Level 1: Likely reliable evidence

The treatment of lateral epicondylitis (tennis elbow) was evaluated in 198 patients who had the condition for at least six weeks (i>BMJ. 2006;333:939; full-text available online free of charge at www.bmj.com/cgi/content/full/333/7575/939. Accessed January 9, 2007). Patients aged 18-65 years were assigned to one of three groups: physiotherapy vs. corticosteroid injections vs. a wait-and-see approach.

Physiotherapy consisted of eight 30-minute sessions over six weeks; patients were given a resistance exercise band and taught self-manipulation and home exercises. The corticosteroid group received 1 mL of lidocaine 1% plus triamcinolone acetonide 10 mg in painful elbow points, with a second injection allowed at two weeks. Patients were told to gradually return to normal activities. The wait-and-see approach included instructions on remaining as active as possible while modifying activities to avoid aggravating pain and using analgesic drugs, heat, cold, or braces as needed.

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Success rates, defined as completely recovered or much improved, varied by follow-up time and type of intervention. Comparing wait-and-see vs. physiotherapy vs. corticosteroid injection, success rates were:
• 16% vs. 23% vs. 75% at three weeks
• 27% vs. 65% vs. 78% at six weeks
• 59% vs. 76% vs. 45% at 12 weeks
• 83% vs. 86% vs. 45% at 26 weeks
• 90% vs. 94% vs. 68% at 52 weeks

Compared with the wait-and-see approach, physiotherapy improved outcomes at six weeks (NNT 3). Steroids improved outcomes at three and six weeks (NNT 2) but worsened outcomes at 26 weeks (NNH 3) and 52 weeks (NNH 4). Comparing corticosteroid injection with physiotherapy, outcomes favored corticosteroid injection at three weeks (NNT 2); outcomes favored physiotherapy at 12 weeks (NNT 3), 26 weeks (NNT 2), and 52 weeks (NNT 4).

Recurrences were more common with corticosteroid injection (72%) than with physiotherapy (8%) or wait-and-see (9%). Seeking off-protocol treatment was less common with physiotherapy (21%) than with corticosteroid injection (49%) or wait-and-see (55%).