Reshma Mirchandani Research Article # 2

Beller E, Bisset L, Brooks P, et al. Mobilization with Movement and Exercise,

Corticosteroid Injection, or Wait and See for Tennis Elbow: Randomized Trial BMJ
2006; 10: 1136

Lateral epicondylitis, also known as “tennis elbow,” is a musculoskeletal disorder

associated with gripping or manual tasks that require manipulation of the hand. Tennis elbow

commonly affects 15% of workers in at risk industries. Corticosteroid injections and

physiotherapy are commonly prescribed conservative treatments for the management of tennis

elbow. Physical therapy treatment for this condition is comprised of massage, ultrasound, and

exercise.

The purpose of this study was to investigate the short term and long term effects of

physiotherapy intervention compared with corticosteroid injections and the wait and see

approach. This study consisted of 198 participants, ages 18-65, with a clinical diagnosis of tennis

elbow and pain for at least six weeks duration. The wait and see group was given instructions on

modifying their daily activities and encouraged to use analgesic drugs, heat, cold, and braces to

avoid aggravating their pain. Another group of participants were given corticosteroid injections

to the painful elbow joints. Lastly, participants in the physiotherapy group received eight

treatments over the course of six weeks, consisting of a program of elbow manipulation and

therapeutic exercise. Outcomes were measured based on global improvement and pain-free grip

force. Global improvement was recorded on a six-point scale from “ completely recovered” to

“much worse.” Recurrence rates were also calculated beyond six weeks as the number of cases

that went from “ successful” to “unsuccessful” on global improvement. Results showed that

corticosteroid injections was initially superior to both wait and see approach and physiotherapy,
but the effect was lost after six weeks and also resulted in a higher recurrence rate. In addition,

the corticosteroid injections proved to be the worst of all the interventions at 52 weeks. At 52

weeks, the wait and see approach was superior to corticosteroid injection on global improvement,

and physiotherapy was superior to the corticosteroid injection for all the outcome measures. In

conclusion, physiotherapy was more beneficial over the wait and see approach in the first six

weeks and to corticosteroids injections in the long term.

In outpatient physical therapy practices, tennis elbow is a very commonly referred

diagnosis. Many patients that I have treated, during the course of their treatment have been

referred to get corticosteroid injections or have already received them prior to coming in for

physiotherapy. It is very common that doctors refer these patients for corticosteroid injections to

aid in pain reduction, however in my experience, most of my patients after a few weeks of

receiving the injection have commonly stated, “ I felt really good when I first had the injection,

but now the pain is back.” This correlates with the study in that the significant short-term

benefits of corticosteroid injections are reversed after six weeks. Also, they have a higher

recurrence rate, which may be attributed to the rapid improvement in pain, which causes

increased activity and overuse of the affected elbow. As therapists, we need to educate patients

on the use of corticosteroid injections and the limitations it may have long term. We also need to

reassure patients that most tennis elbow conditions will improve in the long term with the proper

ergonomic considerations and physiotherapy interventions. Corticosteroid injections used in

conjunction with physiotherapy may provide some benefit to the patient, however should be used

with caution in the management of tennis elbow.