Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial

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 randomised 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.

Fig 1

Flow of participants through each stage

Fig 2

Primary outcome measures: mean assessor's rating of severity (visual analogue scale), mean pain-free grip (PFG—affected/unaffected, expressed as a percentage), and percentage success. Significant differences between study arms at six and 12 weeks: †corticosteroid injection v wait and see; ‡physiotherapy v wait and see; §corticosteroid injection v physiotherapy. ¶Significant difference between corticosteroid and wait and see on per protocol analysis. Bar graphs represent mean (99% confidence interval) area under curve (trapezium method24) analysis of assessor severity, PFG, and global improvement. ^*Significant differences between groups (P<0.01)