The quality of evidence is low, but the applicability is good.
Reference | Study type | Population | Intervention and comparison | Outcomes | Risk of bias |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | SR (13 RCTs) | RCTs «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 Patients had a clinical diagnosis of lateral epicondylitis «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 At least one treatment was ≥ 1 corticosteroid injection «Karanasios S, Korakakis V, Whiteley R ym. Exercise...»3 ≥ 1 clinically relevant outcome measure |
Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation (1 study) |
Pain, Global improvement, grip strength | High |
«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 | RCT | Patients ≥ 18 years (n=185) with pain at the lateral side of the elbow, increasing with pressure on the lateral epicondyle and with resisted dorsiflexion of the wrist; recruited by general practitioners | Corticosteroid injections (n=62) vs. Physiotherapy 6 weeks (n=64) vs. wait-and-see policy (n=59) |
General improvement, severity of the main complaint, pain, elbow disability, patient satisfaction, grip strength. | Moderate |
«Karanasios S, Korakakis V, Whiteley R ym. Exercise...»3 | SR/MA | 30 RCTs (n=2123) comparing the effectiveness of any type of exercise used alone or as an additive intervention compared with another type of conservative intervention in adult patients diagnosed with lateral elbow tendinopathy | Exercise with or without physiotherapy or home exercise programme compared with corticosteroid injection(s) (8 studies) |
Pain, Grip strength, Elbow disability | High |
RCT=randomized controlled trial, SR=systematic review, MA=meta-analysis, PBO=placebo,
Reference | Comments |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 |
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«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 |
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«Karanasios S, Korakakis V, Whiteley R ym. Exercise...»3 |
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Results
Reference | Number of studies and number of patients (I/C) | Follow-up time | Absolute number of events (%) I | Absolute number of events (%) C | RR/MD/SMD (95% CI) |
---|---|---|---|---|---|
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision. |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | 1 RCT (53/53): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation |
6 weeks 52 weeks |
NR | NR | RR: 0.61 (0.48, 0.78) 1.20 (0.96, 1.51) |
«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 | N=126 (62/64) | 3 weeks 6 weeks 12 weeks 26 weeks 52 weeks |
NR | NR | MD: 30 (23, 37) 26 (18, 34) -0.3 (-10, 9) -14 (-23, 5) -11 (-20, -2) |
«Karanasios S, Korakakis V, Whiteley R ym. Exercise...»3 | 8 RCTs (n=933) | 2–3 months 3–12 months > 12 months |
NR | NR | SMD: -0.27 (-0.59, 0.05) -0.69 (-0.91, -0.47) -0.56 (-0.78, -0.34) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; SMD=Standardised mean difference
Reference | Number of studies and number of patients (I/C) | Follow-up time | Absolute number of events (%) I | Absolute number of events (%) C | Relative risk (95% CI) |
---|---|---|---|---|---|
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision. |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | 1 RCT (n=53): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation |
6 weeks 52 weeks |
NR NR |
NR NR |
0.45 (0.29, 0.69) 1.24 (0.81, 1.90) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported
Reference | Number of studies and number of patients (I/C) | Follow-up time | Absolute number of events (%) I | Absolute number of events (%) C | MD/SMD (95% CI) |
---|---|---|---|---|---|
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision. |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | 1 RCT (53 pts): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation |
6 weeks 52 weeks |
NR | NR | SMD: -0.65 (-1.04, 0.25) -0.27 (-0.66, 0.12) |
«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 | 126 pts (62/64) | 3 weeks 6 weeks 12 weeks 26 weeks 52 weeks |
NR | NR | MD: 30 (23, 38) 27 (18, 35) -11 (-21, -0.3) -17 (-28, -6) -24 (-35, -13) |
«Karanasios S, Korakakis V, Whiteley R ym. Exercise...»3 | 8 RCTs (933 patients) | 2–5 months 3–12 months > 12 months |
NR | NR | MD: 12.15 (1.69, 22.60) 22.45 (3.63, 41.30) 18.00 (11.17, 24.84) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; SMD=Standardised mean difference
Adverse events
Short-term (< 6 weeks) adverse events of corticosteroid injections were mostly mild such as facial flushes (3%), post injection pain (11–58%), increased pain > 1 day (16%), red swollen elbow (3%), change of skin colour (11%), local skin atrophy (17–40%) or skin irritation (5%) and other minor or temporary adverse reactions (13%) «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4. Smidt and coworkers reported any adverse event in 58% patients in the cortisone injection group compared to 17% in the wait-and-see group «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2. Two studies reported high recurrence rate (37–72%) in the cortisone injection group after 6–12 weeks compared with physiotherapy or wait-and-see «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4. No serious adverse events were reported «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4.