You are on page 1of 7

O r t o p e d i a Traumatologia Rehabilitacja

© MEDSPORTPRESS, 2015; 4(6); Vol. 17, 351-357
ORIGINAL ARTICLE DOI: 10.5604/15093492.1173377

Exercise and Therapeutic Ultrasound Compared
with Corticosteroid Injection for Chronic Lateral
Epicondylitis: A Randomized Controlled Trial

Ardiana Murtezani1(A,B,C,D,E,F), Zana Ibraimi2(C,D,F), Teuta Osmani Vllasolli1(A,B,E),
Sabit Sllamniku3(A,C,D), Shaip Krasniqi4(B,C,D,E), Lulzim Vokrri5(E,F)
1
Physical and Rehabilitation Medicine Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
2
Department of Pharmacy, Faculty of Medicine, University of Kosovo
3
Orthopedic and Traumatic Clinic, University Clinical Center of Kosovo
4
Department of Pharmacology, Faculty of Medicine, University of Kosovo
5
Department of Vascular Surgery, University Clinical Center of Kosovo

SUMMARY
Background. Lateral epicondylitis, or tennis elbow, is a common overuse syndrome of the extensor tendons
of the forearm. When the condition is chronic or not responding to initial treatment, physical therapy is initiat-
ed. The objective of this study is to compare the effectiveness of corticosteroid injections with physiothera-
peutic interventions (ultrasound and exercise) for the treatment of chronic lateral epicondylitis.
Material and methods. We performed a randomized controlled trial of 12 weeks’ duration in patients with
chronic lateral epicondylitis. We randomly assigned 49 subjects to an exercise group (n=25), who received
ultrasound and exercise, and a control group (n=24), who were treated with local infiltration of 1mL triamci-
nolone acetonide (10mg/mL) and 1mL lidocaine 2%. To evaluate the subjects, three instruments were used:
pain intensity, measured with a Visual Analogue Scale (VAS), functional disability, measured with the Patient-
Rated Tennis Elbow Evaluation (PRTEE) questionnaire, and painfree grip strength. All subjects were evaluat-
ed before treatment and at the 6th and 12th week.
Results. There were no significant differences between the two groups with regard to any variable at base-
line (p>0.05). In the exercise group, significant improvements were demonstrated for VAS, PRTEE pain score,
PRTEE function score and pain free grip strength, compared to the control group. The exercise group report-
ed a significantly greater increase in all variables at 12 weeks than did the control group (p<0.001).
Conclusion. Our results suggest that ultrasound therapy and exercise are beneficial in the treatment of ten-
nis elbow.

Key words: lateral epicondylitis, ultrasound therapy, exercise, corticosteroid injection, treatment

