Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care

Staffordshire Rheumatology Centre, The Haywood, Burslem, Stoke on Trent ST6 7AG.
BMJ Clinical Research (Impact Factor: 14.09). 11/1999; 319(7215):964-8. DOI: 10.1136/bmj.319.7215.964
Source: PubMed

ABSTRACT To compare the clinical effectiveness of local corticosteroid injection, standard non-steroidal anti-inflammatory drugs, and simple analgesics for the early treatment of lateral epicondylitis in primary care.
Multicentre pragmatic randomised controlled trial.
23 general practices in North Staffordshire and South Cheshire.
164 patients aged 18-70 years presenting with a new episode of lateral epicondylitis. Interventions: Local injection of 20 mg methylprednisolone plus lignocaine, naproxen 500 mg twice daily for two weeks, or placebo tablets. All participants received a standard advice sheet and co-codamol as required.
Participants' global assessment of improvement (five point scale) at four weeks. Pain, function, and "main complaint" measured on 10 point Likert scales at 4 weeks, 6 months, and 12 months.
Over 2 years, 53 subjects were randomised to injection, 53 to naproxen, and 58 to placebo. Prognostic variables were similar between groups at baseline. At 4 weeks, 48 patients (92%) in the injection group were completely better or improved compared with 30 (57%) in the naproxen group (P<0.001) and 28 (50%) in the placebo group (P<0.001). At 12 months, 43 patients (84%) in the injection group had pain scores </=3 compared with 45 (85%) in the naproxen group and 44 (82%) in the placebo group (P>0.05).
Early local corticosteroid injection is effective for lateral epicondylitis. Outcome at one year was good in all groups, and effective early treatment does not seem to influence this.

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Available from: Martyn Lewis, Sep 15, 2015
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    • "While the underlying pathology of lateral epicondylitis at the end stage is not inflammatory, the use of nonsteroidal anti-inflammatory drugs (NSAID) may be a useful adjunct to activity modification.7 There is a lack of data to support their oral use.42,54 In contrast, Brunham et al7 noted short-term relief associated with a topical NSAID in their randomized double-blind crossover study. "
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    ABSTRACT: Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations. EVIDENCE ACQUISITIONS: The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy. Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments. Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.
    09/2012; 4(5):384-93. DOI:10.1177/1941738112454651
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    • "In our study group B showed a statistically significant decrease in VAS score and Nirschl stage at one and four weeks compared with group A. Hay et al30 found similar results when local corticosteroid injection was compared with oral naproxen. "
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    ABSTRACT: Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade. A total of 60 patients were included in this prospective randomised study: 30 patients received 2 ml autologous blood drawn from contralateral upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received 2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral epicondyle. Outcome was measured using a pain score and Nirschl staging of lateral epicondylitis. Follow-up was continued for total of six months, with assessment at one week, four weeks, 12 weeks and six months. The corticosteroid injection group showed a statistically significant decrease in pain compared with autologous blood injection group in both visual analogue scale (VAS) and Nirschl stage at one week (both p < 0.001) and at four weeks (p = 0.002 and p = 0.018, respectively). At the 12-week and six-month follow-up, autologous blood injection group showed statistically significant decrease in pain compared with corticosteroid injection group (12 weeks: VAS p = 0.013 and Nirschl stage p = 0.018; six months: VAS p = 0.006 and Nirschl p = 0.006). At the six-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in autologous blood injection group were completely relieved of pain. Autologous blood injection is efficient compared with corticosteroid injection, with less side-effects and minimum recurrence rate.
    08/2012; 1(8):192-7. DOI:10.1302/2046-3758.18.2000095
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    • "It has been claimed that conservative care leads to recovery in up to 90% of TE patients within 1–2 years and that surgery is indicated in less than 10% of the cases [5, 6, 25]. However, recent studies of patients with elbow complaints, including TE, in general practice report a less favourable prognosis [2, 17]. Bot and co-workers found that although 90% of all patients reported at least some improvement after 1 year of follow-up, only 13% of the patients reported full recovery at the 3-month follow-up and 34% at 12 months [2]. "
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    ABSTRACT: The objectives of this study were to evaluate the results in the outpatient treatment of recalcitrant lateral epicondylitis with release of the common extensor origin according to Hohmann and to determine any prognostic factors. Eighty tennis elbows in 77 patients with a characteristic history of activity-related pain at the lateral epicondyle interfering with the activities of daily living refractory to conservative care for at least 6 months and a confirmatory physical examination were included. Clinical outcome was evaluated using the QuickDASH score system. Data were collected before the operation and at the medians of 18 months (range 6-36 months; short term) and 4 years (range 3-6 years; medium term) postoperatively. The mean QuickDASH was improved both at the short- and the medium-term follow-ups and did not change significantly between the follow-ups. At the final follow-up, the QuickDASH was improved in 78 out of 80 elbows and 81% was rated as excellent or good (QuickDASH<40 points). We found a weak correlation between residual symptoms (a high QuickDASH score) at the final follow-up and high level of baseline symptoms (r=0.388), acute occurrence of symptoms (r=0.362), long duration of symptoms (r=0.276), female gender (r=0.269) and young age (r=0.203), whereas occurrence in dominant arm, a work-related cause or strenuous work did not correlate significantly with the outcome. Open lateral extensor release performed as outpatient surgery results in improved clinical outcome at both short- and medium-term follow-ups with few complications. High baseline disability, sudden occurrence of symptoms, long duration of symptoms, female gender and young age were found to be weak predictors of poor outcome. Case series, Level IV.
    Knee Surgery Sports Traumatology Arthroscopy 03/2011; 19(6):1023-7. DOI:10.1007/s00167-011-1477-1 · 3.05 Impact Factor
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