Author Names: Bisset L., Beller E., Jull G., Brooks P., Darnell R., Vicenzino B.
Reviewer Name: Kendall Bietsch, SPT
Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract: Objective: To investigate the efficacy of physiotherapy compared with a wait and see approach or corticosteroid injections over 52 weeks in tennis elbow. Design: Single blind randomized controlled trial. Setting: Community setting, Brisbane, Australia. Participants: 198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks’ duration, who had not received any other active treatment by a health practitioner in the previous six months. Interventions: Eight sessions of physiotherapy; corticosteroid injections; or wait and see. Main outcome measures: Global improvement, grip force, and assessor’s rating of severity measured at baseline, six weeks, and 52 weeks. Results: Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections. Conclusion: Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.
NIH Risk of Bias Tool: Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT: Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?: Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?: No
- Were study participants and providers blinded to treatment group assignment?: No
- Were the people assessing the outcomes blinded to the participants’ group assignments?: Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?: Cannot Determine, Not Reported, or Not Applicable
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?: Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?: Yes
- Was there high adherence to the intervention protocols for each treatment group?: Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?: Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?: Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?: No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?: Cannot Determine, Not Reported, or Not Applicable
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?: Yes
Key Finding #1: When comparing 3 different types of management of lateral elbow pain, corticosteroid injection was the most effective intervention within the first 6 weeks of treatment, over the physiotherapy (joint mobilization with movement and exercise) and the control (“wait and see”) groups. However, in the mid- to long-term stages of treatment (i.e.: 6-52 weeks), the corticosteroid group had higher lateral elbow pain recurrence rates and experienced delayed recovery compared to the other groups.
Key Finding #2: After the first 6 weeks of treatment, the effects of physiotherapy (mobilization and exercise) were superior to both the corticosteroid injection and the “wait and see” groups. However, at 52 weeks, there was no significant difference between the physiotherapy and “wait and see” groups.
Key Finding #3: In most cases, lateral elbow pain (i.e.: tennis elbow) is a self-limiting condition at 52-weeks post-onset.
Key Finding #4: The physiotherapy group had significantly less use of analgesics or non-steroidal anti-inflammatory drugs compared to the corticosteroid and “wait and see” groups.
Reviewer Paper Summary: This randomized controlled trial compared the effectiveness between corticosteroid injection, physiotherapy (joint mobilizations with movement + exercise), and the “wait and see” approach to treating lateral elbow pain (i.e.: tennis elbow). Effectiveness was measured by analyzing each participant’s severity rating, pain-free grip ratio (comparing involved versus non-involved sides), and global improvement on a 6-point Likert scale, ranging from “completely recovered” to “much worse.” The corticosteroid injections consisted of a 1 mL local injection of 1% lidocaine and 10 mg of triamcinolone, administered at painful points in the elbow (maximum number of injections: 2). The physiotherapy group consisted of elbow manipulation and therapeutic exercise in 8, 30-minute sessions throughout the course of 6 weeks. The “wait and see” group was instructed not to seek additional treatment during the study. Results showed that short-term outcomes favored corticosteroid injection over physiotherapy or “wait and see” interventions for improving tennis elbow symptoms. However, after the initial 6 weeks of treatment, physiotherapy outcomes showed significant improvements compared to the other management approaches. By 52 weeks, there were no differences in outcomes between the physiotherapy or “wait and see” groups. The authors therefore suggested that combining elbow manipulation and exercise is the most effective form of treatment in the first 6 weeks of lateral elbow pain onset, but that most cases will be self-limiting (i.e.: not require intervention) in the long-term (i.e.: 52 weeks). Of note, the physiotherapy group had significantly less use of analgesics or non-steroidal anti-inflammatory drugs compared to the corticosteroid and “wait and see” groups, and this should be considered when managing patients with lateral elbow pain with regard to adverse side-effects.
Reviewer Clinical Interpretation of this paper: This study highlights the timeline of effectiveness in the following approaches for treating lateral elbow pain (tennis elbow): corticosteroid injections, physiotherapy (joint manipulation + therapeutic exercise), and “wait and see.” Because corticosteroid injections produce the quickest symptom relief (i.e.: within the first 6 weeks), they may be more heavily considered in patients whose contextual situation requires a prompt recovery. For example, corticosteroid injections may be more ideal treatment options in athletes who are competing in his/her final season of sport and require a quick recovery to complete the season. However, if the patient’s contextual situation allows for a more gradual progression of recovery (>6 weeks), it may be more optimal to utilize the physiotherapy approach (with joint manipulation + therapeutic exercise) in order to achieve better long-term outcomes (e.g.: decreased likelihood of recurrence/overall improved recovery). Using this physiotherapy approach could decrease the risk for adverse side-effects of corticosteroid injections and/or other drugs such as analgesics or non-steroidal anti-inflammatory drugs that were more prevalent in the “wait and see” group. Regardless of the treatment approach, providers should educate patients about the natural progression of tennis elbow by highlighting the fact that it is typically a self-limiting condition within one year. Sharing this information could assist in facilitating shared decision making between the patient and provider to utilize a treatment approach that is most optimal for the patient’s activities, participation, and overall contextual requirements.