351

are commonly used to treat lateral a physiotherapeutic group (n = 25) or a corticosteroid epicondylitis. Intervention The objective of this study was to compare the The subjects assigned to the corticosteroid injec- effectiveness of corticosteroid injections with phys. The study was approved by the Ethical Board of wrist [1. mL) and 1mL lidocaine 2%. Local corticosteroid injection was administered to the most painful area MATERIAL AND METHODS on pressure around the lateral epicondyle. 352 . Exclusion criteria comprised: carpal or ra- nefit or do not appear to be effective in the reduction dial tunnel syndrome. A total of 49 patients with tennis elbow lasting for Physical therapy regimens. disease. is a com. extended.9].8. have been found to provide short-term be.3. years of age. and pain increasing on resisted middle finger exten- sage. con. Subjects were advised not to use the affected arm trolled trial of 12 weeks’ duration in patients with for any activity which provoked pain during the six weeks of the treatment period. cervical radiculopathy. injection group (n = 24).7% [3. It is a common disorder with a prevalence the Faculty of Medicine. patients referred by general health practitioners. trauma to the affected elbow in the past 6 Patients may benefit from surgical intervention weeks. bilateral elbow symptoms. et al. of at least 1. tion group were treated by an orthopedist with local iotherapeutic interventions. Partici- A multitude of treatment options are available to pants were enrolled over 9 months: of a group of 77 reduce symptoms and to attempt to stimulate or en. over 18 initial treatment. acupuncture. at the Clinic of Physical and Rehabilitation Medicine mon overuse syndrome of the extensor tendons of of the University Clinical Center of Kosovo. occurring most often between the Subjects third and sixth decades of life with a peak occurrence The study population consisted of subjects with in the fifth decade [5]. a maximum of two Study design injections was recommended. All sub- the forearm causing pain in the elbow and forearm jects gave written informed consent before entering the and lack of strength and function of the elbow and study. ice. epicondylitis symptoms after six to 12 months [2]. double-blind. We performed a randomized. when the condition is chronic or does not respond to Eligible participants were of both sexes. to in the trial. manipulations and mobilizations. painful of pain or improvement in function for patients with shoulder or rotator cuff tendinitis. assessed for their suitability. physical therapy is initiated. information and baseline measurements. lateral pedists. more than 3 months were randomly allocated to ning and stretching.7]. with lateral elbow pain for more than 3 rious rehabilitation modalities. The assessor was blinded studies have found that long-term effectiveness of to the allocation of participants to the treatment groups. electromagnetic field the. but the improvement in grip strength is less clear [3. grams can reduce pain. or tennis elbow. The trial was conducted Lateral epicondylitis. corticosteroid injections and their advantages over other conservative treatments are uncertain [11-13]. ortho- hance the tendon healing response.2]. During the initial visit. Several trally by the trial statistician.6. inflammatory joint lateral epicondylitis [2. bracing. a clinical diagnosis of lateral epicondylitis.Murtezani A. Va. the study were randomly allocated in accordance Local corticosteroid injection provides short-term with recognized procedures by computer-generated benefit in pain reduction and grip strength compared random allocation sequences that were prepared cen- with other conservative treatments [11. including strength trai. and stretching and strengthening sion and resisted wrist extension with the elbow exercises. US and exercise for the infiltration of 1mL triamcinolone acetonide (10mg/ treatment of lateral epicondylitis (tennis elbow). Initially. extracor. During the six-week intervention period. friction mas. However. contraindications when conservative strategies fail to relieve lateral for corticosteroid use and previous elbow surgery. including demographic administered either orally or topically [1]. phonophoresis. The condition affects men and women equally. The diagnosis was based on a history of lateral elbow poreal shock wave therapy. Exercise therapy and Randomisation stretching exercises have been used either alone or in The patients who had consented to participate in conjunction with physical interventions [10]. laser. subjects were and non-steroidal anti-inflammatory drugs (NSAIDs).12]. Evidence suggests that exercise pro.4]. pain and tenderness over the forearm extensor origin rapy. Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis BACKGROUND chronic lateral epicondylitis. months with a verified diagnosis of tennis elbow. University of Prishtina. and rheumatologists 49 were finally included epicondylitis can be treated with rest. such as ultrasound. electrical stimulation.

