Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial

Brooke K. Coombes, Leanne Bisset, Peter Brooks, Asad Khan, Bill Vicenzino

Research output: Contribution to journalArticleResearchpeer-review

180 Citations (Scopus)

Abstract

Importance: Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking. Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia. Design, Setting, and Patients: A2x2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011. Interventions: Corticosteroid injection (n=43), placebo injection (n=41), corticosteroid injection plus physiotherapy (n=40), or placebo injection plus physiotherapy (n=41). Main Outcome Measures: The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P<.01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks. Results: Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P=.01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P<.001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P=.56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P=.25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P<.001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P=.84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P=.01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P=.004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P=.57). Conclusion and Relevance: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences. Trial Registration; anzctr.org Identifier: ACTRN12609000051246

Original languageEnglish
Pages (from-to)461-469
Number of pages9
JournalJAMA
Volume309
Issue number5
DOIs
Publication statusPublished - 6 Feb 2013
Externally publishedYes

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