Tennis elbow Musculoskeletal disorders

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1 Search date April 2003 Willem Assendelft, Sally Green, Rachelle Buchbinder, Peter Struijs, and Nynke Smidt QUESTIONS Effects of treatments TREATING TENNIS ELBOW Beneficial Topical non-steroidal anti-inflammatory drugs for short term pain relief Likely to be beneficial Oral non-steroidal anti-inflammatory drugs for short term pain relief Trade off between benefits and harms Corticosteroid injections INTERVENTIONS Unknown effectiveness Acupuncture Exercise and mobilisation Non-steroidal anti-inflammatory drugs for longer term pain relief Orthoses (braces) Surgery Unlikely to be beneficial Extracorporeal shock wave therapy To be covered in future updates Physiotherapy 1753 Key Messages Topical non-steroidal anti-inflammatory drugs for short term pain relief One systematic review has found that topical non-steroidal anti-inflammatory drugs improve pain in the short term compared with placebo. Minor adverse effects have been reported. We found no RCTs comparing oral versus topical non-steroidal anti-inflammatory drugs. Oral non-steroidal anti-inflammatory drugs for short term pain relief One systematic review found limited evidence that an oral non-steroidal antiinflammatory drug reduced pain and improved function compared with placebo in the short term, although we found limited evidence that it was less effective than corticosteroid injection in the short term. Corticosteroid injections One systematic review and subsequent RCTs of corticosteroid injections found limited evidence of a short term improvement in symptoms with steroid injections compared with placebo, a local anaesthetic, orthoses (elbow strapping), physiotherapy, or oral non-steroidal antiinflammatory drugs. We found no good evidence on long term effects of corticosteroids compared with placebo, local anaesthetic, physiotherapy (mobilisation plus massage) or elbow strapping, and found limited evidence that corticosteroid injection was less effective than physiotherapy or oral non-steroidal anti-inflammatory drugs in the long term. Acupuncture We found insufficient evidence from small, methodologically weak RCTs about effects of needle acupuncture, laser acupuncture, or electroacupuncture) in people with tennis elbow. Clin Evid 2004;12:

2 1754 Exercise and mobilisation One small RCT identified by a systematic review found limited evidence that exercise reduced symptoms at 8 weeks compared with ultrasound plus friction massage. However, we were unable to draw reliable conclusions from this small study. Non-steroidal anti-inflammatory drugs for longer term pain relief We found insufficient evidence to assess the longer term effects of oral or topical non-steroidal anti-inflammatory drugs, although one RCT found that oral non-steroidal anti-inflammatory drugs were more effective than corticosteroid injections in the long term. Orthoses One systematic review found insufficient evidence about the effects of orthoses (braces) compared with placebo or physiotherapy. It found limited evidence of a short term improvement in symptoms compared with corticosteroid infections. Surgery One systematic review found no RCTs of surgical treatment. Extracorporeal shock wave therapy One systematic review and one subsequent RCT found no significant difference in symptoms between extracorporeal shock wave therapy and sham treatment at 3 months. DEFINITION has many analogous terms, including lateral elbow pain, lateral epicondylitis, rowing elbow, tendonitis of the common extensor origin, and peritendinitis of the elbow. is characterised by pain and tenderness over the lateral epicondyle of the humerus and pain on resisted dorsiflexion of the wrist, middle finger, or both. For the purposes of this review, tennis elbow is restricted to lateral elbow pain or lateral epicondylitis. INCIDENCE/ Lateral elbow pain is common (population prevalence 1 3%). 1 Peak PREVALENCE incidence is at years of age, and for women of years of age the incidence increases to 10%. 2,3 The incidence of lateral elbow pain in general practice is 4 7/1000 people a year. 3 5 AETIOLOGY/ is considered to be an overload injury, typically after RISK FACTORSminor and often unrecognised trauma of the extensor muscles of the forearm. Despite the title tennis elbow, tennis is a direct cause in only 5% of those with lateral epicondylitis. 