Ljub- exercise treatment consisted of progressive. the two groups were similar at base- The Patient-Rated Tennis Elbow Evaluation line. version 12. Conti- questionnaire which included information regarding nuous data were compared between groups using the the following individual characteristics: age. No significant differences were found between (PRTEE) questionnaire is an instrument that has been the groups for any variable (p>0. ANG 2010/01. Higher scores represent greater se- received 18 sessions of ultrasound therapy and an verity and the maximum score is 100 [19]. flow diagram of subject progression through the study. session lasted 50 minutes. Iskra Medical. For each item.5 w/cm2. for 5 to hand was measured using a hand-held dynamometer 7 minutes on three days a week for 6 weeks [14]. The used: pain intensity. and occupational exercise administered in All of the outcomes were measured at baseline and at four steps of increasing intensity two times daily on follow-up visits at 6. 21 women. Iskra Medical. Subjects were asked to indicate their pain level 51. PRTEE pain score. The marking system score and grip strength (p>0.com). “no pain” and 10 was classified as “worst possible Forty-nine subjects (28 men. The level of pain was commenced physiotherapy (n=2) and unreachable recorded on a 10 cm line where 0 was classified as (n=2). and 6 from the control group) withdrew spontaneous- ly for medical and personal reasons after randomiza- The Visual Analogue Scale tion: difficulties in transportation (n=2). Patient-Rated Tennis Elbow Evaluation (PRTEE) ques- tionnaire. The ana- The subjects were interviewed using a structured lyses were carried out according to a protocol. ues for the VAS. three instruments were scores between the assessments were calculated. percentage changes in the PRTEE total and subscale To evaluate the subjects. during which time they received no other All hypothesis tests were two-tailed and a P-value treatment. Figure 1 shows a by placing a mark along this horizontal line [15]. cise and control group. the respondent uses a 0. RESULTS On the basis of current literature we assumed a 50% A total of 77 subjects were screened: 60 entered improvement from baseline in elbow pain or function the trial. ensures that pain and function are weighted equally 353 . Murtezani A. muscle con. low back pain (n=1). Eleven subjects (5 from the exercise group to represent clinically important change [18]. et al. ure pain intensity during rest. of 0. Analyses were carried out with SPSS and previous treatment given during the current epi. functional disability. The ultrasound (Medio SONO. postintervention assessment separately for the exer- 10 numerical scale to rate the average pain or diffi. One treatment the same blinded assessor. educational level.3±6. smoking habits. Adherence to the exercise group was 82%. with Fis- height.05). All had been developed specifically for use with this disorder [16]. TE history. “got better” A Visual Analogue Scale (VAS) was used to meas.05). PRTEE function monly painful in tennis elbow. Slovenia) treatment The pain free grip strength was applied in a pulsed mode with a 20% duty cycle. her’s exact test. ditioning. treated in different ways before entering the study.spss. weight.05 was considered statistically significant. There were no significant dif- culty they have experienced over the previous week ferences between the two groups in the baseline val- while carrying out various activities that are com. slow. The (Hand Force. Absolute and sode. Overall. ljana. with five Table 2 summarizes the outcome variables meas- items addressing pain and 10 concerned with func. and 12 weeks of treatment by three days a week for 6 weeks [10]. measured by the completed the 6-week interventional period. Muscle strength of the forearm repetitive wrist and forearm stretching. and painfree grip strength [15-17]. (n=2).0 (available at www.4 years) completed the study. It takes the form of a 15-item questionnaire. Mann–Whitney U-test and categorical data. ured at baseline and during the 6 and 12 weeks’ tional deficit. The treatment for each group was continued for Statistical analysis six weeks. frequency of 1MHz. Differences from the baseline values were compared Outcome measures for both treatment groups at 6 and 12 weeks. Slovenia) [17]. exercise programme over 6 weeks. extensor muscles was also measured at all visits. Table 1 describes the demographic and medical Patient-Rated Tennis Elbow Evaluation characteristics of the 49 subjects who completed the questionnaire study. mean age pain”. measured by the Visual Analogue data analyses included only those participants who had Scale (VAS). Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis The subjects assigned to the physiotherapy group in the total score. personal reason (n=2). The pain free grip strength (GS) of the affected intensity of 1.

Flow of participants through the trial Tab. et al. 1.Murtezani A. 1. Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis Fig. Baseline characteristics 354 .

Results from randomized controlled tri. phoresis.28]. However. A few recent studies have reported a clear tenden- In our study lateral elbow pain and functional dis. However. DISCUSSION 28]. Effect of Interventions on outcome parameters The mean scores of VAS. et al. Murtezani A. and grip tennis elbow.20]. and grip strength improved significantly ment [4. also continued even after 12 weeks. ponent of physiotherapy) offers the best prospect for when the exercise group was significantly better in good long-term outcomes [11. believe that rehabilitation should assessment compared with the baseline score. This is in line more in the exercise group. Although there is a grow. be the primary therapeutic means for patients with the best VAS.20. physiotherapeutic interventions were effective in the In our study. other trials suggest that corticosteroid injections ly better than the exercise group in VAS. Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis Tab. toms. due however. and low frequency magnetic field. albeit reaching conflicting results [3. a study done in 81 subjects with groups during a 12-week period. The to the limited evidence presented [11.25-28].5. PRTEE pain. PRTEE function and grip strength. They concluded that all these 355 . (p<0. Recent years have seen a growing interest in exercise as treatment for chronic tendinopathies [10. 14. in the exercise group we have com- intermediate and long term in treating patients with bined exercises with ultrasound therapy and have lateral epicondylitis (tennis elbow).20-24]. PRTEE exercise therapy is more effective than inactive treat- function. 2. with the findings of pain psychologists. out the negative effects of inactivity and related fear where the authors concluded that corticosteroid in. [3. the results of three that at six weeks the injection group was significant. specifically being TE concluded that chronic TE should not be treated greater in the control group after 6 weeks.001) in both groups at the 6th-. phono- in the management of tendinopathies [10. In concordance with this. PRTEE function. avoidance behavior and suggest graded activity as jections were effective in the short term and that a means of overcoming this problem [27].13. provide clinically significant and lasting improvement Comparison between the two groups confirmed [23]. compared the effectiveness of three ing recognition of the importance of exercise therapy methods of physical therapy: iontophoresis. finding was in agreement with other studies which There are contradictions in various scientific pa. as the corticosteroid injections do not strength scores were seen at 6 weeks in both groups. although these gained significant improvement after 6 weeks that.5. who point This finding is in line with previous reviews.13. and physiotherapy (perhaps the exercise com- these differences were no longer evident by 12 weeks. but lasting with rest but with graded exercise [26]. conclusions should be interpreted with caution. als have been conflicting.5]. on epicon- most studies concluded that it is still unclear whether dylitis treatment [25].25]. and 12th-week Newcomer et al. included combinations of various physical therapy pers on the type of treatment concerning TE subjects modalities.25. Latala et al. all parameters. PRTEE pain. cy in favor of exercise as compared with expectation ability showed significant improvement in both [26.29-32]. Likewise. PRTEE offer the best prospects for short term relief of symp- pain.

