Evaluation of short-term conservative treatment in patients with tennis elbow (lateral epicondylitis): A prospective randomised, assessor-blinded trial.

Abstract

The complexity of the pathophysiology of tennis elbow is reflected by the lack of consensus on management and remains a therapeutic challenge. This study was a prospective randomised, assessor-blinded trial. 64 patients with tennis elbow referred by their GP to either the physiotherapy, orthopaedic or MSK CAT services, subject to eligibility criteria, were randomised into one of 3 treatment arms: injection, ultrasound or exercise, to which the assessor remained blinded. The outcome measures of thermal difference, median frequency (MDF), patient-rated tennis elbow evaluation questionnaire (PRTEE), pain-free grip strength (PFG) and patient preference were assessed twice at baseline, at 10 days, 6 weeks and 6 months and analysed as an intention to treat analysis.

In the short term of 6 weeks injection was the most effective treatment demonstrating both statistically significant and minimum clinically important differences (MCID) for PFG and PRTEE in comparison to ultrasound and exercise. Patients had a strong preference for injection and a strong aversion for exercise. No statistically significant differences were found between ultrasound and exercise although a MCID was found in favour of ultrasound for thermal difference and MDF at 10 days. In to the long term of 6 months, although this was on a limited subgroup, no statistically significant differences were found between any of the groups. A MCID was found in favour of ultrasound for MDF and a MCID was found in favour of exercise over injection for all aspects of PRTEE and over ultrasound for PRTEE pain only.

This research supports the superior effectiveness of injection in the short term of 6 weeks and should be advocated for patients who present early with severe limiting pain and have important short term goals, although patients need to be warned that a 1/3rd will have a recurrence of symptoms within 6 months. In contrast, for those patients who present with moderate to low pain physiotherapy including exercise and/ or ultrasound should be advocated. Thermal difference is a sensitive outcome measure for tennis elbow. Continuous 3 MHz therapeutic ultrasound at 2W/cm2 for 5 minutes utilises thermal effects which optimise the healing process and demonstrate an accumulative effect of ultrasound in to the long term. Further research on the effectiveness of a combination of injection with physiotherapy is required.