Tennis Elbow: No Long-Term Benefit From PT, Corticosteroids

Yael Waknine

February 06, 2013

A steroid injection and 2 months of physical therapy may not be the solution for lateral epicondylalgia, commonly known as tennis elbow, suggest research findings published in the February 5 issue of JAMA.

Brooke K. Coombes, PhD, from the University of Queensland, St. Lucia, Australia, and colleagues found that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for reinjury at 1 year relative to placebo.

Eight weeks of physical therapy appeared to have no long-term benefit with the exception of decreased analgesic use. However, the physical therapy did improve short-term pain and disability outcomes at 1 month, although those benefits were lost when steroid injection was added to the treatment.

"The results of this study make sense clinically, since lateral not an inflammatory condition in the truest sense of the word," Joel R. Cooper, DO, a family physician in Phoenix, Arizona, told Medscape Medical News in an interview. He noted that steroid shots work best when inflammation is the culprit, and even then usually provide only temporary relief at best.

"I would not be inclined to recommend a corticosteroid injection for this condition, since there is no available evidence that such a measure affects outcomes positively, long-term," added Dr. Cooper, who was not involved in the study.

Although use of steroid injections to treat tennis elbow has been increasingly discouraged because of lack of long-term efficacy data and high recurrence rates, the authors note that the long-term effects of physical therapy on these poor outcomes remains unclear.

To fill this knowledge gap, researchers randomly assigned 165 adults with unilateral lateral epicondylalgia of more than 6 weeks' duration to receive 1 of 4 treatments: a steroid injection, placebo injection, steroid injection + physical therapy, and placebo injection + physical therapy.

Physical therapy consisted of 8 half-hour sessions over the course of a 2-month period, during which a qualified trainer worked with the study participant according to a personalized per protocol regimen of elbow manipulation techniques, sensorimotor retraining of gripping, and concentric and eccentric exercise to progressively load the wrist extensors using restrictive latex bands.

Participant status was self-reported using the 6-point Likert scale to express being "completely recovered" to "much worse." The researchers considered ratings of complete recovery or much improvement as a positive outcome.

At 26 weeks steroid injections were linked to a lower likelihood of positive outcome relative to placebo (55% vs 85%; relative risk [RR], 0.79; 99% confidence interval [CI], 0.62 - 0.99; P < .001), with no differences observed between the physical therapy and no physical therapy groups (71% vs 69%; RR, 1.22; 99% CI, 0.97 - 1.53; P = .84).

One-year findings confirmed the pattern, as steroid injections were associated with significantly lower rates of positive outcome (83% vs 96%; relative risk [RR], 0.86; 99% confidence interval [CI], 0.75 - 0.99]; P = .01) and with significantly higher rates of recurrence after the 2-month mark vs placebo (54% vs 12%; RR, 0.23; 99% CI, 0.10 - 0.51; P < .001).

Likewise, physical therapy did not improve positive outcome rates at 1 year (91% vs 88% for no physical therapy; RR, 1.04; 99% CI, 0.90 - 1.19; P = .56), nor did it reduce recurrence after the 2-month mark (29% vs 38%; RR, 1.31; 99% CI, 0.73 - 2.35; P = .25).

Secondary measures revealed no benefits for the steroid injection or physical therapy in terms of resting pain, pain and disability (based on the validated Patient-Rated Tennis Elbow Evaluation), and quality of life (based on the EuroQol quality of life questionnaire).

Short-Term Benefits

Participants receiving placebo and physical therapy were more likely to report positive outcomes at the 1-month mark relative to placebo/no physical therapy (complete recovery/much improvement, 39% vs 10%; RR, 4.00; 99% CI, 1.07 - 15.00; P = .004). However, the benefit disappeared with the steroid injection (steroid injection plus physical therapy, 68% vs 71% for steroid alone; RR, 0.95; 99% CI, 0.65 -1.38; P = .57).

Physical therapy was also linked with medium-sized benefits in terms of worst pain (standardized mean difference [SMD], 0.88; 99% CI, 0.29 - 1.48; P < .001), resting pain (SMD, 0.60; 99% CI, 0.02 - 1.19; P = .01), and pain and disability (SMD, 0.77; 99% CI, 0.18 - 1.37; P = .001).

Moreover, participants enrolled in physical therapy were less likely to use analgesics or anti-inflammatory medications at 1 year (20% vs 39%; P = .008).

"I believe strongly in physical therapy for tennis elbow, both to help the patient through the acute phase of the injury and to provide the patient with exercises/knowledge to prevent reinjury down the line," Dr. Cooper told Medscape Medical News.

"In many cases, patients will benefit considerably just from knowledge gained in physical therapy. If they apply this knowledge consistently, they may achieve better long-term outcomes," Dr. Cooper added.

The authors acknowledge that lack of patient and therapist blinding to physical therapy may have biased estimates of its benefits.

"This study adds to our knowledge base and lends support to what most physicians already know about tennis elbow: Repetitive motion is the causative factor, and treatment must target the true etiology," Dr. Cooper concluded.

This study was supported by the Australian National Health and Medical Research Council. One author reported receiving payment from the Australian Catholic University for lectures on physiotherapy assessment and management of the elbow. One author reported receiving payment and travel reimbursement from various conferences for lectures on sports health related topics and receiving royalties from Elsevier for a book that covers some of the treatments in the treatment program used in this study. The other authors and Dr. Cooper have disclosed no relevant financial relationships.

JAMA. 2013;309:461-469. Abstract