Coombes tennis elbow injection RCT

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.

Coombes BK, Bisset L, Brooks P, et al. JAMA 2013 · PMID 23385272 · doi:10.1001/jama.2013.129

Question

Does a corticosteroid injection, a course of physiotherapy, or both together improve long-term outcomes in tennis elbow compared with placebo injection?

Design

2x2 factorial, injection-blinded, placebo-controlled RCT run from a university research centre and primary care practices in Brisbane, Australia.

Patients

Adults with unilateral lateral epicondylalgia of more than six weeks' duration.

Intervention

Corticosteroid injection, with or without eight weeks of physiotherapy

Comparison

Placebo (saline) injection, with or without physiotherapy

Primary outcome

Global rating of change (complete recovery or much improvement) at 1 year, plus recurrence

Key result

Patients given corticosteroid had significantly worse 1-year recovery and higher recurrence than those given placebo injection. Adding physiotherapy to steroid did not offset this harm.

Limitations

Modest sample from one city; physiotherapy could not be blinded.

Impact on practice

Supports avoiding routine steroid injection for tennis elbow; short-term relief comes at the cost of poorer long-term outcome, so education and loading exercise are first line.