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


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

BOTTOM LINE
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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EVIDENCE
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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Author(s):

  • 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.