’s manipulation and eccentric exercise.

The primary outcome measure was the patient's evaluation of improvement after 6, 12, 26 and 52 weeks. Secondary outcome measures was pain, function and severity of main complaint, pain-free grip strength, maximal grip strength, pressure-pain threshold, the patient's satisfaction with the treatment and duration of sick leave. We included 177 patients, and 157 of them completed the trial.

Financing

General Practice Research Foundation

Cooperation

We cooperate with physiotherapists Jørn Ove Jansen and Tommy Aasli, Sarpsborg, Norway, and patients are referred from general practitioners in the city of Sarpsborg, Norway.

Start - Finish

The first patient was included in April 2009, and the treatment study was completed in june 2013. The results were published in may 2015

Publications

Olaussen, Morten; Holmedal, Øystein; Mdala, Ibrahimu; Brage, Søren Karl & Lindbæk, Morten (2015). Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.  BMC Musculoskeletal Disorders.  ISSN 1471-2474.  16 . doi: 10.1186/s12891-015-0582-6

Olaussen, Morten; Holmedal, Øystein; Lindbæk, Morten; Brage, Søren Karl & Solvang, Hiroko Kato (2013). Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open.  ISSN 2044-6055.  3 . doi: 10.1136/bmjopen-2013-003564

Olaussen M, Holmedal Ø, Lindbæk M, Brage S. Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: A protocol for a randomised, placebo-controlled study. BMC Musculoskeletal Disorders.2009; 10.

Published June 7, 2011 10:38 AM - Last modified Feb. 17, 2020 8:55 AM

Contact

Morten Olaussen