et al. Br J Sports Med. Zastrow I. Haker and co-workers and Lundeberg and ultrasound therapy showed improvement in pain colleagues reported no significant difference in the and function among subjects with TE. Buchbinder R. Binder A. Forthomme B. Therefore. Duley J. 83: 355-78. Smidt N. Tennis elbow. 14. (11): 1633-44. Arola H. Greenwood AM. 13. ned if the effect of treatment can be maintained over Binder and colleagues reported significantly im. Struijs P. REFERENCES 1. Rompe JD. Dire (MC. 2006. As of yet. Scheffel SB. physio- therapy. Cadwallader K. A few limitations should be noted. Hazelman BL. and the application of treatment at different stages of heal. Long-term outcomes were not elbow tendon insertions. Is therapeutic ultrasound effective in treating soft tis- sue lesions? British Medical Journal 1985. elec. Treatment of lateral epicondylitis. 11. We would like to thank GEN Daniel J. Vanharanta H. Tarvainen TK. 17(2): 243-66. small sample and involving a larger number of patients. Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and quali- tative analysis. Varonen H. 2004. 2008. 12. ACKNOWLEDGEMENT ing. 2007. 7. Buchbinder R. 2007. 6. Prevalence and determinants of lateral and medial epicondylitis:a pop- ulation study. Hay EM. treatment programme was satisfactory and we had ques [3]. Ann Med 2003. Davidson R. Bouter LM.29]. In future studies we should evaluate the efficacy treated groups and sham ultrasound-treated groups of similar programs and exercises with other phy- using either continuous or pulsed ultrasound [30. offering short-term pain re. and what is on the horizon.Murtezani A. 82(9): 522-30. Lopes-Martins RAB. Weak evidence for efficacy was only found a low rate of loss to follow-up. 9. In another study. for ultrasound. Am J Epidemiol. ilar studies [10. A et al. vention over others. Maffulli N. Joensen J. Corticosteroid injections. its randomi- the methods can be used alternatively as none of zed controlled design. Assendelft W. Hodge G. Croisier JL. Dessalle MF. Progressive Strengthening and Stretching Exercises and Ultrasound for Chronic Lateral Epicondylitis. characteristics at baseline. In contrast to the positive findings of 1. Andres BM. 356 . healing of lateral epicondylitis between ultrasound. what does not. Am Fam Physician. Smidt N. Korthalsde Bos IB. 9: 75. Epperly TD. forts are needed to determine which method is more effective. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Clin Evid. Pain 2002. 290: 512-4. Windt DA. 96(1–2): 23-40. Bouter LM. 164(11): 1065-74. 76(6): 843-8. Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis types of therapy offer benefits in epicondylitis and This study had several strengths. BMC Musculoskeletal Disorders 2008.g. Trudel D. 8. variety of treatment strategies used. 359: 657-62. Deville WL. Cochrane Database of Systematic Reviews: Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. e. Crielaard JM. Clinical Orthopaedics and Related Research. Kerr E W. Johnson GW. Tinant F. 4. Heliövaara M. 51-62. Treatment of Tendinopathy: What works. evaluated in these subjects so it cannot be determi- lief and less disability in TE [5]. sizes. van der Windt DA. Journal of Hand Therapy 2004. This study uti- stered low level laser therapy directly to the lateral lized a small sample. Combined 6-week programme of exercises with this study. Pienimäki TT. et al. Murrel GAC. According to the subjects’ them were superior to the rest.13. Bjordal JM. sical therapy modalities during a longer time span Due to heterogeneity of the studies. A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). Physiotherapy 1996. Assendelft JJ. 41(4): 269-75. reviewing this manuscript. Siira PT. further research ef. and exercises and mobilisation techni. Page Thomas DP. Viikari-Juntura E. 466(7): 1539-54. Smidt N. Shiri R. or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002. Rehabilitation for patients with lateral epicondylitis: a systematic review. The subjects’ adherence to the trotherapy. Smidt N. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. MacDermid J C. no optimal strategy US Army Res) for providing helpful suggestions and has been identified. 5. proved recovery in patients with TE treated with ultrasound compared with those treated with sham CONCLUSION ultrasound [14]. 2001. the authors admini. our subjects were similar 23 RCTs were included in a review evaluating the and corresponded to those participating in other sim- effects of laser therapy. ultrasound treatment. Assendelft WJ. Br Med Bull 2007. Corticosteroid injections for lateral epicondylitis: a systematic review. Green S. 2. it is difficult to recommend any particular inter.31]. 2. Malmivaara. Assendelft WJ. time. 3. 10.

