Management of lateral epicondylitis – local steroid injection versus extra corporeal shock wave therapy Rajan Sharma MBBS*, RK Sharma MS**, Randhir Singh MS***, RPS Boparai MS****, P Sathyadharan MBBS* *Junior Resident, **Assistant Professor, ***Associate Professor, **** Professor & Head Department of Orthopaedics Government Medical College & Hospital, Amritsar ABSTRACT Tennis elbow or lateral epicondylitis is an intractable condition, difficult to treat. We conducted a controlled trial in our institution to compare the results of local steroid injections & the use of Extra-corporeal Shock Wave Therapy (ESWT) for managing tennis elbow. Of the two groups of 25 patients each, one group received three injections of 40mg methylprednisolone with 2cc of 2% lidocaine at fortnightly intervals. The other group received 1000 impulses of shock waves in three sessions at weekly intervals. Pain assessment was done using VAS scale and the results were evaluated at six weeks, three months and six months after the completion of the therapy. We concluded that ESWT cannot give us better results compared to the age old practice of local steroid injections despite being a newer and costly modality. Keywords: Tennis elbow, lateral epicondyle, extra corporeal shock wave therapy, steroids INTRODUCTION Tennis elbow is one of the entities occurring as a part of a broad category of overuse syndromes. It is by far the commonest cause of elbow pain in patients attending the orthopaedic clinics 1 . The condition is a self-limiting enthesopathy of middle age usually occurring in patients between 30 and 50 years of age. It is commonly seen in persons involved in repetitive screwing movements of the hand like those seen in carpenters, electricians, plumbers and housewives. Tennis elbow occurs most commonly in the tendon of extensor carpi radialis brevis at its origin from the lateral epicondyle1. Pathophysiology involves repetitive micro-tears in the tendon leading to hemorrhage, rough granulation formation and later on calcification2. Diagnosis is clinical by reproducing the pain over lateral epicondyle by putting the common extensor origin under tension. Differential diagnosis involves entrapment of posterior interosseous nerve or musculocutaneous nerve, cervical degenerative disc disease, radial capitellar degeneration & anconeus muscle inflammation2. Corresponding Author Dr. Rakesh Sharma, Assistant Professor, Department of Orthopaedics, Government Medical College & Hospital, Amritsar E-mail: [email protected] Pb Journal of Orthopaedics Vol-XI, No.1, 2009 The best method of treatment has not yet been established and includes both conservative and operative regime. Conservative methods are anti-inflammatory medications, elbow braces with physiotherapy, ultrasound, autologous blood injection, laser therapy, platelet rich plasma and bioptrons, local steroid injections, botulinum toxin injection, acupuncture, extra corporeal shock wave therapy (ESWT), manipulation under anesthesia2-7. Surgically the pathology can be removed with or without sacrificing the common extensor origin, excision of the bursa & synovial fringes, epicondylar resection and anconeus muscle transfer etc8. ESWT also known as ‘orthotripsy’, is a newer non-surgical method of treating orthopaedic and musculoskeletal disorders. It is theorized that when given in low doses the shock waves disrupt the scar tissue, reduce inflammation, reduce pain signal transmission and stimulate healing9. It is approved by FDA for tennis elbow and plantar fascitis. Many studies have shown little or no difference between placebo and ESWT in terms of pain and function in tennis elbow10-12. Potential complications are temporary, namely numbness, erythema, migraine, syncope & small hematoma locally. If other conservative methods fail, local corticosteroid injections can be used to relieve pain in short term13. These injections are usually given for 3 doses. Complications from repeated steroid injections include hypopigmentation and fat atrophy. Studies show that compared 80 Management of lateral epicondylitis to placebo or NSAIDS, local steroid injections seems to be effective 14-16. We conducted a study in our institution to compare the effectiveness of ESWT vs local steroid injection in lateral epicondylitis of humerus. Table 3 Results at 3 months follow-up Grades Male Group I Female Total Group II Male Female Total Excellent 2 - 2 - - - MATERIALSAND METHODS Good 13 9 22 2 - 2 50 patients with lateral epicondylitis of humerus were randomly divided into 2 groups of 25 each. Group I received local steroid injections of 40 mg methlyprednisolone mixed with 2 ml of 2% lidocaine. 