Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care

BMJ 1999;319:964-968 ( 9 October )

General Practice

Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care

Elaine M Hay, senior lecturer in community rheumatology, ^a Susan M Paterson, research nurse, ^b Martyn Lewis, statistician, ^b Gillian Hosie, general practitioner, ^c Peter Croft, professor of epidemiology. ^b

^a Staffordshire Rheumatology Centre, The Haywood, Burslem, Stoke on Trent ST6 7AG, ^b Primary Care Sciences Research Centre, Keele University School of Postgraduate Medicine, Hartshill, Stoke on Trent ST4 7QB, ^c 1980 Great Western Road, Glasgow G13 2SW

Correspondence to: E M Hay Pra19{at}keele.ac.uk

Objective: To compare the clinical effectiveness of localcorticosteroid injection, standard non-steroidal anti-inflammatorydrugs, and simple analgesics for the early treatment of lateralepicondylitis in primarycare.
Design: Multicentre pragmatic randomised controlledtrial.
Setting: 23 general practices in North Staffordshireand SouthCheshire.
Participants: 164 patients aged 18-70 years presenting witha new episode of lateralepicondylitis.
Interventions: Local injection of 20 mg methylprednisoloneplus lignocaine, naproxen 500 mg twice daily for two weeks, orplacebo tablets. All participants received a standard advice sheetand co-codamol asrequired.
Main outcome measures: Participants' global assessment of improvement(five point scale) at four weeks. Pain, function, and "main complaint"measured on 10 point Likert scales at 4 weeks, 6 months, and 12months.
Results: Over 2 years, 53 subjects were randomisedto injection, 53 to naproxen, and 58 to placebo. Prognostic variableswere similar between groups at baseline. At 4 weeks, 48 patients(92%) in the injection group were completely better or improvedcompared with 30 (57%) in the naproxen group (P<0.001) and 28(50%) in the placebo group (P<0.001). At 12 months, 43 patients(84%) in the injection group had pain scores $=<$ 3 compared with45 (85%) in the naproxen group and 44 (82%) in the placebo group(P>0.05).
Conclusions: Early local corticosteroid injection is effectivefor lateral epicondylitis. Outcome at one year was good in allgroups, and effective early treatment does not seem to influencethis.

Key messages

Most lateral epicondylitis is managed by general practitioners, but optimum treatment is unclear
This large pragmatic randomised trial showed that corticosteroid injection was significantly better than non-steroidal anti-inflammatories or placebo tablets at four weeks
A two week course of a standard non-steroidal anti-inflammatory was no better than placebo
A few patients who respond well initially to injection relapse by six months.
Long term outcome was good, irrespective of initial treatment allocation

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