Lateral epicondylitis of the elbow is a frequently encountered complaint in general practice with an incidence of 4–7/1000/year.1–3
It is characterised by pain and tenderness over the lateral humeral epicondyle and pain on resisted dorsiflexion and radial deviation of the wrist. It is usually a self-limiting condition, often resolving in 6–12 months regardless of treatment, but complaints may last up to 2 years or longer.4
Owing to considerable pain and discomfort, many patients need time off from work.
Most authors attribute the condition to a lesion in the short radial extensor muscle.1
A recent study has found evidence of reduced hyperaemia measured with spectral and colour Doppler in lateral epicondylitis treated with corticosteroid injection, suggesting the evidence of an inflammatory component.6
Others, finding little evidence of inflammation, have proposed the term ‘lateral epicondylalgia’ for the condition.7
Most patients with lateral epicondylitis are treated in general practice, and although a large number of treatments are in use, there is no consensus on which treatments are most effective. The Cochrane Library has reviewed several treatments. For topical non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs taken orally, the conclusion is that both may have a short-term effect.8
For extracorporeal shockwave therapy, a review of nine studies including 1000 patients found this treatment to have no effect.9
deep friction massage,11
the reviews were inconclusive due to few published studies.
Four review articles have been published on the effect of corticosteroid injections.14–17
They found a short-term effect of corticosteroid injection, but no proven long-term effect, and one review found evidence of a negative long-term effect.15
However, some of the reviews included non-controlled studies14
and non-randomised studies.16
In one review,15
4 of the 12 included studies had no control group and one was a small pilot study with a short follow-up. Based on this, we find evidence in published reviews on the long-term effect of corticosteroid injections to be conflicting.
Five reviews of physiotherapeutic interventions show that there are few published studies on the effect of non-electrotherapeutic treatment, and many have methodological weaknesses.16
Bisset et al18
found evidence that manipulation and exercise had a short-term effect. Four other reviews16
found short-term effects of mobilisation, manipulation and exercise. Three of these reviews included non-randomised or non-controlled studies.16
Most previous systematic reviews have included electrotherapeutic physiotherapy such as ultrasound and extracorporeal shockwave.14
Since there is no established, well-documented treatment to which new treatments can be compared, the use of a control group is important. The natural course of the condition, where most patients eventually recover regardless of the intervention, makes this even more necessary. In a comparison of two different treatments, any effect found may only reflect this natural course of recovery unless the treatments prove better than a control group with no treatment.
It has been shown that systematic reviews which include studies with low scores on internal validity may overestimate effect sizes, thus introducing a potential bias to the review.22
There may also be a problem using rating scales with heterogeneous criteria, including that is, criteria related to external validity, interpretation or ethical issues.22
To address these issues, a new systematic review on non-electrotherapeutic physiotherapy and corticosteroid injection seemed warranted. We wanted to include only randomised studies with a control group with no treatment or studies in which the groups only differed in regard to the investigated treatment. An established quality rating scale would be used. We also wanted to review the most current evidence on the efficacy of corticosteroid injections, since previous reviews have differing conclusions on the long-term effect.
The aim of this review was to assess the current evidence for the efficacy of corticosteroid injections and non-electrotherapeutical physiotherapy compared with control in patients with tennis elbow.