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General Practice

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

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7215.964 (Published 09 October 1999) Cite this as: BMJ 1999;319:964
  1. Elaine M Hay, senior lecturer in community rheumatology (Pra19{at}keele.ac.uk)a,
  2. Susan M Paterson, research nurseb,
  3. Martyn Lewis, statisticianb,
  4. Gillian Hosie, general practitionerc,
  5. Peter Croft, professor of epidemiologyb
  1. a Staffordshire Rheumatology Centre, The Haywood, Burslem, Stoke on Trent ST6 7AG
  2. b Primary Care Sciences Research Centre, Keele University School of Postgraduate Medicine, Hartshill, Stoke on Trent ST4 7QB
  3. c 1980 Great Western Road, Glasgow G13 2SW
  1. Correspondence to: E M Hay
  • Accepted 29 July 1999

Abstract

Objective: To compare the clinical effectiveness of local corticosteroid injection, standard non-steroidal anti-inflammatory drugs, and simple analgesics for the early treatment of lateral epicondylitis in primary care.

Design: Multicentre pragmatic randomised controlled trial.

Setting: 23 general practices in North Staffordshire and South Cheshire.

Participants: 164 patients aged 18-70 years presenting with a new episode of lateral epicondylitis.

Interventions: Local injection of 20 mg methylprednisolone plus lignocaine, naproxen 500 mg twice daily for two weeks, or placebo tablets. All participants received a standard advice sheet and co-codamol as required.

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 12 months.

Results: Over 2 years, 53 subjects were randomised to injection, 53 to naproxen, and 58 to placebo. Prognostic variables were similar between groups at baseline. At 4 weeks, 48 patients (92%) in the injection group were completely better or improved compared 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 with 45 (85%) in the naproxen group and 44 (82%) in the placebo group (P>0.05).

Conclusions: Early local corticosteroid injection is effective for lateral epicondylitis. Outcome at one year was good in all groups, and effective early treatment does not seem to influence this.

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

Footnotes

  • Funding Arthritis Research Campaign. Methylprednisolone injections were provided by UpJohn and enteric coated naproxen by Syntex.

  • Competing interests None declared.

  • website extra A further table and members of the the Community Musculoskeletal Research Group are given on the BMJ's website www.bmj.com

  • Accepted 29 July 1999
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