Archives of Orthopaedic and Trauma Surgery

, Volume 133, Issue 6, pp 757–763 | Cite as

The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial

  • Mohsen Mardani-Kivi
  • Mahmoud Karimi-Mobarakeh
  • Ali Karimi
  • Niloofar Akhoondzadeh
  • Khashayar Saheb-Ekhtiari
  • Keyvan Hashemi-Motlagh
  • Farzaneh Bahrami
Orthopaedic Surgery

Abstract

Introduction

This study seeks to compare two treatment methods of lateral epicondylitis: corticosteroid injection (CSI) and a local anesthetic injection (LAI).

Materials and methods

In this single-blinded randomized clinical trial, 138 patients with the diagnosis of lateral epicondylitis were assigned either into CSI group receiving methylprednisolone 1 ml (49 patients) or LAI group (51 patients) receiving procaine 1 ml 2 % in a single dose at the maximal point tenderness site. The primary outcome measure was elbow disability using Quick DASH, and secondary outcome measures were pain intensity using Visual Analogue Scale (VAS) and recurrence rate at pretreatment visit and at 3-, 6- and 12-week post-treatment visits.

Results

There were no significant differences between the patients in both groups for demographic factors including age, gender, dominant hand, involved hand, and work pressure. Before treatment, the patients in both groups were suffering from the same rates of elbow disability and pain as measured by Quick DASH and VAS, respectively, (p > 0.05). In general, the recovery rate (comparison between pretreatment visit and last post-treatment visit) was significantly more effective and higher in CSI than LAI. CSI was dramatically more effective at 3-week visit, but less and less effective at 6- and 12-week visits. At 12-week visit the recurrence rate was 34.7 % (17 patients) in CSI group.

Conclusion

For lateral epicondylitis, CSI has the best short-term treatment results yet the highest recurrent rates. The combination of CSI with other treatment option or with a change in injection technique from single injection to peppering injection may be promising.

Keywords

Tennis elbow Lateral epicondylitis Intra-lesional injection Corticosteroids Local anesthetic Visual analogue scale Treatment outcome 