6 PROGNOSIS Although lateral elbow pain is generally self limiting, in a minority of people symptoms persist for 18 months to 2 years and in some cases for much longer. 7 The cost is therefore high, both in terms of lost productivity and healthcare use. In a general practice trial of an expectant waiting policy, 80% of the people with elbow pain of already greater than 4 weeks duration had recovered after 1 year. 8 AIMS OF To reduce lateral elbow pain and improve function, with minimal INTERVENTIONadverse effects. OUTCOMES Pain at rest, with activities and resisted movements (visual analogue scale or Likert scale); function (validated disability questionnaire, includes 30 point Disabilities of the Arm, Shoulder, and Hand questionnaire, or visual analogue scale or Likert scale); quality of life (validated questionnaire); grip strength (dynamometer); return to work, normal activities, or both; overall participant reported improvement; adverse effects (participant or researcher report); Roles Maudsley subjective pain score where 1 = excellent, no

3 METHODS QUESTION pain, full movement, full activity; 2 = good, occasional discomfort, full movement and full activity; 3 = fair, some discomfort after prolonged activity; and 4 = poor, pain limiting activities. Clinical Evidence search and appraisal April We included all RCTs and quasi-rcts of any of the listed interventions in (1) people older than 16 years of age with (2) lateral elbow pain for greater than 3 weeks duration and (3) no history of significant trauma or systemic inflammatory conditions such as rheumatoid arthritis. We included trials in people with various soft tissue diseases and pain due to tendinitis at all sites, provided that the lateral elbow pain results were presented separately or that greater than 90% of people had lateral elbow pain. What are the effects of treatments? OPTION ACUPUNCTURE Sally E Green and Rachelle Buchbinder We found insufficient evidence from small, methodologically weak RCTs about effects of needle acupuncture, laser acupuncture, or electro-acupuncture in people with tennis elbow. Benefits: Versus placebo We found one systematic review (search date 2001, 4 RCTs, 239 people with tennis elbow defined as lateral elbow pain aggravated by wrist and finger dorsiflexion) 9 and one subsequent RCT. 10 None of the RCTs evaluated the effects of acupuncture on quality of life or return to work. The review found that there were important problems with the methodology of the included trials (particularly small populations, uncertain allocation concealment, and substantial loss to follow up) and clinical differences between trials. Results could not be combined in a metaanalysis. The first RCT (48 people) comparing needle acupuncture with sham acupuncture (with needles not inserted) found that acupuncture significantly increased the duration of pain relief and significantly increased the proportion of people with at least 50% reduction in pain after one treatment (duration of pain relief: WMD 18.8 hours, 95% CI 10.1 hours to 27.5 hours; pain reduction: 19/24 [79%] with acupuncture v 6/24 [25%] with sham treatment; RR 3.2, 95% CI 1.5 to 6.5; see comment below). 11 The second RCT found that needle acupuncture significantly increased the proportion of people with a self reported good or excellent result compared with sham treatment (22/44 [50%] with needle acupuncture v 8/38 [21%] with sham treatment; RR 2.4, 95% CI 1.2 to 4.7) after 10 treatments. 12 However, it found no significant difference in the longer term (after 3 or 12 months). The third RCT found no significant difference between laser acupuncture and sham treatment in the proportion of participants reporting no improvement or worsening of symptoms (after 10 sessions: 6/23 [26.1%] with laser v 5/26 [19.2%] with sham treatment; RR 1.36, 95% CI 0.48 to 3.86; at 3 months: 2/22 [9.1%] with laser v 6/25[24%] with sham treatment; RR 0.38, 95% CI 0.09 to 1.69; after 12 months: 1/18 [5.6%] v 0/21 [0%] with sham treatment; RR 3.47, 95% CI 0.15 to 80.36). 9 The fourth RCT found no significant difference in cure rate 1755