Physical therapy in treatment of lateral and medial epicondylitis.2014 r. 333(7575): 939. Speed CA. Liczba słów/Word count: 3435 Tabele/Tables: 2 Ryciny/Figures: 1 Piśmiennictwo/References: 32 Adres do korespondencji / Address for correspondence Ardiana Murtezani University Clinical Center of Kosovo. McMaster University. Denison HJ. Br J Sports Med 2005. Jones J. MacDermid J. Photomed Laser Surg 2005. 23: 115-8. Birtane M. MacDermid J. Ups J Med Sci. 95(4): 251-65. Poltawski L. 22. Cerisola FL. 116(4): 269. 23. Stasinopoulos DI. 15(3): 185-7. Measuring clinically important change with patient-rated tennis elbow evaluation. 20: 99-101. Rheumatology 2006: 566-70. 25. 27. Latala B. 61(2): 240-6. Tonks JH. 40(4): 423-9. Vicenzino B. Lundeberg T. 20. Murtezani A. 11(4): 214-22. Bisset L. Huskisson EC. Lundeberg T. Vicenzino B. Jull G. 18. 23(4): 425-30. or wait and see for tennis elbow: randomised trial. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospec- tive randomized controlled trial. Brooks P. corticosteroid injec- tion. Idank DM. Clin Rheumatol 2007. Exercise and Therapeutic Ultrasound Compared with Corticosteroid Injection for Chronic Lateral Epicondylitis 15.12. Tastekin N. Int J Clin Pract 2007. Haker E. rr. Svärdsudd K. Pulsed ultrasound treatment in lateral epicondylitis. A systematic review and meta-analysis of clinical trials on physical interven- tions for lateral epicondylalgia. Beller E. 19. et al. Watson T. The Patient-Rated Tennis Elbow Evaluation (PRTEE) User Manual. Update: The Patient-rated Forearm Evaluation Questionnaire is now the Patient-rated Tennis Elbow Evaluation. 2007. Linton SJ. 28. Fizjoterapia 2009. A comparative study of continuous ultrasound. Johnson MI: Effectiveness of low-level laser therapy for lateral elbow tendinopathy. 16: 52-7. 10000 Prishtina Otrzymano / Received 10. Physiotherapy 2009.02. Republic of Kosovo. Pai SK. Hamilton. Otfinowski J.com Zaakceptowano / Accepted 03. 16. et al. Barr S. Beller E. Ostor AJK. Canada: School of Rehabilita- tion Science. 21. Clinical Journal of Sport Medicine 2001. 30. Peterson M. placebo ultrasound and rest in epi- condylalgia. A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Haker E. 18: 407-10 17. McLean TJ. 85: 317-32. Egan KS. 357 . e-mail: ardianaa@yahoo. BMJ 2006. Application of visual-analogue scales to the measurement of functional capacity. 2011. Scand J Rehab Med 1991. 32. Spitalit pn. 29. Laskowski ER. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a random- ized controlled trial. 2011. 26: 69-74. Newcomer KL. Hand Therapy 2011. Eriksson M. D’Vaz AP. Blanchard V. Age Ageing. Uzunca K. A randomized controlled trial of exercise versus wait list in chronic tennis elbow (lateral epicondylosis). J Hand Ther 2005. 17(1): 3-10. Regula K. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. 24. Butler S. Harnish MP.2015 r. Darnell R. Corticosteroid Injection in Early Treatment of Lateral Epicondylitis. Murali SR. Mobilisation with movement and exercise. 26. Effectiveness of pulsed electromagnetic field therapy in lateral epicondylitis. Mosurska D. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. et al. 39: 411-22. Rhe- umatology 1976. Vlaeyen JW. Abrahamsson P. Scott PJ. 31. Scand J Rehabil Med 1988. Pain 2000. Paungmali A. Roberts HC. Bisset L.