Injections, Needling and Tennis Elbow - What Should We Do?

The results of a recent study (Coombes, 2013) are very interesting when it comes to clinical decision making in the treatment of lateral epicondylalgia (tennis elbow). This was a large RCT looking at those with clinical signs and symptoms of LE, without evidence of cervical/ neural involvement. The participants were randomised into four groups and received either cortisone injection only, cortisone with physiotherapy, placebo injection only, and placebo injection with physiotherapy. I have summarised the results as follows.

Those who had cortisone injections achieved some short term pain relief but at 12 months they are less likely to have recovered completely or be much improved, there is also a high recurrence rate at 24 month follow up. This did not change when physiotherapy was added.

Those who had ‘Placebo’ needling ie no injected substance were much more likely to recover completely or be much improved, and had a lower recurrence rate at 24 months. There was no change to this result when physiotherapy was added, however physiotherapy brought about quicker relief in the short term.

How could we interpret these results?

Cortisone injections, even when combined with physiotherapy should not be considered first line of treatment. They could be used at a later stage, should physiotherapy treatment fail.

The group that did best received ‘placebo’ needling and physiotherapy treatment. It would be incorrect to dismiss the ‘placebo’ needling as those who received placebo needling only also did very well in the results. It could be argued that the introduction of a needle in the region of the lateral epicondyle is sufficient to evoke specific physiological changes (in addition to non-specific/ placebo) effects (White et al, 2008) which resulted in symptom relief and that this process was enhanced, in the short term by physiotherapy.

Take home message?

Does this study support the use of medical acupuncture in the treatment of this condition? I certainly think so on the basis of another study (Altay et al, 2002) which have showed symptomatic improvements following injections, regardless of the substances injected - the common factor being the actual needle itself! Clinically I would routinely include acupuncture alongside manual therapy and graded exercises and have found my results with acupuncture to be far superior than without.

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