4 1756 (definition of cure not reported) between vitamin B12 injection plus acupuncture and vitamin B12 injection alone (risk of cure with B12 injection alone: RR 0.44, 95% CI 0.15 to 1.29). 9 The subsequent RCT (45 people) compared 10 treatments of acupuncture with sham acupuncture. 10 It found significantly greater reductions in pain intensity and functional impairment with acupuncture compared with sham treatment at 2 weeks (on 30 mm visual analogue scale pain improved by 8.43 with acupuncture v 4.89 with sham treatment, P < 0.05; Disabilities of the Arm, Shoulder, and Hand questionnaire improved by with acupuncture v 8.54 with sham treatment, P < 0.05). Manual versus electroacupuncture: We found one small RCT (20 people) comparing manual versus electro-acupuncture and assessed pain immediately following a course of six treatments over 2 weeks. 13 It found that electro-acupuncture significantly reduced pain compared with manual acupuncture (pain scored on 10 cm visual analogue scale; pain reduction: 50% with electro-acupuncture v 32% with manual acupuncture, P < 0.001). We found no RCT on the effect of acupuncture on quality of life, strength, or return to work. Harms: Long term follow up of one RCT 10 found that one person (1/45) withdrew due to pain from acupuncture. 14 It found no other adverse events. The other RCTs did not report on harms. Comment: Versus placebo: Although statistically significant, an increase of 18 hours in pain relief after needle acupuncture may not be clinically important. 9 OPTION ORTHOSES (BRACES) Willem JJ Assendelft and Peter AA Struijs One systematic review found insufficient evidence about the effects of orthoses (braces) compared with placebo or physiotherapy. It found limited evidence of a short term improvement in symptoms compared with corticosteroid injections. Benefits: We found one systematic review (search date 1999). 15 Results were not pooled because of considerable heterogeneity among trials. Versus placebo or no treatment: The review identified no RCTs. 15 We found no subsequent RCTs. Versus corticosteroid injections: The review found two RCTs comparing orthoses versus corticosteroid injections. 15 The first RCT (16 people) compared an orthotic device versus corticosteroid injections. It found no significant difference in short term improvement in pain (improvement: 27.1 with corticosteroid v 13.6 with orthotic device; 100 mm visual analogue score difference +13.5, 95% CI 4.6 to +31.6). 15 The second RCT (70 people, 4 treatment groups) found that corticosteroid injection significantly increased the proportion of people having a good or excellent self reported outcome at 2 weeks compared with a splint or elbow band but found no significant difference at 6 or 12 months (2 weeks: AR 34/37 [92%] pooled results for splint and elbow band group v 6/19 [32%] with injection; RR 2.9, 95% CI 1.8 to 5.7; 6 months: 19/37 [51%] v 14/19 [74%]; RR 0.7, 95% CI 0.46 to 1.05; 12 months: 22/37 [59%] v 13/19

5 [68%]; RR 0.9, 95% CI 0.6 to 1.03). 15 Versus physiotherapies: The review found one RCT (84 people) comparing an elbow support versus an unspecified physical therapy. 15 It found no significant difference in short term self reported satisfaction (23/49 [47%] with elbow support v 16/35 [46%] with unspecified physical therapy; RR 1.03, 95% CI 0.64 to 1.64). This study provided insufficient information to assess pain improvement. It also had a withdrawal rate of 30%. Versus non-steroidal anti-inflammatory cream: The review found one RCT (17 people) comparing a non-steroidal anti-inflammatory cream (details of cream not reported in review) versus an elbow strap. 15 It found greater short term pain reduction with the cream (WMD [scale not specified] 0.38, 95% CI 0.02 to 0.70). Harms: The review did not report on harms. 15 Comment: The review reported that validity scores for the RCTs ranged from low to medium. 15 The review identified three RCTs comparing adding an orthotic device to corticosteroid injections or ultrasound. All three RCTs reported only short term results and there were insufficient data or the power of the study was too low to indicate the effect of orthoses OPTION CORTICOSTEROID INJECTIONS Willem JJ Assendelft and Nynke Smidt One systematic review and subsequent RCTs of corticosteroid injections found limited evidence of a short term improvement in symptoms with steroid injections compared with placebo, a local anaesthetic, orthoses (elbow strapping), physiotherapy, or oral non-steroidal anti-inflammatory drugs. We found no good evidence on long term effects of corticosteroids compared with placebo, local anaesthetic, physiotherapy(mobilisation plus massage), or