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ORIGINAL ARTICLE
Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 151-154

Analyzing short and long-term results of various nonsurgical treatment modalities in lateral epicondylitis


Department of Orthopaedics, Government. Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Muzamil Ahmad Baba
Department of Orthopaedics, Government. Medical College, Srinagar, Jammu and Kashmir
India
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DOI: 10.4103/1319-6308.142373

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  Abstract 

Background: Lateral epicondylitis (LE) is a common disorder and as of now no consensus exists as to the most appropriate management strategy for lateral epicondylitis. Aim: To compare the outcome of different nonsurgical treatment modalities in lateral epicondylitis. Materials and Methods: One hundred and twenty patients were randomly distributed in three groups. Group A patients received 2 ml of corticosteroid injection, Group B 2 ml of autologous blood, and Group C 2 ml of 5% dextrose. The visual analogue scale (VAS) scores were recorded at preprocedure and postprocedure at 4 weeks and 6 months. Results: The mean VAS scores changed at 4 weeks from a preprocedure mean of 7 to 3 in Group A, 8 to 5 in group B, and a mean of 7 to 6 in group C. The VAS scores changed at 6 months from 7 to 5 in Group A, 8 to 2 in group B, and 7 to 5 in group C. Conclusion: In our study, although corticosteroid showed an early advantage over the autologous blood group, but long-term follow-up results were better for autologous blood group. It is hence proposed that further research studying the effect of combination of steroid followed later by an autologous blood injection would show the efficacy of this combined treatment modality.

  Abstract in Arabic 

تحليل لطرق علاج التهاب اللقيمة الجانبي غير الجراحية على المديين القصير و الطويل
خلفية البحث: التهاب اللقيمة الجانبي (LE) هو اضطرلب شائع إلاّ أنه لم يحظ بإجماع حول الإستراتيجية الأنسب للتعامل معه .
هدف الدراسة : كان هدف هذه الدراسة مقارنة النتائج المختلفة لطرق العلاج غير الجراحية في التهاب اللقيمة الجانبي .
المواد ومنهج الدراسة : تم توزيع مائة و عشريمن مريضا بشكل عشوائي على ثلاث مجموعات : المجموعة ( أ ) تلقت 2 ملم من حقن الكورتيكوسترويد . و تلقت المجموعة (ب) 2ملم من الدم ، و تلقت المجموعة (ج) 5% من سكر العنب . بعد ذلك سجلت معدلات التماثلية البصرية قبل إجراء العملية و بعده في أربعة اسابيع و ستة أشهر .
النتائج: لوحظ تغير متوسط (VAS ) في أربعة أسابيع قبل إجراء العملية و كان المتوسط 3 - 7 في المجموعة (أ) وبين 5-8 المجموعة (ب) و كان المتوسط 6 ــ 7 في المجموعة ( ج).
الخلاصة: أظهرت الدراسة أن الكورتيكوسترويد قد أظهر ميزة مبكرة على مجموعة من فصيلة الدم الذاتي إلاّ أن المتابعة على المدى الطويل كانت لصالح فصيلة الدم الذاتي ، فبالتالي توصي الدراسة بمزيد من البحث لمعرفة تأثير السترويد وحقن الدم الذاتي ؛ وذلك من شأنه أن يظهر فعالية هذه الطريقة من العلاج.

Keywords: Autologous blood, dextrose, lateral epicondylitis, steroid, visual analogue scale


How to cite this article:
Baba MA, Shikari AB, Mir BA, Halwai MA, Rashid S, Shabeer M. Analyzing short and long-term results of various nonsurgical treatment modalities in lateral epicondylitis . Saudi J Sports Med 2014;14:151-4

How to cite this URL:
Baba MA, Shikari AB, Mir BA, Halwai MA, Rashid S, Shabeer M. Analyzing short and long-term results of various nonsurgical treatment modalities in lateral epicondylitis . Saudi J Sports Med [serial online] 2014 [cited 2019 Aug 24];14:151-4. Available from: http://www.sjosm.org/text.asp?2014/14/2/151/142373


