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First-Line Treatment for Tennis Elbow- Physiotherapy Preferred

Tennis elbow recurrence rates have been measured as high as 72% at one year - especially if patients were treated with corticosteroids. A study out of the University of Queensland earlier this year shows that physiotherapy proves the most cost-effective means for improving quality of life, compared to placebo or corticosteroid as first-line interventions. Combining corticosteroid with physiotherapy may negate the positive effects of physiotherapy. One-year recurrence rates with physiotherapy alone have been measured between 5% and 8%.

Tennis elbow, or lateral epicondylalgia of the elbow, affects an estimated 3% of the population, and is connected to repetitive stress activities. The condition was previously considered relatively benign and self-limiting, but research has found one-year recurrence rates reaching 72% in usual care groups. Epicondylalgia was also previously thought to be primarily an inflammatory condition (epicondylitis), but current science demonstrates that it is more a degenerative process than an inflammatory process. With the high one-year recurrence rates coming to light and a new understanding of the histopathology, there has been a movement to re-evaluate first-line treatments.


The latest contribution to this process is a study out of the University of Queensland. Dr. Coombes and colleagues randomised 165 adults with unilateral tennis elbow for longer than six weeks into four groups:


1.    placebo injection,

2.    corticosteroid injection,

3.    physiotherapy plus placebo injection, and

4.    physiotherapy plus corticosteroid injection.


Their study was structured to compare the interventions in terms of incremental cost per quality-adjusted life years. Compared to placebo, physiotherapy was the only intervention to cause a statistically significant improvement in quality of life at one year. Therefore, even though physiotherapy costs more, it is the preferred first-line treatment.


These results are consistent with the findings of previous studies showing that corticosteroid injections create the greatest short-term pain relief, but no improvement or actual harm at one year, while physiotherapy tends to have some short-term pain relief with the greatest benefit apparent in recurrence rates at one year.1,3,6-9 For instance, Bisset and colleagues found one-year recurrence rates to be 72% with corticosteroid injection and 8% with physiotherapy.8 Similarly, a study recently published in the Journal of the American Medical Association finds one-year recurrence rates to be 55% for corticosteroid, 54% for corticosteroid plus physiotherapy, and 5% for physiotherapy alone.

To manage societal costs, ensure that patients can return to previously enjoyable sports, and ensure that patients are not limited occupationally, recurrence of tennis elbow must be minimised. It may be that eight sessions of physiotherapy is the best intervention for protecting these patients.

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