title: Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
abstract: BACKGROUND
  Lateral 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  One 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.
  
  
  CONCLUSIONS
  Acute 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.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier: NCT00826462.
authors.affiliation: Department of General Practice, Institute of Health and Society, University of Oslo, Kirkeveien 166, 0450, Oslo, Norway. morten.olaussen@medisin.uio.no.
authors.forename: Morten
authors.initials: M
authors.lastname: Olaussen
authors.affiliation: Department of General Practice, Institute of Health and Society, University of Oslo, Kirkeveien 166, 0450, Oslo, Norway. oystein.holmedal@medisin.uio.no.
authors.forename: Øystein
authors.initials: Ø
authors.lastname: Holmedal
authors.affiliation: Department of General Practice, Institute of Health and Society, University of Oslo, Kirkeveien 166, 0450, Oslo, Norway. ibrahimu.mdala@odont.uio.no.
authors.forename: Ibrahimu
authors.initials: I
authors.lastname: Mdala
authors.affiliation: Research section, Directorate for Labour and Welfare, Oslo, Norway. Soren.Brage@nav.no.
authors.forename: Søren
authors.initials: S
authors.lastname: Brage
authors.affiliation: Department of General Practice, Institute of Health and Society, University of Oslo, Kirkeveien 166, 0450, Oslo, Norway. morten.lindbak@medisin.uio.no.
authors.forename: Morten
authors.initials: M
authors.lastname: Lindbæk
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D001696:Biomechanical Phenomena; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D004311:Double-Blind Method; D004551:Elbow Joint / Q000187:drug effects* / Q000503:physiopathology; D005260:Female; D006801:Humans; D007270:Injections, Intra-Articular; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008405:Massage; D008875:Middle Aged; D052580:Muscle Stretching Exercises; D009664:Norway; D016017:Odds Ratio; D011320:Primary Health Care; D020127:Recovery of Function; D016037:Single-Blind Method; D013716:Tennis Elbow / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones