Restricted accessResearch articleFirst published online 2022-8
Effects of Heavy Slow Resistance Training Combined With Corticosteroid Injections or Tendon Needling in Patients With Lateral Elbow Tendinopathy: A 3-Arm Randomized Double-Blinded Placebo-Controlled Study
Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy.
Purpose/Hypothesis:
The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks’ follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy.
Study Design:
Randomized controlled trial; Level of evidence, 1.
Methods:
A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area).
Results:
A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ–2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks.
Conclusion:
These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up.
AgergaardASSvenssonRBMalmgaard-ClausenNM, et al. Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy: a randomized clinical trial. Am J Sports Med. 2021;49(4):982-993.
2.
Alakhdar MohmaraYCookJBenitez-MartinezJC, et al. Influence of genetic factors in elbow tendon pathology: a case-control study. Sci Rep. 2020;10(1):6503.
3.
AlfredsonHLjungBOThorsenKLorentzonR. In vivo investigation of ECRB tendons with microdialysis technique: no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand. 2000;71(5):475-479.
4.
BeyerRKongsgaardMHougs KjaerB, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704-1711.
5.
BissetLBellerEJullG, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.
6.
BissetLSmidtNVan der WindtDA, et al. Conservative treatments for tennis elbow: do subgroups of patients respond differently?Rheumatology (Oxford). 2007;46(10):1601-1605.
7.
BissetLMVicenzinoB. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015;61(4):174-181.
8.
BudtzCRAndersenJHde Vos AndersenNBChristiansenDH. Responsiveness and minimal important change for the quick-DASH in patients with shoulder disorders. Health Qual Life Outcomes. 2018;16(1):226.
9.
CoombesBKBissetLBrooksPKhanAVicenzinoB. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469.
10.
CoombesBKBissetLVicenzinoB. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767.
11.
CouppeCSvenssonRBSilbernagelKGLangbergHMagnussonSP. Eccentric or concentric exercises for the treatment of tendinopathies?J Orthop Sports Phys Ther. 2015;45(11):853-863.
12.
du ToitCStielerMSaundersRBissetLVicenzinoB. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med. 2008;42(11):872-876.
13.
GaidaJEAsheMCBassSLCookJL. Is adiposity an under-recognized risk factor for tendinopathy? A systematic review. Arthritis Rheum. 2009;61(6):840-849.
14.
HaraldssonBTAagaardPCrafoord-LarsenDKjaerMMagnussonSP. Corticosteroid administration alters the mechanical properties of isolated collagen fascicles in rat-tail tendon. Scand J Med Sci Sports. 2009;19(5):621-626.
15.
HaraldssonBTLangbergHAagaardP, et al. Corticosteroids reduce the tensile strength of isolated collagen fascicles. Am J Sports Med. 2006;34(12):1992-1997.
16.
HayEMPatersonSMLewisMHosieGCroftP. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319(7215):964-968.
17.
HeinemeierKMLorentzenMPJensenJK, et al. Local trauma in human patellar tendon leads to widespread changes in the tendon gene expression. J Appl Physiol (1985). 2016;120(9):1000-1010.
18.
HerupAMerserSBoeckstynsM. [Validation of questionnaire for conditions of the upper extremity]. Ugeskr Laeger. 2010;172(48):3333-3336.
19.
HjermstadMJFayersPMHaugenDF, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073-1093.
20.
JohannsenFEHerzogRBMalmgaard-ClausenNM, et al. Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):5-12.
21.
KaranasiosSKorakakisVWhiteleyR, et al. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. Br J Sports Med. 2021;55(9):477-485.
22.
KennedyCABeatonDE. A user’s survey of the clinical application and content validity of the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure. J Hand Ther. 2017;30(1):30-40.e2.
23.
KongsgaardMKovanenVAagaardP, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802.
24.
KongsgaardMQvortrupKLarsenJ, et al. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. Am J Sports Med. 2010;38(4):749-756.
25.
KraushaarBSNirschlRP. Tendinosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259-278.
26.
KreyDBorchersJMcCameyK. Tendon needling for treatment of tendinopathy: a systematic review. Phys Sportsmed. 2015;43(1):80-86.
27.
KroghTPBartelsEMEllingsenT, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435-1446.
28.
KroghTPFredbergUAmmitzbollCEllingsenT. Clinical value of ultrasonographic assessment in lateral epicondylitis versus asymptomatic healthy controls. Am J Sports Med. 2020;48(8):1873-1883.
29.
KroghTPFredbergUStengaard-PedersenK, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-635.
30.
LjungBOAlfredsonHForsgrenS. Neurokinin-1 receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerus: studies on tennis elbow and medial epicondylalgia. J Orthop Res. 2004;22(2):321-327.
31.
LjungBOForsgrenSFridenJ. Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow. J Orthop Res. 1999;17(4):554-559.
32.
LundquistCBDossingKChristiansenDH. Responsiveness of a Danish version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Dan Med J. 2014;61(4):A4813.
33.
MacdermidJ. Update: the Patient-Rated Forearm Evaluation Questionnaire is now the Patient-Rated Tennis Elbow Evaluation. J Hand Ther. 2005;18(4):407-410.
34.
MagnussonSPKjaerM. The impact of loading, unloading, ageing and injury on the human tendon. J Physiol. 2019;597(5):1283-1298.
35.
MalliarasPBartonCJReevesNDLangbergH. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286.
36.
OlaussenMHolmedalOMdalaIBrageSLindbaekM. Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial. BMC Musculoskelet Disord. 2015;16:122.
37.
PetersonMButlerSErikssonMSvardsuddK. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011;116(4):269-279.
38.
PetersonMSvardsuddKAppelL, et al. PET-scan shows peripherally increased neurokinin 1 receptor availability in chronic tennis elbow: visualizing neurogenic inflammation?PLoS One. 2013;8(10):e75859.
39.
RabelloLMvan den Akker-ScheekIBrinkMS, et al. Association between clinical and imaging outcomes after therapeutic loading exercise in patients diagnosed with Achilles or patellar tendinopathy at short- and long-term follow-up: a systematic review. Clin J Sport Med. 2020;30(4):390-403.
40.
RamanJMacDermidJCGrewalR. Effectiveness of different methods of resistance exercises in lateral epicondylosis: a systematic review. J Hand Ther. 2012;25(1):5-25.
41.
ReesJGaidaJESilbernagelKG, et al. Rehabilitation of tendon problems in patients with diabetes mellitus. Adv Exp Med Biol. 2016;920:199-208.
42.
RompeJDNafeBFuriaJPMaffulliN. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35(3):374-383.
43.
SalaffiFStancatiASilvestriCACiapettiAGrassiW. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;8(4):283-291.
44.
ShalabiASvenssonLKristoffersen-WibergMAspelinPMovinT. Tendon injury and repair after core biopsies in chronic Achilles tendinosis evaluated by serial magnetic resonance imaging. Br J Sports Med. 2004;38(5):606-612.
45.
ShiriRViikari-JunturaE. Lateral and medial epicondylitis: role of occupational factors. Best Pract Res Clin Rheumatol. 2011;25(1):43-57.
46.
SilbernagelKGCrossleyKM. A proposed return-to-sport program for patients with midportion Achilles tendinopathy: rationale and implementation. J Orthop Sports Phys Ther. 2015;45(11):876-886.
47.
SmidtNLewisMHayEM, et al. A comparison of two primary care trials on tennis elbow: issues of external validity. Ann Rheum Dis. 2005;64(10):1406-1409.
48.
SmidtNLewisMvan der WindtDA, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006;33(10):2053-2059.
49.
SmidtNvan der WindtDA. Tennis elbow in primary care. BMJ. 2006;333(7575):927-928.
50.
SmidtNvan der WindtDAAssendelftWJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657-662.
51.
SmidtNvan der WindtDAAssendelftWJ, et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil. 2002;83(8):1145-1150.
52.
SorensenAAHowardDTanWHKetchersidJCalfeeRP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am. 2013;38(4):641-649.
53.
StratfordPWNormanGRMcIntoshJM. Generalizability of grip strength measurements in patients with tennis elbow. Phys Ther. 1989;69(4):276-281.
54.
Torp-PedersenTETorp-PedersenSTQvistgaardEBliddalH. Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasonography: evidence of inflammation. Br J Sports Med. 2008;42(12):978-982.
55.
van der VlistACWintersMWeirA, et al. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med. 2021;55(5):249-256.
56.
VuvanVVicenzinoBMellorRHealesLJCoombesBK. Unsupervised isometric exercise versus wait-and-see for lateral elbow tendinopathy. Med Sci Sports Exerc. 2020;52(2):287-295.
57.
ZeisigEOhbergLAlfredsonH. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthrosc. 2006;14(7):659-663.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
