Tools for Practice

#48 Steroid Injections & Lateral Epicondylitis (Tennis Elbow) – What is the Evidence?

Are corticosteroid injections effective in the management of lateral epicondylitis (tennis elbow)?

Corticosteroid injections are effective for symptom management of lateral epicondylitis in the short term (≤4 weeks), however in the long term (6-12 months) they result in poorer outcomes than no intervention at all. Physiotherapy seems to have the best outcomes overall. 

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Randomized controlled trial (RCT) of 198 patients with long-term outcomes of corticosteroid injections:1 
  • At three weeks: Corticosteroid injections significantly reduced symptoms compared to physiotherapy or wait-and-see, Number Needed to Treat (NNT)=2. 
  • By 52 weeks: Corticosteroids injections had significantly worse outcomes, Number Needed to Harm (NNH)=4.   
    • Recurrences significantly worse in corticosteroid injections group (72%) versus physiotherapy (8%) or wait-and-see (9%). 
RCT of 165 patients randomized to corticosteroid injection, physiotherapy, both (steroid/physio), or placebo.2 
  • At four weeks: Steroid or steroid/physio much improved or better in 68-71% while physiotherapy was 39% and placebo was 10%. 
  • At 52 weeks: Steroid or steroid/physio much improved or better in 82-84% while physiotherapy was 100% and placebo was 93%. 
    • Recurrence: Steroid or steroid/physio was 54-55% while physiotherapy was 5% and placebo was 20%. 
Systematic review (12 RCTs, 1,171 patients) of steroid injection for lateral epicondylagia.3 
  • 3-7 weeks: Corticosteroid injections significantly improved pain and function over no intervention or NSAIDs (inconsistent evidence for physical therapy).  
  • 26 weeks and one year: Corticosteroid injections significantly less effective than no intervention.  
  • Magnitude of these findings is difficult to determine due to heterogeneity and differences in reporting among trials. 
More recent long-term RCTs and a systematic review found similar.4-6   Context:   
  • Other systematic reviews7 and evidence-based reviews8 also report corticosteroid injections are helpful in short-term but are no better or worse in the long-term.  
  • The natural history of epicondylitis is that 83%9 to 90%1 will heal within a year with a simple wait-and-see approach. 
    • In high-quality studies of varying primary care populations, response to steroids and other treatments is very consistent at one, six, and 12 months.10   

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  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP

1. Bisset L, Beller E, Jull G, et al. BMJ. 2006 Nov 4; 333(7575):939.

2. Coombes BK, Bisset L, Brooks P, et al. JAMA. 2013; 309:461-9.

3. Coombes BK, Bisset L, Vicenzino B. Lancet. 2010 Nov 20; 376(9754):1751-67.

4. Tahririan MA, Moayednia A, Momeni A, et al. J Res Med Sci. 2014 Sep; 19(9):813-8.

5. Wolf JM, Ozer K, Scott F, et al. J Hand Surg Am. 2011 Aug; 36(8):1269-72.

6. Olaussen M, Homledal O, Lindbaek M, et al. BMJ Open. 2013; 3(10):e003564.

7. Gaujoux-Viala C, Dougados M, Gossec L. Ann Rheum Dis. 2009 Dec; 68(12):1843-9.

8. Beard JM, Safranek SM, Spogen D. J Fam Pract. 2009 Mar; 58(3):159-61.

9. Smidt N, van der Windt DA, Assendelft WJ, et al. Lancet. 2002 Feb 23; 359(9307):657-62.

10. Smidt N, Lewis M, Hay EM, et al. Ann Rheum Dis. 2005; 64(10):1406-9.

Authors do not have any conflicts of interest to declare.