  Introduction Top


Lateral epicondylitis (LE) or tennis elbow, a common musculoskeletal disorder, is a tendinopathy of the common extensor tendon of the elbow which is characterized by pain in the lateral epicondylar area that is often exacerbated by activities involving gripping. [1] The problem was first described by Runge; [1] it is a soft tissue lesion affecting men and women equally, with a reported incidence of up to 3% in the population and a peak occurrence in the 5 th decade. [2] Despite the frequently used term 'tennis elbow' it seldom occurs in tennis players and less than 5% cases are associated with sports. [3] This entity is most prevalent (up to 65%) in jobs requiring repetitive manual tasks, it results in restricted function, and it is one of the costly of all work-related illnesses. [4] The duration of symptoms may vary ranging from few weeks to several years. [5] Traditional conservative treatments for LE include cross friction massage, electrical and thermal modalities, bracing, and therapeutic exercise. Various injection treatment modalities have been described for the syndrome. Patients who fail to respond to conservative measures may require surgery (< 10%). Various operative techniques including open, percutaneous, and arthroscopic techniques have been described. [6]

Currently, no general consensus exists as to the most appropriate management strategy for lateral epicondylitis , even though several systematic reviews have been published. The purpose of this study was to evaluate the results of various nonsurgical treatment modalities used in lateral epicondylitis .


  Materials and methods Top


After obtaining the ethical board approval (IRB) the study was done over a 3 year period (2009-2012). One hundred and twenty patients of lateral epicondylitis of 3-6 months duration in age group of 20-60 years were randomly distributed in three groups (A, B, and C) based on the treatment modality used in the three groups. Block randomization was used to prevent unequal treatment group sizes and thus each study group enrolled 40 patients. All patients in the age group 20-60 years of either sex with clinically diagnosed lateral epicondylitis of 3-6 months duration with no history of trauma or any previous injections were included in the study. Patients with history of rheumatoid disorder, other autoimmune diseases, surgery in the area over lateral elbow, neck symptoms, or compressive neuropathy were also excluded from the study. Groups were comparable with regard to age, gender, occupation, or hand dominance. All patients completed the visual analogue scale (VAS) pain score preprocedure as well as at each follow-up.

The procedure was done under all aseptic precautions using a 21 gauge needle. A 2 ml of autologous blood, steroid, and 5% dextrose were used after mixing 1 ml of lidocaine to each of the solution. Patients were randomly assigned to each group and a written consent was taken from all the patients. The needle was inserted just distal to the most tender spot with a single skin penetration followed by multiple deep tissue insertions (peppering technique).

During follow-up, none of the patients were prescribed any additional drugs, any orthotics or splints. All patients were advised to avoid any heavy labor for the 1 st week following the treatment. All patients completed the VAS pain scores (range 0-10, 0 representing no pain and 10 representing the worst pain ever), at 4 weeks and 6 months of follow-up.


  Results Top


A total of 120 patients were included in the study. There were 74 males and 46 females with an average age of 43.4 years (range 28-59 years). Each group received a total of 40 patients each. A significant improvement in the VAS scores were seen in Groups A and B with least improvement in Group C [Table 1]. The mean pre procedure VAS score was 7 for the steroid (Group A), 8 for the autologous blood (Group B), and 7 for the dextrose (Group C). The mean VAS scores for the steroid, autologous blood, and 5% dextrose groups were 3, 5, and 6 at 4 weeks and 5, 2, and 5 at 6 months, respectively [Table 1].
Table 1: Depicts the mean visual analogue scale pain scores at various stages of treatment in the three groups

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Statistical analysis was done using graphpad.com online website for statistical calculations. Statistical results were derived using unpaired Student's t-test. The data in the three groups and the statistical calculations is demonstrated in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5].
Table 2: Individual data in group A patients

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Table 3: Individual data in group B patients

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Table 4: Individual data in group C patients

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Table 5: Statistical analysis in the three groups

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As is clear from the data in [Table 2], [Table 3], [Table 4], [Table 5], the difference in VAS scores was statistically significant at 4 weeks (P = 0.001) in the steroid (Group A), but not statistically significant at 6 months (P = 1.00) as compared to the dextrose (Group C). However, statistically significant difference is seen both at 4 weeks and 6 months (P = 0.002/0.001) in the autologous blood (Group B) as depicted in [Table 5].


