title: Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial.
abstract: OBJECTIVE
  To determine the cost-effectiveness of corticosteroid injection, physiotherapy and a combination of these interventions, compared to a reference group receiving a blinded placebo injection.
  
  
  METHODS
  165 adults with unilateral lateral epicondylalgia of longer than 6 weeks duration from Brisbane, Australia, were randomised for concealed allocation to saline injection (placebo), corticosteroid injection, saline injection plus physiotherapy (eight sessions of elbow manipulation and exercise) or corticosteroid injection plus physiotherapy. Costs to society and health-related quality of life (estimated by EuroQol-5D) over the 1 year follow-up were used to generate incremental cost per quality-adjusted life year (QALY) ratios for each intervention relative to placebo.
  
  
  RESULTS
  Intention-to-treat analysis was possible for 154 (93%) of trial participants. Physiotherapy was more costly, but was the only intervention that produced a statistically significant improvement in quality of life relative to placebo (MD, 95% CI 0.035, 0.003 to 0.068). Similar cost/QALY ratios were found for physiotherapy ($A29 343; GBP18 962) and corticosteroid injection ($A31 750; GBP20 518); however, the probability of being more cost-effective than placebo at values above $A50 000 per quality-adjusted life year was 81% for physiotherapy and 53% for corticosteroid injection. Cost/QALY was far greater for a combination of corticosteroid injection and physiotherapy ($A228 000; GBP147 340).
  
  
  CONCLUSIONS
  Physiotherapy was a cost-effective treatment for lateral epicondylalgia. Corticosteroid injection was associated with greater variability, and a lower probability of being cost-effective if a willingness to pay threshold of $A50 000 is assumed. A combination of corticosteroid injection and physiotherapy was ineffective and cost-ineffective. Physiotherapy, not corticosteroid injection, should be considered as a first-line intervention for lateral epicondylalgia.
  
  
  BACKGROUND
  anzctr.org Trial identifier: ACTRN12609000051246.
authors.affiliation: The University of Queensland, School of Biomedical Sciences, Brisbane, Queensland, Australia.|The University of Queensland, School of Health and Rehabilitation Sciences, Physiotherapy, Brisbane, Queensland, Australia.
authors.forename: Brooke K
authors.initials: BK
authors.lastname: Coombes
authors.affiliation: Faculty of Medicine and Biomedical Sciences, the University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Luke
authors.initials: L
authors.lastname: Connelly
authors.affiliation: Menzies Institute, Griffith University, Gold Coast, Queensland, Australia.
authors.forename: Leanne
authors.initials: L
authors.lastname: Bisset
authors.affiliation: The University of Queensland, School of Health and Rehabilitation Sciences, Physiotherapy, Brisbane, Queensland, Australia.
authors.forename: Bill
authors.initials: B
authors.lastname: Vicenzino
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000191:economics; D000328:Adult; D001315:Australia; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007270:Injections, Intra-Articular; D008297:Male; D008875:Middle Aged; D026741:Physical Therapy Modalities / Q000191:economics*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D013716:Tennis Elbow / Q000191:economics / Q000628:therapy*
chemical_list: D000305:Adrenal Cortex Hormones
keywords: Physiotherapy; Tendinopathy; Tendinosis; Tennis elbow