Short Term Effect Of Local Steroid Injection In Lateral Epicondylitis

Introduction:
Lateral epicondylitis, also commonly referred to as tennis elbow, describes an overuse injury

secondary to eccentric overload of the common extensor tendon at the origin of the extensor

carpi radialis brevis (ECRB) tendon.1 Tennis elbow primarily results from the repetitive strain

caused by activities that involve loaded and repeated gripping and/or wrist extension. It is

common in individuals who play tennis, squash, or badminton or any activity involving

repetitive wrist extension, radial deviation, and/or forearm supination.2,3

Despite the condition being commonly referred to as tennis elbow, tennis players make up only

10% of the patients’ population. 4 Half of tennis players develop pain around the elbow, of which

75% represent true tennis elbow. It is more common in individuals older than 40 years of age.

Smoking, obesity, a repetitive movement for at least two hours daily, and vigorous activity

(managing physical loads over 20 kg) are risk factors in the general population for the

development of this condition.5 The natural course of the condition is favorable with spontaneous

recovery within one to two years in 80% to 90% percent of the patients.6

First-line management for the treatment of lateral epicondylitis includes rest from offending

activity as guided by the level of pain. Brace use in the form of a cock-up wrist splint can be

prescribed to take stress off of the wrist extensors.7

Local injection of steroids, autologous blood, platelet rich plasma, sodium hyaluronate

injections, and extracorporeal shock wave therapy are being used. Surgical methods include

percutaneous needling, tenodesis and open or arthroscopic release of the extensor carpi radialis

brevis tendon.
In a study by Bashir SI, et al. has shown that mean visual analogue scale (VAS) for pain was

5.62±1.15 with autologous blood injection and 1.60±1.19 with local steroid injection after 2

weeks in management of lateral epicondylitis.8

In another study by Ghorpade NA, et al. has shown that mean visual analogue scale (VAS) for

pain was 4.37 ± 0.96 with local anaesthetic injection only and 2.40 ± 1.03 with local steroid

injection after 2 weeks in management of lateral epicondylitis.9

Rationale: In primary care, tennis elbow is commonly treated with analgesics and physiotherapy

but results are not good, may be due to poor compliance to treatment due to requirement of

repetitive hospital visits and side effects of long term analgesics. 10 Hence, present study will

evaluate the effect of local steroid injection as compared to local anaesthetic injection for

treatment of tennis elbow. Results of my study will be used by practitioners.

Objective:

To compare the outcome of local steroid injection and local anaesthetic injection after 2 weeks in

management of lateral epicondylitis.

Operational Definitions:

Lateral epicondylitis: It will be defined as when any one of following seen on MRI….

 Abnormal thickening and increased signal intensity within the common extensor origin
from the lateral epicondyle 

 Abnormal thickening and abnormal separation of the radial collateral ligaments and the
extensor carpi radials brevis (ECRB) tendon with granulation tissue
Outcome: It will be in terms of pain score on visual analogue scale.

Visual analogue scale: The Visual analog scale scores range from zero (no pain) to 10

(maximum pain). Visual analog scale scores of 1–3, 4–6, and 7–10 will be designated as

corresponding to mild, moderate, and severe pain, respectively.

Hypothesis: It is hypothesized that there is a difference in visual analogue scale for pain with

local steroid injection as compared to local anaesthetic injection after 2 weeks in management of

lateral epicondylitis.

Material and Methods:

Study design:

Randomized Controlled Trail.

Setting:

Department of orthopedics, Hayatabad Medical Complex, Peshawar.

Duration of study:

Six months after approval of synopsis

Sample size: Using WHO sample size calculator.

Level of significance= 5% Power of test=80% Using mean visual analogue scale (VAS) for

pain by 4.37 ± 0.96 with local anaesthetic injection and 2.40 ± 1.03 with local steroid injection

after 2 weeks in management of lateral epicondylitis.9

Total sample size= 10 but I will use 60 (30 in each group)

Sampling technique: Non-probability consecutive sampling

Inclusion Criteria:

 Age 18-60 years

 Both genders

 Lateral epicondylitis as per operational definition for > two week

 Baseline pain VAS score > 6

Exclusion Criteria:

 H/o previous operation on the lateral side of the elbow

 H/o arthritis or allied conditions

 H/o neurological disorders of the painful extremity (such as the cervical root compression

syndrome and compression of the posterior interosseous branch of the radial nerve)