elbow strapping, and found limited evidence that corticosteroid injection was less effective than physiotherapy or oral non-steroidal anti-inflammatory drugs in the long term. Benefits: We found one systematic review (search date 1999) 16 and two subsequent RCTs. 17,18 None of the RCTs evaluated the effects of corticosteroid injections on quality of life or return to work. Versus placebo or no treatment: The review identified two RCTs comparing corticosteroid injection (1 ml methylprednisolone acetate) versus injection of saline solution. The first RCT (29 people in smallest group; see comment below) found that corticosteroid significantly increased short term global improvement compared with saline injection (timescale not further specified; RR 0.11, 95% CI 0.04 to 0.33). The RCT did not measure pain or grip strength. The second RCT (10 people in smallest group) found no significant difference in short term pain, global improvement, or grip strength. The first subsequent RCT (39 people with symptoms > 4 weeks) compared corticosteroid injection versus a control injection. 17 All people received rehabilitation. It found that corticosteroid injection significantly improved pain compared with control from 8 weeks to 6 months (improvement on 100 point visual analogue scale: 24.3 with steroid injection v 8.9 with control injection; P = 0.04; CI not

6 1758 reported). It found no significant difference in other pain outcomes or grip strength. The second subsequent RCT (59 people in smallest group) compared corticosteroid injection with no treatment and with physiotherapy. 18 It found corticosteroid injection significantly improved mean main complaint and functional disability at 3 and 6 weeks compared with no treatment (at 6 weeks, mean difference in main complaint 24%, 95% CI 14% to 35%). It found no significant difference at 12, 26, and 52 weeks (at 52 weeks, mean difference in main complaint 9%, 95% CI 19% to +2%). Versus local anaesthetic: The review identified three RCTs comparing corticosteroid injections versus local anaesthetic alone. 16 Two RCTs (18 and 35 people in smallest groups) found greater global improvement in the short term (4 weeks; follow up not stated) with corticosteroid injections (1 ml hydrocortisone acetate 25 mg and 1 ml methylprednisolone acetate 10 mg), but data could not be pooled because of heterogeneity. The third RCT (7 people in smallest group) reported only medium term results. It found no significant difference in global improvement at 9 17 weeks (chance of not getting a good outcome: RR 0.97, 95% CI 0.41 to 2.32). Versus orthoses: See benefits of orthoses, p Versus physiotherapies: The review identified two RCTs comparing corticosteroid injections (1 ml triamcinolone acetate 1% plus 1 ml lidocaine [lignocaine]) versus physiotherapies, 16 and we found one additional RCT. 18 The first RCT identified by the review (53 people in smallest group) found that friction massage and a manipulation technique significantly reduced the chance of overall improvement compared with steroid injection (overall improvement: RR 0.45, 95% CI 0.29 to 0.69). It found no significant difference in any outcome at 52 weeks. The review was unable to report measured results for the second RCT (12 people in smallest group). The additional RCT (59 people in smallest group) compared a corticosteroid injection with no treatment and with physiotherapy consisting of nine sessions of ultrasound, deep friction massage, and an exercise programme over 6 weeks (see versus placebo or no treatment above). 18 It found that corticosteroid injection significantly improved the main complaint and functional disability at 3 and 6 weeks compared with physiotherapy (at 6 weeks, mean difference in main complaint 20%, 95% CI 10% to 31%). However, there was no significant difference at 12 weeks, and at 26 and 52 weeks physiotherapy significantly improved the main complaint compared with corticosteroid injection (at 52 weeks, mean difference in main complaint 15%, 95% CI 5% to 25%). Versus non-steroidal anti-inflammatory drugs: See oral non-steroidal anti-inflammatory drugs versus corticosteroid injections, p Harms: Comment: The review (8 RCTs) found no significant difference in adverse events between corticosteroid injections and control interventions (including facial flushes, post-injection pain, and local skin atrophy). 16 However, the review did not report P values. The review provided the number of people in the smallest group for each trial rather than the total number of people in the trial. The review found that in the longer term there was a high rate of improvement in all groups. 16 It found that in general the quality of the methodology of the RCTs was poor to modest. The corticosteroid

