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Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care.

ABSTRACT: OBJECTIVE:To compare the clinical effectiveness of local corticosteroid injection, standard non-steroidal anti-inflammatory drugs, and simple analgesics for the early treatment of lateral epicondylitis in primary care. DESIGN:Multicentre pragmatic randomised controlled trial. SETTING:23 general practices in North Staffordshire and South Cheshire. PARTICIPANTS:164 patients aged 18-70 years presenting with a new episode of lateral epicondylitis. INTERVENTIONS:Local injection of 20 mg methylprednisolone plus lignocaine, naproxen 500 mg twice daily for two weeks, or placebo tablets. All participants received a standard advice sheet and co-codamol as required. MAIN OUTCOME MEASURES:Participants' global assessment of improvement (five point scale) at four weeks. Pain, function, and "main complaint" measured on 10 point Likert scales at 4 weeks, 6 months, and 12 months. RESULTS:Over 2 years, 53 subjects were randomised to injection, 53 to naproxen, and 58 to placebo. Prognostic variables were similar between groups at baseline. At 4 weeks, 48 patients (92%) in the injection group were completely better or improved compared with 30 (57%) in the naproxen group (P<0.001) and 28 (50%) in the placebo group (P<0.001). At 12 months, 43 patients (84%) in the injection group had pain scores 0.05). CONCLUSIONS:Early local corticosteroid injection is effective for lateral epicondylitis. Outcome at one year was good in all groups, and effective early treatment does not seem to influence this.

SUBMITTER: Hay EM

PROVIDER: S-EPMC28251 | biostudies-literature | 1999 Oct

REPOSITORIES: biostudies-literature

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Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care.

Hay E M EM Paterson S M SM Lewis M M Hosie G G Croft P P

BMJ (Clinical research ed.) 19991001 7215

<h4>Objective</h4>To compare the clinical effectiveness of local corticosteroid injection, standard non-steroidal anti-inflammatory drugs, and simple analgesics for the early treatment of lateral epicondylitis in primary care.<h4>Design</h4>Multicentre pragmatic randomised controlled trial.<h4>Setting</h4>23 general practices in North Staffordshire and South Cheshire.<h4>Participants</h4>164 patients aged 18-70 years presenting with a new episode of lateral epicondylitis.<h4>Interventions</h4>Lo ...[more]

PMID: 10514160

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Project description:BackgroundLateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis.MethodsA randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale.ResultsOne hundred fifty-seven patients (89 %) completed the trial. 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 (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success.ConclusionsAcute 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.Trial registrationClinicalTrials.gov Identifier: NCT00826462.

Project description:ObjectivesTo evaluate the current evidence for the efficacy of corticosteroid injection and non-electrotherapeutic physiotherapy compared with control for treating lateral epicondylitis.DesignSystematic review.ParticipantsWe searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages.InterventionsCorticosteroid injection and non-electrotherapeutic physiotherapy.Outcome measuresRelative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4-12, 26 and 52 weeks of follow-up.ResultsCorticosteroid injection gave a short-term reduction in pain versus no intervention or non-steroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or long-term follow-up. We found moderate evidence for short-term and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect.ConclusionsCorticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.

Project description:Corticosteroid (CS) injections are a frequently used treatment modality for lateral epicondylitis (LE) despite an increasing number of studies suggesting their lack of efficacy. The objective of this study was to review the annual utilization of CS injections for treatment of LE, as well as that of other nonsurgical treatments and surgical treatments, to understand how recent publications have affected the practice of physicians in treating LE. Patients with LE from 2010 to 2017 were identified within a national insurance database and grouped by treatment modalities of CS injections, physical therapy, bracing treatment, and surgery. Epidemiologic and demographic data were reported using descriptive statistics. The number of patients receiving each treatment and the number of CS injections per patient were quantified for each year, and annual trends were analyzed using logistic regression. Among 80,169 qualifying patients, 16,476 received CS injections, 12,180 received physical therapy, 1,874 received bracing treatment, and 2,650 underwent surgery, with patients receiving multiple modalities being members of each respective group. We found a significant decrease in the proportion of patients with LE receiving CS injections from 23.3% in 2010 to 18.8% in 2017 (R2 = 0.956, P < 0.001). Interestingly, the number of CS injections per patient increased during this period from 1.33 to 1.83 (R2 = 0.843, P = 0.001). No notable changes in utilization trends for other modalities were found. Overall, our data support a decline in the use of CS injection as a treatment modality for LE from 2010 to 2017. Although correlational, this trend may reflect the increasing body of published evidence demonstrating the ineffectiveness of CS injections for the treatment of LE. In addition, the increasing number of injections per patient among those who received injections contrasts with the overall decrease in steroid utilization among all patients. Further study is needed to fully understand the mechanisms behind these trends.

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Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care.

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Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care.

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