 H/o ulnar neuropathy

 H/o carpal tunnel syndrome

 H/o medial epicondylitis

 Pregnancy on ultrasound
Data Collection Procedure:

60 patients fulfilling the inclusion criteria from Department of orthopedics, Hayatabad Medical

Complex, Peshawar will be included in the study after permission from ethical committee of

institution. At study entry baseline demographics (age, gender, weight on weighing machine,

baseline VAS score) will be recorded. A detailed explanation about the participation in the study

will be given to the patient and an informed consent will be obtained explaining the risks and

benefits in detail. Randomization will be performed by block randomization for both groups

when the patients are enrolled for procedure. 30 patients will be in local steroid injection group

(A) while 30 patients will be in local anaesthetic injection group (B).

The patients in A group will be treated with local injection of 1ml (40mg) of methylprednisolone

acetate (Steroid) at the maximal point tenderness at lateral epicondyle by single-injection

technique. The patients in ‘B” group will be treated with local injection of 2ml of 2% lignocaine

at the area of maximum tenderness at lateral epicondyle by peppering injection technique.

All the patients will be followed up at the 2nd week, after the injection. Patients will be

evaluated by Visual analogue scale (VAS) and noted on especially designed proforma

(Annexure-I).

Data Analysis:

Data will be analyzed with statistical analysis program (SPSS version 23). Mean ±SD will be

presented for quantitative variables like age, weight, base line VAS score and VAS score after 2

weeks. Frequency and percentage will be computed for qualitative variables like gender. The

differences in the mean VAS score after 2 weeks of both groups will be statistically tested using

the student t test, p ≤0.05 will be considered statistically significant. VAS score after 2 weeks
will be stratified with regard to age, gender, weight, base line VAS score. Post stratification

using the student t test for both groups, p ≤0.05 will be considered statistically significant.

References:

1. Welsh P. Tendon neuroplastic training for lateral elbow tendinopathy: 2 case reports. J Can
Chiropr Assoc. 2018;62(2):98-104.

2. Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-rich plasma for

elbow pathologies: a descriptive review of current literature. Curr Rev Musculoskelet Med.
2018;11(4):598-606.

3. Patiño JM, Corna AR, Michelini A, Abdon I, Ramos Vertiz AJ. Elbow posterolateral rotatory
instability due to cubitus varus and overuse. Case Rep Orthop. 2018;2018:1491540.

4. Degen RM, Conti MS, Camp CL, Altchek DW, Dines JS, Werner BC. Epidemiology and
disease burden of lateral epicondylitis in the USA: analysis of 85,318 patients. HSS J.
2018;14(1):9-14.

5. Chevinsky JD, Newman JM, Shah NV, Pancholi N, Holliman J, Sodhi N, et al. Trends and
epidemiology of tennis-related sprains/strains in the United States, 2010 to 2016. Surg Technol
Int. 2017;31:333-8.

6. Hassebrock JD, Patel KA, Makovicka JL, Chung AS, Tummala SV, Hydrick TC, et al. Elbow
injuries in national collegiate athletic association athletes: a 5-season epidemiological study.
Orthop J Sports Med. 2019;7(8):2325967119861959.

7. Balakatounis K, Angoules AG, Angoules NA, Panagiotopoulou K. Synthesis of evidence for

the treatment of intersection syndrome. World J Orthop. 2017;8(8):619‐23.

8. Bashir SI, Khan MA, Khan MA. Injection of autologous blood versus corticosteroid injection
in the treatment of tennis elbow: a prospective randomized comparative study. Int J Health Sci
Res. 2018;8(10):64-8.

9. Ghorpade NA, Hatwar BR. Evaluation of the effectiveness of two different local injection
types for treatment of patients of chronic tennis elbow. Int J Contemp Med Res.
2017;4(10):2099-103.

10. Dimitrios S. Lateral elbow tendinopathy: evidence of physiotherapy management. World J

Orthop. 2016;7(8):463‐6.
 ANNEXURE- I
Short Term Effect Of Local Steroid Injection In Lateral Epicondylitis
Serial No______________ Reg No._________________

Name______________________________ Age (years):_______________

Address:________________________________________________________

Contact No___________________

Gender(Male/Female)_____________________

Weight (Kg):_________________

Baseline VAS score:_________________

Group: A B

VAS score after 2 weeks_______________

Signature_____________________