Tennis elbow needs more than a shot in the arm

London - A corticosteroid injection may provide temporary relief from the pain of tennis elbow, but only physiotherapy or a "wait and see" approach actually relieves the problem over the long term, Australian researchers report.

Tennis elbow, formally called lateral epicondylitis, is a common cause of elbow pain. However, the condition is not the result of inflammation, but results from small tears of the tendons that attach the muscles of the forearm to the arm bone at the elbow joint.

"Patients and their health care practitioners should be mindful that the rapid resolution brought about by corticosteroid injections is associated with poorer long term results when compared to both physiotherapy and a wait-and-see approach," noted lead researcher Bill Vicenzino, an associate professor of physiotherapy at the School of Health and Rehabilitation Sciences at the University of Queensland.

"We found that patients allocated to physiotherapy appeared to express greater satisfaction with their overall management, in that they sought out far fewer other treatments over the 12-month period of the study," he added.

Vicenzino's team published their report in the Sept. 28 online edition of the British Medical Journal.

In the study, the researchers tried different treatments on three groups of patients with tennis elbow. One group were enrolled in a "wait and see" approach. These patients were told that the condition would eventually settle down and were encouraged to wait. They were also given instructions on modifying their daily activities so as to avoid aggravating their elbow condition.

Another group was given a corticosteroid injection and told to gradually return to normal activities. The third group got eight 30-minute physiotherapy sessions over six weeks and was taught home exercises and self-manipulation. The researchers measured the patients' progress at six weeks and again after one year.

Initially, corticosteroid injections worked best, with 78 percent of patients reporting improvement. This was followed by physiotherapy, where 65 percent of the patients reported improvement. In contrast, only 27 percent of the patients in the "wait and see" group reported improvement, the researchers found.

A year later, however, the results were very different. Patients who received a corticosteroid injection had significantly worse improvement than patients who got physiotherapy. People who got injections also had the most recurrences.

In fact, 72 percent of these patients had deterioration in their condition after three or six weeks. This could be due, in part, to faster initial recovery, leading to greater use and over-taxing of the elbow, the researchers said.

Moreover, long-term effects of physiotherapy were similar to the wait-and-see approach. At the end of the study, people who received physiotherapy or a wait-and-see approach were either significantly improved or had completely recovered, the researchers report.

"Patients with tennis elbow can be reassured that with a self-care approach, their condition will resolve after about three to six months," Vicenzino said. "The short-term or early effects of corticosteroid injections should be considered in view of the longer term delay in healing and generally poorer outcomes overall," he added.

"Should a patient wish to speed up the recovery of tennis elbow, a physiotherapy program of exercises and elbow manipulation should be considered in favor of a corticosteroid injection," he advised.

One expert agreed with the findings.

"It didn't surprise me that people who had injections did the best early on, and that people will get recurrent symptoms after that," said Dr. Reid Abrams, professor and vice chairman of Hand and Microvascular Surgery, and Hand, Wrist, Elbow and Upper Extremity Surgery at the University of California, San Diego.

Abrams understands that patients are looking for relief as soon as possible, so, he said an injection followed by physiotherapy may be the best overall treatment. Resting the muscle and giving it time to rebuild is key to curing the condition, Abrams said.

"Education about ergonomics and modifying activities is also important," he said. "Once you educate patients about what muscle is involved and the specific activities that set it off, patients can modify what they do to avoid setting off that particular muscle," he said. -- Health Day

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