First-Line Treatment for Epicondylalgia

Lateral EpicondylalgiaLateral epicondylalgia affects an estimated 3% of the population, and is connected to repetitive stress activities. The condition was previously considered relatively benign and selflimiting, but research has found one-year recurrence rates reaching 72% in usual care groups. Epicondylalgia was also previously thought to be primarily an inflammatory condition (epicondylitis), but current science demonstrates that it is more a degenerative process than an inflammatory process. With the high one-year recurrence rates coming to light and a new understanding of the histopathology, there has been a movement to re-evaluate first-line treatments.

The latest contribution to this process is a study out of the University of Queensland. Dr. Coombes and colleagues randomized 165 adults with unilateral, lateral epicondylalgia for longer than six weeks into four groups: (1) placebo injection, (2) corticosteroid injection, (3) physical therapy plus placebo injection, and (4) physical therapy plus corticosteroid injection. Their study was structured to compare the interventions in terms of incremental cost per quality-adjusted life years. Compared to placebo, physical therapy was the only intervention to cause a statistically significant improvement in quality of life at one year. Therefore, even though physical therapy costs more, it is the preferred first-line treatment.

These results are consistent with the findings of previous studies showing that corticosteroid injections create the greatest short-term pain relief, but no improvement or actual harm at one year, while physical therapy tends to have some short-term pain relief with the greatest benefit apparent in recurrence rates at one year. For instance, Bisset and colleagues found one-year recurrence rates to be 72% with corticosteroid injection and 8% with physical therapy.

To manage societal costs, ensure that patients can return to previously enjoyable sports, and ensure that patients are not limited occupationally, recurrence of epicondylalgia must be minimized. It may be that eight sessions of physical therapy is the best intervention for protecting these patients.

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