Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ.333:939

School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, QLD, Australia 4072.
BMJ (online) (Impact Factor: 17.45). 12/2006; 333(7575):939. DOI: 10.1136/bmj.38961.584653.AE
Source: PubMed


To investigate the efficacy of physiotherapy compared with a wait and see approach or corticosteroid injections over 52 weeks in tennis elbow.
Single blind randomised controlled trial.
Community setting, Brisbane, Australia.
198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks' duration, who had not received any other active treatment by a health practitioner in the previous six months.
Eight sessions of physiotherapy; corticosteroid injections; or wait and see.
Global improvement, grip force, and assessor's rating of severity measured at baseline, six weeks, and 52 weeks.
Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections.
Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.

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Available from: Leanne M Bisset, Jul 15, 2014
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    • "Citation Level of evidence Score Elbow Abbott (2001a) 3 19 Abbott et al (2001b) 3 25 Amro et al (2010) 3 30 Baltaci et al (2001) 2 25 Bisset et al (2006) 2 44 Burton (1988) 2 26 Dreschler et al (1997) 2 28 Kochar et al (2002) 2 31 Manchanda et al (2008) 2 34 Nagrale et al (2009) 2 37 Paungmali et al (2003) 3 42 Paungmali et al (2004) 3 37 Stasinopoulos (2006) 2 42 Struijs et al (2003) 2 35 Verhaar (1996) 2 32 Vincenzino (2001) 2 38 Wrist Kay et al (2000) 2 43 Naik et al (2007) 2 20 Tal-Akabi et al (2000) 2 32 Taylor et al (1994) 2 28 Hand Randall et al (1992) 2 34 Villafane et al (2011) 2 40 "
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    ABSTRACT: Systematic review. Joint mobilizations are used as an intervention for improving range of motion, decreasing pain and ultimately improving function in patients with a wide variety of upper extremity diagnoses. However, there are only a limited number of studies describing this treatment for conditions affecting the elbow, wrist, and hand. Furthermore, it is unclear as to the most effective joint mobilization technique utilized and the most beneficial functional outcomes gained. Examine the current evidence describing joint mobilizations for treatment of conditions of the elbow, wrist and hand, and offer informative practical clinical guidance. Twenty-two studies dated between 1980 and 2011 were included in the systematic review for analysis. The current evidence provides moderate support for the inclusion of joint mobilizations in the treatment of lateral epicondylalgia (LE). In particular, mobilization with movement as described by Mulligan is supported with evidence from nine randomized clinical trials as an effective technique for the treatment of pain. Other described techniques include those known as Kaltenborn, Cyriax physical therapy, and Maitland, but the evidence for these techniques is limited. There is also limited evidence for the joint mobilizations in the treatment of wrist and hand conditions. The current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for LE. There is moderate support for mobilization with movement. 2A.
    Full-text · Article · Sep 2013 · Journal of Hand Therapy
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    • "Local corticosteroid injection is one of the commonest treatment prescribed in cases where initial activity modification and NSAIDs don’t work. However, a randomised control trial conducted by Bisset et al. [16] found out that corticosteroid although effective at short term yielded poorer results at long term follow up (1 year) than physiotherapy. "
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    ABSTRACT: Background It has been recently reported that local injection of autologous blood in tennis elbow offers a significant benefit by virtue of various growth factors contained therein. The objective of our study was assessment of efficacy of autologous blood injection versus local corticosteroid injection in the treatment of tennis elbow. Methods and trial design A single blinded, prospective parallel group trial was undertaken. 50 consecutive patients of untreated lateral epicondylitis were enrolled. Randomisation was done on alternate basis and two groups were constituted, first one receiving steroid injection and second one injection of autologous blood. Both groups were evaluated at 2 and 6 weeks for pain relief and stage of disease. Results Baseline evaluation showed no difference between the two groups (chi square test, P > 0.05). Between group analysis at 2 weeks showed no difference in pain relief and Nirschl stage (unpaired t test, P > 0.05). Evaluation at 6 weeks demonstrated a significant decrease in pain levels and stage of disease in blood group (unpaired t test, p < 0.05). Conclusions Autologous blood injection was more effective than steroid injection in the short term follow up in tennis elbow.
    Full-text · Article · Apr 2013 · Journal of Orthopaedic Surgery and Research
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    • "17 Physiotherapy: tendon stretching exercises, cross friction massage, heat and ice, along with eccentric loading exercises, are the mainstay of physiotherapeutic treatment of tennis elbow. A study by Bisset et al in 2006 18 reported that physiotherapy was superior to expectant treatment in the short term. Patients who had physiotherapy required less additional treatment such as NSAIDs than patients who underwent a 'wait and see' policy or who had a corticosteroid injection. "
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    ABSTRACT: Tennis and Golfer's elbow are common conditions. They typically present with a gradual onset of pain without a history of trauma. They are characterized by an absence of inflammatory mediators with histological evidence of chronic fibroblastic proliferation, vascular hyperplasia and disorganized collagen. This article reviews these two conditions and current treatment options. Surgery is only indicated in the small number of refractory cases.
    Preview · Article · Oct 2012 · Orthopaedics and Trauma
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