7 suspensions used in these trials were methylprednisolone (2 RCTs), triamcinolone (4 RCTs), betamethasone (2 RCTs), hydrocortisone (5 RCTs), and dexamethasone (1 RCT). In one RCT, two different substances were used. The RCTs with longer term results for corticosteroid compared with non-steroidal anti-inflammatory drugs and with physiotherapy suggested that a steroid injection improved outcomes in the short term but increased recurrences in the medium term. OPTION NON-STEROIDAL ANTI-INFLAMMATORY DRUGS Sally E Green and Rachelle Buchbinder One systematic review has found that topical non-steroidal anti-inflammatory drugs improve symptoms in the short term compared with placebo. Minor adverse effects have been reported. The review found limited evidence that oral non-steroidal anti-inflammatory drugs improved symptoms in the short term compared with placebo, although we also found limited evidence that it was less effective than corticosteroid injection in the short term. We found insufficient evidence to assess the longer term effects of non-steroidal anti-inflammatory drugs compared with placebo, although one RCT found that oral non-steroidal anti-inflammatory drugs were more effective than corticosteroid injections in the long term. We found no RCTs comparing oral versus topical non-steroidal anti-inflammatory drugs. Benefits: We found one systematic review (search date 2001) 19 and no subsequent RCTs. None of the RCTs in the review evaluated the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on return to work or quality of life. Topical NSAIDs versus placebo: The review found that topical NSAIDs significantly improved pain at up to 4 weeks compared with placebo and significantly reduced participant opinion of no benefit (3 RCTs, 130 people; pain: WMD 1.88, 95% CI 2.54 to 1.21; scale 0 [no pain] to 10 [maximum pain]; no benefit: 2 RCTs; RR 0.39, 95% CI 0.23 to 0.66). 19 Inclusion of unblinded trials did not significantly change the results. It found no significant differences between topical NSAIDs and placebo for grip strength (reported as non-significant, further data not reported) or range of motion (RR for limitation of movement 1.01, 95% CI 0.80 to 1.28). It found that NSAIDs significantly improved the doctor s opinion of effect on pain and in tenderness with placebo (pain: WMD 1.88, 95% CI 2.54 to 1.21; scale 0 [no pain] to 10 [maximum pain]; RR for tenderness 0.83, 95% CI 0.70 to 0.99). The topical NSAIDs used were diclofenac (2 RCTs) and benzydamine (1 RCT). Oral NSAIDs versus placebo: The review found two RCTs. 19 The RCTs were not pooled because one reported means and standard deviations and the other medians and ranges. One RCT found limited evidence that diclofenac improved short term pain and function compared with placebo but did not assess long term results (WMD 13.9, 95% CI 23.2 to 4.6 on 100 point scale). The second RCT found no significant difference in pain over 28 days, 6 months, or 1 year or for function at 6 months or 1 year (median [range] pain score, 28 days: 4 [2 6] with naproxen v 3.5 [2 6] with placebo; 6 months: 1 [0 3] with NSAIDs v 1 [0 2.2] with placebo; 12 months: 0 [0 2] with NSAIDs v 0 [0 2] with placebo; 1759

8 1760 function at 6 months: 0 [0 2.75] with NSAIDs v 0.5 [0 2] with placebo; at 12 months: 1 [0 1] with NSAIDs v 0 [0 0] with placebo). Oral NSAIDs versus corticosteroid injection: The review found three RCTs. 19 Only two RCTs were included in the meta-analysis because of incomplete reporting of results. The first of these RCTs compared 20 mg methylprednisolone plus lidocaine versus 500 mg naproxen, and the second compared 6 mg betamethasone plus prilocaine plus placebo tablets versus 500 mg naproxen (initial high dose, then 250 mg). Meta-analysis of self reported perception of benefit found a significant difference in favour of injection at 4 weeks (RR of participant perceived benefit of injection 3.06, 95% CI 1.55 to 6.06). One RCT was not included in the meta-analysis because of skewed data; it found less functional limitation at 4 weeks in the injection group (median [range] 0 [0 2] with injection v 3 [1 5] with NSAIDs). The greater benefit of injection compared with naproxen was only found in the short term. The largest RCT (53 people in smallest group) found significantly greater improvement in pain at 26 weeks with an NSAID (RR 1.71, 95% CI 1.17 to 2.51). It found no significant difference in grip strength and results were not reported for global improvement. Harms: Comment: Topical NSAIDs: One RCT identified by the review found that topical NSAIDs significantly increased any adverse event compared with placebo (RR 2.26, 95% CI 1.04 to 4.94). 