  Discussion Top


Historically, tennis elbow has been referred to as "tendinitis," suggesting the presence of an acute inflammatory process. However, recent research has shown lack of acute inflammatory markers in patients with tennis elbow and suggests using the terms "tendinosis" or "tendinopathy" to describe the condition. [7],[8] Cyriax in 1936 had explained about 26 etiological factors of tennis elbow, and still the pathology is uncertain as no published data have examined patients with acute diagnosis of tennis elbow. [9] As pathogenesis remains controversial, no single treatment modality has been established. The cornerstone of the diagnosis are detailed history regarding aggravating and relieving factors and the provocative tests such as resisted wrist and long finger extension and resisted forearm supination, a decrease in grip strength is often noted. [10] Differential diagnosis includes radial tunnel syndrome, radio humeral arthritis, osteochondritis of capitellum, posterolateral instability of the elbow and injury to lateral antebrachial cutaneous nerve. [6],[10],[11]

The use of injection as a treatment modality for lateral epicondylitis is common, and multiple types of injection have been proposed to treat tendinopathy. Although most studies have indicated use of steroid injections relieve pain in tennis elbow primarily in the short-term. In addition, local steroids are associated with complications and may cause lipodystrophy. [12],[13] The injection of autologous blood has been performed for tendinopathies including lateral epicondylitis, [12],[13] plantar fasciitis, [15],[17] and patellar tendinopathy [14] with comparable results.

In our study the patients receiving steroid injections (Group A) although showed an early response with VAS pain scores decreasing from a mean of 7 preprocedure to a mean of 3 at 4 weeks. However, a high recurrence of symptoms occurred in this group of patients with a mean VAS score of 5 at final follow-up. Other studies that have been done on use of steroids have also documented a high recurrence with only a short-term benefit in most of the cases. [12],[16] In other randomized controlled trial with 1-year follow-up, recurrence was evident in 72% of patients receiving corticosteroid injection. [18] At long-term follow-up, the efficacy of steroid is not well-established. The group of patients receiving autologous blood injection in our study revealed a modest improvement at 4 weeks of follow-up, but long-term follow-up at 6 months revealed a significant improvement in VAS score from a preprocedure mean of 8 to a mean score of 2 at final follow-up. Thus, our study reveals better results with steroids in the short-term and significantly improved results in patients receiving autologous blood injection at 6 months follow-up.


  Conclusion Top


In our study although corticosteroid showed an early advantage over the autologous blood group, but at long-term follow-up of 6 months; results were much better for autologous blood group. It is hence proposed that further research studying the effect of combination of steroid followed later by an autologous blood injection would show the efficacy of this combined treatment modality.


  Acknowledgements Top


We thank Dr. Manan and Dr. Naila for their technical help during manuscript preparation.

 
  References Top

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Runge F. The genesis and treatment of write-spasm. Berl Klin Wochenshr 1873;10:245-8.  Back to cited text no. 1
    
2.
Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol 1974;3:145-53.  Back to cited text no. 2
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3.
Wadsworth TG. Tennis elbow: Conservative, surgical, and manipulative treatment. Br Med J 1987;294:621-4.  Back to cited text no. 3
    
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Dimberg L. The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics 1987;30:573-9.  Back to cited text no. 4
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Binder AI, Hazelman BL. Lateral humeral epicondylitis: A study of natural history and the effect of conservative therapy. Br J Rheumatol 1983:22:73-6.  Back to cited text no. 5
    
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Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: A systematic review. Clin Orthop Relat Res 2007;463:98-106.  Back to cited text no. 6
    
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Waugh EJ. Lateral epicondylalgia or epicondylitis: What's in a name? J Orthop Sports Phys Ther 2005;35:200-2.  Back to cited text no. 8
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Coonrad RW, Hooper WR. Tennis elbow: Its course, natural history, conservative and surgical management. J Bone Joint Surg Am 1973;55:1177-82.  Back to cited text no. 9
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Boyer MI, Hastings H 2 nd . Lateral tennis elbow: "Is there any science out there?" J Shoulder Elbow Surg 1999;8:481-91.  Back to cited text no. 10
    
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Pomerance J. Radiographic analysis of lateral epicondylitis. J Shoulder Elbow Surg 2002;11:156-7.  Back to cited text no. 11
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Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 2003;28A: 272-8.  Back to cited text no. 12
    
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Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol 2006;35:371-7.  Back to cited text no. 13
    
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James SL, Ali K, Pocock C, Robertson C, Walter J, Bell J, et al. Ultrasound guided dry needling and autologous blood injection for patella tendinosis. Br J Sports Med 2007;41:518-21.  Back to cited text no. 14
    
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Logan LR, Klamar K, Leon J, Fedoriw W. Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity. Am J Phys Med Rehabil 2006;85:699-703.  Back to cited text no. 15
    
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Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: A prospective randomised controlled trial. Int J Clin Pract 2007;61:240-6.  Back to cited text no. 16
    
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Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int 2007;28:984-90.  Back to cited text no. 17
    
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Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999;319:964.  Back to cited text no. 18
    


    Figures

  [Table 1]
 
 
    Tables

  [Table 2], [Table 3], [Table 4], [Table 5]



 

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