Corticosteroids may offer short-term relief from the symptoms of lateral epicondylalgia, but they significantly increase the risk of recurrence compared with physiotherapy or placebo, according to a randomized controlled trial reported in JAMA.
The 1-year study of 165 patients also examined the interaction between corticosteroids and physiotherapy, finding that patients randomized to placebo injection and physiotherapy had better outcomes than did those who received corticosteroids and physiotherapy, or corticosteroids alone.
The senior author of the study, Bill Vicenzino, Ph.D., said the study was not quite the death knell for use of corticosteroids in the treatment of lateral epicondylalgia but it did call for more careful consideration.
"The take-home message is that both physician and patient need to be informed that there’s a higher risk of recurrence and delayed healing and that other approaches should be taken, such as good exercise, good advice, and physiotherapy, and then if that doesn’t work, then maybe you need to consider steroids," Dr. Vicenzino of the University of Queensland, Australia, said in an interview.
Lead author Brooke K. Coombes, Ph.D., of the School of Health and Rehabilitation Sciences at the University of Queensland and her associates conducted the study in patients over age 18, with unilateral lateral epicondylalgia lasting longer than 6 weeks. The patients were randomized to one of four groups: corticosteroid injection, placebo injection, corticosteroid injection plus multimodal physiotherapy, or placebo injection plus multimodal physiotherapy (JAMA 2013;309:461-9).
Of the patients treated with 10 mg/mL of triamcinolone in a 1-mL injection, 83% demonstrated complete recovery or much improvement at 1 year, compared with 96% of patients treated with saline injection (relative risk, 0.86; 99% confidence interval, 0.75-0.99). Symptoms recurred in 54% of those given the corticosteroid, compared with 12% of those given placebo (RR, 0.23; 99% CI, 0.10-0.51).
Among patients treated with multimodal physiotherapy, consisting of eight 30-minute sessions of local elbow manipulation and exercise over 8 weeks, there was no significant difference in outcomes at 1 year or in the risk of recurrence, compared with patients who did not receive physiotherapy.
However, at 4 weeks, patients given corticosteroid injections alone were significantly more likely to experience complete recovery or much improvement than were those given placebo (RR, 7.32; 99% CI, 2.1-25.5). They also reported less pain and disability and improved quality of life.
But patients who received physiotherapy and placebo injection also had improved outcomes at 4 weeks, compared with the no-physiotherapy placebo group, reporting higher rates of complete recovery or much improvement (RR, 4.00; 99% CI, 1.07-15.00).
"Physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates (4.9%) and 100% complete recovery or much improvement at 1 year," the investigators reported.
The study was funded by the Australian National Health and Medical Research Council. The researchers reported receiving payment and travel reimbursement for lectures and conference presentations on physiotherapy and musculoskeletal-related topics.