20 Adverse effects were mild and no one was withdrawn from the study. Adverse effects reported in the published trials were foul breath and minor skin irritation. Oral NSAIDs: One trial of oral NSAIDs found an increased risk of abdominal pain and diarrhoea (pain: RR 3.17, 95% CI 1.35 to 7.41; diarrhoea: RR 1.92, 95% CI 1.08 to 3.14). One systematic review (search date 1994, 12 RCTs of NSAIDs in a variety of disorders) 21 found that the overall relative risk of complications from oral NSAIDs was Adverse effects were predominantly gastrointestinal. See important differences between available NSAIDs in the NSAIDs chapter, p Both topical and oral NSAIDs may provide short term relief of pain in tennis elbow, although topical NSAIDs may be associated with fewer adverse effects. Further placebo controlled and comparative trials of oral compared with topical NSAIDs would help to clarify the effects of NSAIDs in the treatment of tennis elbow. Few trials used intention to treat analysis, and the sample size of most was small (populations range from people for trials included in the meta-analysis). 19 OPTION EXERCISE AND MOBILISATION Willem JJ Assendelft and Nynke Smidt One small RCT identified by a systematic review found limited evidence that exercise reduced symptoms at 8 weeks compared with ultrasound plus friction massage. However, we were unable to draw reliable conclusions from this small study. We found no RCTs of mobilisation.

9 Benefits: We found one systematic review (search date 1999, 1 RCT, 19 people). 22 The small RCT found that exercise significantly improved symptoms at 8 weeks compared with ultrasound plus friction massage (SMD 0.95, 95% CI 1.64 to 0.26). Four other RCTs were either of poor validity or provided insufficient data on relevant outcome measures. We found no RCTs of mobilisation. Harms: No harms were described in the systematic review. 22 Comment: None. OPTION EXTRACORPOREAL SHOCK WAVE THERAPY Rachelle Buchbinder and Sally E Green One systematic review and one subsequent RCT found no significant difference in symptoms between extracorporeal shock wave therapy and sham treatment at 3 months Benefits: Versus placebo: We found one systematic review (search date 2001, 2 RCTs, 286 people) 23 and one subsequent RCT comparing extracorporeal shock wave therapy (ESWT) versus placebo. 24 Both RCTs identified by the review had similar study populations (mean age years, slightly more women) with chronic symptoms (mean duration months) who had not improved on at least 6 months of conservative treatment, including non-steroidal anti-inflammatory drugs, injections, brace or taping, casting, and physiotherapy. The frequency, doses, and technique of ESWT application were similar in both trials. The first RCT in the review used 1000 impulses of 0.08 mj/mm 2 of ESWT at weekly intervals for 3 weeks. 23 The second RCT in the review used low energy ESWT with 2000 pulses under local anaesthesia (3 ml mepivacaine 1%) at weekly intervals for 3 weeks using device dependent energy flux density (ED+) between 0.07 and 0.09 mj/mm The review found no significant difference in treatment failure (defined as Roles Maudsley subjective pain score of 4) between ESWT and placebo at 6 weeks and at 1 year (6 weeks: RR 0.40, 95% CI, 0.08 to 1.91; 1 year: RR 0.44, 95% CI 0.09 to 2.17). After 6 weeks, it found no significant improvement in pain at rest, pain with resisted wrist extension, or pain with resisted middle finger extension (pain scored out of 100 points; pain at rest: WMD 11.4, 95% CI 26.1 to +3.3; pain with resisted wrist extension: WMD 16.2, 95% CI 47.8 to +15.4; pain with resisted middle finger extension: WMD 20.5, 95% CI 56.6 to +15.6). At 12 and 24 weeks, it found no significant difference between treatments