References

  1. 1.
    Coonrad RW, Hooper WR (1973) Tennis elbow: its course, natural history, conservative and surgical management. J Bone Joint Surg Am 55(6):1177–1182PubMedGoogle Scholar
  2. 2.
    Gruchow HW, Pelletier D (1979) An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med 7(4):234–238PubMedCrossRefGoogle Scholar
  3. 3.
    Nirschl RP (1992) Elbow tendinosis/tennis elbow. Clin Sports Med 11(4):851–870PubMedGoogle Scholar
  4. 4.
    Dimberg L (1987) The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics 30(3):573–579. doi:10.1080/00140138708969746 PubMedCrossRefGoogle Scholar
  5. 5.
    Walz DM, Newman JS, Konin GP, Ross G (2010) Epicondylitis: pathogenesis, imaging, and treatment. Radiographics 30(1):167–184. doi:10.1148/rg.301095078 PubMedCrossRefGoogle Scholar
  6. 6.
    Ollivierre CO, Nirschl RP (1996) Tennis elbow. Current concepts of treatment and rehabilitation. Sports Med 22(2):133–139PubMedCrossRefGoogle Scholar
  7. 7.
    Assendelft WJ, Hay EM, Adshead R, Bouter LM (1996) Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J Gen Pract 46(405):209–216PubMedGoogle Scholar
  8. 8.
    Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF (2002) Time to abandon the “tendinitis” myth. BMJ (Clin res ed) 324(7338):626–627CrossRefGoogle Scholar
  9. 9.
    Smidt N, Assendelft WJ, van der Windt DA, Hay EM, Buchbinder R, Bouter LM (2002) Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 96(1–2):23–40PubMedCrossRefGoogle Scholar
  10. 10.
    Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM (2002) Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 359(9307):657–662. doi:10.1016/S0140-6736(02)07811-X PubMedCrossRefGoogle Scholar
  11. 11.
    Bunata RE, Brown DS, Capelo R (2007) Anatomic factors related to the cause of tennis elbow. J Bone Joint Surg Am 89(9):1955–1963. doi:10.2106/JBJS.F.00727 PubMedCrossRefGoogle Scholar
  12. 12.
    Dogramaci Y, Kalaci A, Savas N, Duman IG, Yanat AN (2009) Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial. Arch Orthop Trauma Surg 129(10):1409–1414. doi:10.1007/s00402-009-0832-x PubMedCrossRefGoogle Scholar
  13. 13.
    Okcu G, Erkan S, Senturk M, Ozalp RT, Yercan HS (2012) Evaluation of injection techniques in the treatment of lateral epicondylitis: a prospective randomized clinical trial. Acta Orthop Traumatol Turc 46(1):26–29PubMedCrossRefGoogle Scholar
  14. 14.
    Olaussen M, Holmedal O, Lindbaek M, Brage S (2009) Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: a protocol for a randomised, placebo-controlled study. BMC Musculoskelet Disord 10:152. doi:10.1186/1471-2474-10-152 PubMedCrossRefGoogle Scholar
  15. 15.
    Peterson M, Butler S, Eriksson M, Svardsudd K (2011) A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci 116(4):269–279. doi:10.3109/03009734.2011.600476 PubMedCrossRefGoogle Scholar
  16. 16.
    Rabago D, Best TM, Zgierska AE, Zeisig E, Ryan M, Crane D (2009) A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med 43(7):471–481. doi:10.1136/bjsm.2008.052761 PubMedCrossRefGoogle Scholar
  17. 17.
    Stefanou A, Marshall N, Holdan W, Siddiqui A (2012) A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg Am 37(1):104–109. doi:10.1016/j.jhsa.2011.10.005 PubMedCrossRefGoogle Scholar
  18. 18.
    Szabo RM (2009) Steroid injection for lateral epicondylitis. J Hand Surg Am 34(2):326–330. doi:10.1016/j.jhsa.2008.10.011 PubMedCrossRefGoogle Scholar
  19. 19.
    Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE (2011) Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am 36(8):1269–1272. doi:10.1016/j.jhsa.2011.05.014 PubMedCrossRefGoogle Scholar
  20. 20.
    Coombes BK, Bisset L, Connelly LB, Brooks P, Vicenzino B (2009) Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison. BMC Musculoskelet Disord 10:76. doi:10.1186/1471-2474-10-76 PubMedCrossRefGoogle Scholar
  21. 21.
    Saccomanni B (2010) Corticosteroid injection for tennis elbow or lateral epicondylitis: a review of the literature. Curr Rev Musculoskelet Med 3(1–4):38–40. doi:10.1007/s12178-010-9066-3 PubMedCrossRefGoogle Scholar
  22. 22.
    Price R, Sinclair H, Heinrich I, Gibson T (1991) Local injection treatment of tennis elbow–hydrocortisone, triamcinolone and lignocaine compared. Br J Rheumatol 30(1):39–44PubMedCrossRefGoogle Scholar
  23. 23.
    Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM (2010) Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord 11:206. doi:10.1186/1471-2474-11-206 PubMedCrossRefGoogle Scholar
  24. 24.
    Barr S, Cerisola FL, Blanchard V (2009) Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. Physiotherapy 95(4):251–265. doi:10.1016/j.physio.2009.05.002 PubMedCrossRefGoogle Scholar
  25. 25.
    Faro F, Wolf JM (2007) Lateral epicondylitis: review and current concepts. J Hand Surg Am 32(8):1271–1279. doi:10.1016/j.jhsa.2007.07.019 PubMedCrossRefGoogle Scholar
  26. 26.
    Hart L (2011) Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med 21(6):540–541. doi:10.1097/01.jsm.0000407929.35973.b9 PubMedCrossRefGoogle Scholar
  27. 27.
    Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R (2012) Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. doi:10.1177/0363546512458237 PubMedGoogle Scholar
  28. 28.
    Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH (1992) Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br 74(5):646–651PubMedGoogle Scholar
  29. 29.
    Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B (2006) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ (Clin res ed) 333(7575):939. doi:10.1136/bmj.38961.584653.AE CrossRefGoogle Scholar
  30. 30.
    Hay EM, Paterson SM, Lewis M, Hosie G, Croft P (1999) Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ (Clin res ed) 319(7215):964–968CrossRefGoogle Scholar
  31. 31.
    Bellapianta J, Swartz F, Lisella J, Czajka J, Neff R, Uhl R (2011) Randomized prospective evaluation of injection techniques for the treatment of lateral epicondylitis. Orthopedics 34(11):e708–e712. doi:10.3928/01477447-20110922-13 PubMedGoogle Scholar
  32. 32.
    Alfredson H, Ljung BO, Thorsen K, Lorentzon R (2000) In vivo investigation of ECRB tendons with microdialysis technique–no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand 71(5):475–479. doi:10.1080/000164700317381162 PubMedCrossRefGoogle Scholar
  33. 33.
    Ljung BO, Alfredson H, Forsgren S (2004) Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerus. Studies on tennis elbow and medial epicondylalgia. J Orthop Res 22(2):321–327. doi:10.1016/s0736-0266(03)00183-9 PubMedCrossRefGoogle Scholar
  34. 34.
    Ljung BO, Forsgren S, Friden J (1999) Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow. J Orthop Res 17(4):554–559. doi:10.1002/jor.1100170414 PubMedCrossRefGoogle Scholar
  35. 35.
    Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, Vicenzino B (2007) Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford) 46(10):1601–1605. doi:10.1093/rheumatology/kem192 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Mohsen Mardani-Kivi
    • 1
  • Mahmoud Karimi-Mobarakeh
    • 2
  • Ali Karimi
    • 1
  • Niloofar Akhoondzadeh
    • 1
  • Khashayar Saheb-Ekhtiari
    • 1
  • Keyvan Hashemi-Motlagh
    • 1
  • Farzaneh Bahrami
    • 1
  1. 1.Orthopedic Research Center, Poursina HospitalSchool of Medicine, Guilan University of Medical SciencesRashtIran
  2. 2.Orthopedic Department, Kerman University of Medical SciencesKermanIran

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