In a randomized study with 3 treatment arms, 185 patients were treated with a corticosteroid injection, physiotherapy, or a wait-and-see approach (ergonomic advice, rest, and oral anti-inflammatory medication). Corticosteroid injections were significantly more effective for the patients’ main complaint at 6 weeks compared with wait-and-see (mean difference in improvement [MDI] on a 100-point scale=24; 95% CI, 14-35; NNT=2) or physiotherapy (MDI=20; 95% CI, 10-31; NNT=2).3 By contrast, at 26 and 52 weeks’ follow-up, physiotherapy was more effective than steroid injections (MDI=15; 95% CI, 5-25) but statistically equivalent to a wait-and-see approach (MDI=7; 95% CI, –4 to 17).
Physiotherapy, exercise, acupuncture bring short-term relief
In a separate RCT, physiotherapy and exercise were significantly better than a wait-and-see approach at 6 weeks for pain-free grip force, rating of pain severity, and global improvement (RR=0.5; 99% CI, 0.2-0.8; NNT=3), but by 52 weeks the outcomes were statistically equal.4
An individual RCT, cited in a Cochrane review, showed acupuncture had a very short-term benefit for pain relief compared with placebo (WMD=18.8 hours; 95% CI, 10.1-27.5).5 Another individual RCT, which was not included in the meta-analysis because of methodologic problems in the other studies, found that a short course of 10 acupuncture treatments resulted in an excellent or good outcome (as reported by participants) compared with placebo (RR=0.09; 95% CI, 0.01-0.64; NNT=4).5 No benefit was noted after 3 or 12 months.
Physiotherapy techniques, orthotics are hard to evaluate
Systematic reviews of specific physiotherapy or orthotic (bracing) treatments are hampered by the large number of treatment options available and the heterogeneity of the available studies, which prevent statistically useful evaluation.6,7
Shock wave, ultrasound, massage offer little or no benefit
In a meta-analysis of 3 trials, shock wave therapy provided no significant benefit at 4 to 6 weeks compared with placebo (WMD on a 100-point scale=-9.42; 95% CI, -20.70 to 1.86).8 Pooling 2 studies in a different systematic review showed weak evidence that ultrasound reduced pain at 13 weeks compared with placebo (standardized mean difference=–0.98; 95% CI, –1.64 to –0.33).6 Another Cochrane review found no added benefit in function from combining deep transverse friction massage with ultrasound or a placebo ointment (RR=3.3; 95% CI, 0.4-24.3).9
Recommendations
The Work Loss Data Institute recommends ice, rest, ergonomic modifications, and short-term topical or oral NSAIDs. Progressive physical or occupational therapy may follow if no improvement is seen in 2 weeks.
Splinting, acupuncture, and corticosteroid administration by injection or iontophoresis may reduce pain for as long as 2 to 6 weeks. If these conservative measures fail, surgical treatment is recommended as a last resort.10