in pain at 12 to 24 weeks (pain scored out of 100 points; improvement in pain at rest: WMD 14.7, 95% CI 35.4 to +6.1; pain with resisted wrist extension: WMD 14.70, 95% CI 43.4 to +14.0; pain with resisted middle finger extension: WMD 21.1, 95% CI 58.3 to +16.1). The effect of ESWT on function, quality of life, and return to work was not reported. The effect of ESWT on grip strength was reported in both trials but the results were difficult to interpret in one RCT. The other RCT found no difference in improvement in grip strength between groups at 6 weeks, 12 weeks, or 1 year. The subsequent RCT (75 people) found no significant difference between ESWT (1500

10 1762 Harms: Comment: pulses at 0.18 mj/mm 2 at weekly intervals for 3 weeks) and sham treatment in pain at 3 months (50% or greater improvement in pain measured on 10 mm visual analogue scale: 14/40 [35%] with ESWT v 12/35 [34%] with sham; RR 1.3, 95% CI 0.75 to 2.4). 24 One RCT in the review did not report adverse events. 23 The other RCT in the review reported significantly more adverse effects in the EWST group compared with placebo (OR 4.3, 95% CI 2.9 to 6.3). However, there were no treatment discontinuations or dosage adjustments related to adverse effects. The most frequently reported adverse effects in the ESWT treated group were transitory reddening of the skin (21.1% with ESWT v 4.7% with placebo); pains (4.8% with ESWT v 1.7% with placebo); and petechiae, bleeding, or haematomas (4.5% with ESWT v 1.7% with placebo). Migraine occurred in four people and syncope in three people after ESWT, compared with no people treated with placebo. No significant adverse effects were reported in the subsequent RCT. 24 The two RCTs in the review found conflicting results. 23 When data from both trials were pooled, the benefits observed in the first trial were no longer apparent. This RCT, which found a significant improvement, had uncertain allocation concealment and no analysis of early withdrawals (15/115 [13%]). OPTION SURGERY Rachelle Buchbinder and Sally E Green One systematic review found no RCTs of surgical treatment. Benefits: We found one systematic review (search date 2001), which identified no RCTs. 25 We found no subsequent RCTs. Harms: We found no RCTs. Comment: Various open and percutaneous operations for lateral elbow pain have been described based upon the surgeon s concept of the pathological entity. The most commonly described surgical procedures involve excision of abnormal tissue (comprising microscopic degeneration, rupture, or both, and immature reparative tissue) within the origin of extensor carpi radialis brevis, release of the extensor carpi radialis brevis from the lateral epicondyle region, or both. Additional procedures include release of the anterior capsule, removal of inflamed synovial folds, resection of a third of the orbicular ligament, debridement of articular damage, release of the posterior interosseous nerve, denervation of the lateral epicondyle, denervation of the radiohumeral joint, and excision of a radiohumeral bursa REFERENCES 1. Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol 1974;3: Chard MD, Hazleman BL. a reappraisal. Br J Rheumatol 1989;28: Verhaar J. : anatomical, epidemiological and therapeutic aspects. Int Orthop 1994;18: Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract 1986;36:

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12 Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop 1992;278: Yerger B, Turner T. Percutaneous extensor tenotomy for chronic tennis elbow. Orthopedics 1985;8: Willem Assendelft Head of Department of Guideline Development and Research Policy Dutch College of General Practitioners Utrecht The Netherlands Sally Green Senior Lecturer Institute of Health Services Research Monash University Melbourne Australia Rachelle Buchbinder Director Department of Clinical Epidemiology Cabrini Hospital and Monash University Department of Epidemiology and Preventive Medicine Melbourne Australia Peter Struijs Academic Medical Center Amsterdam The Netherlands Nynke Smidt Institute for Research in Extramural Medicine Amsterdam The Netherlands Competing interests: The authors of this piece are the authors of the Cochrane Reviews from which most of the evidence is drawn. WA has supervised and PS has conducted a trial sponsored by Bauerfeind, a manufacturer of orthoses. RB, SG, and NS none declared.