3 such dosages were given at intervals of two weeks, at the maximum point of tenderness. Patients with diabetes were excluded from this group. Group II received extra corporeal shock wave therapy (ESWT) of 1000 impulses of 0.08 mJ / mm2 at frequency of 3Hz per session for 20-30 minutes at weekly interval. Pregnant women, children, anyone with a pacemaker or anti-coagulant therapy and with history of bleeding disorders were excluded from this group. Fair - 1 1 10 11 21 Poor - - - 1 1 2 Patients were assessed as per VAS at the start of treatment and then at 1.5 months, 3 months & 6 months. Results were graded as excellent (0), good (0-30), fair (30-60) and poor (60100) depending on the VAS score. All the patients completed treatment and turned up regularly for follow-up. RESULTS In our study male to female ratio was 28:22 with majority (38) of them falling between age group of 30-49. The duration of pain was on an average 4 weeks. Table 1 Occupation of patients Occupation Group I Group II Total 4 2 3 1 7 8 4 3 2 2 10 4 8 5 5 3 17 12 Carpenter Electrician Plumber Labourer Housewives Office workers Table 2 Results at 1.5 months follow-up Grades Excellent Good Fair Poor Male Group I Female 3 12 - 9 1 - Total 3 21 1 Group II Male Female 5 6 2 2 10 - Total 7 16 2 The results at 1.5 months were encouraging towards group I, as 24 patients had excellent & good results compared to 7 in group II. Pb Journal of Orthopaedics Vol-XI, No.1, 2009 At 3 months, group I had the same results as at 1.5 months, while in the group II, the number of patients with excellent and good results reduced to 2. Table 4 Results at 6 months follow-up Grades Male Group I Female Excellent 3 1 4 - - - Good 10 8 18 2 - 2 Fair 2 1 3 7 11 18 Poor - - - 3 2 5 Total Group II Male Female Total At the end of the study the number of satisfied patients in group I fell down to 22, while 3 had a fair result. In contrast only 2 patients had a satisfactory result in Group II while 5 had a poor result. DISCUSSION Occupational activities that require forceful and repetitive forearm dorsiflexion, radial deviation and supination can cause increased stress on the wrist extensors, resulting in degenerative changes, most commonly within the extensor carpi radialis brevis 1. Even though the different modalities of treatment have been claimed to be effective in treating this condition, due to its chronic nature and tendency to recur with resumption of activity, no single modality has been considered the best. Corticosteriod injections reduce inflammation and pain by their anti-inflammatory action, but only for short term. ESWT has been used by urologists for urinary calculi and most recently in orthopaedic conditions like Achilles/patellar tendonitis, pseudoarthrosis, plantar fascitis, tennis elbow, myositis ossificans and avascular necrosis. The control of pain by intense stimulation is ascribed to mechanisms in the brain stem which exert a descending inhibitory control of transmission through the dorsal horns as well as higher levels in the somatic projection system. 81 Sharma et al In our study the average age of patients was 41.76 years, 56% were men and 44% were women. The study also showed that 46 were dominant arm (right) and only 4 were non-dominant arm (left). All cases in our study had insidious onset of pain, gradually increasing with function and relieved by rest. No case of sudden onset of lateral epicondylitis was encountered. From the results at different follow-ups it is observed that the Group I patients receiving local steroid injection showed significantly better results compared to Group II patients receiving ESWT at all periods of time (Fig. 1) Group I REFERENCE 1. Nirschl RP and Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979; 61: 832-839. 2. 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In Group II, 2 patients suffered from local redness and slight swelling at the point of application of shock waves. CONCLUSION We conclude that both steroid injection and ESWT are simple outdoor procedures for the treatment of tennis elbow. Although both have a role in decreasing pain of tennis elbow but injection of steroid mixed with local anesthetic is more effective in treatment of tennis elbow pain. Further randomized longitudinal clinical trials are required to study the exact role of both the modalities. Pb Journal of Orthopaedics Vol-XI, No.1, 2009 10. Buchbinder R, Green SE, youd JM et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev 2005; (4): CD003524. 11. Blue Cross Blue Shield Association, Technology Evaluation Center. Extracorporeal Shock Wave Therapy (ESWT) for Chronic tendinitis of the elbow (lateral epicondylitis). Technology assessment; 2005; Feb. Accessed Oct 27, 2007. Available at URL address: http:// www.bcbs.com/tec/vol19/19-16.pdf. 12. 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