JAMA：治疗网球肘不宜注射皮质醇

　　澳大利亚昆士兰大学的Coombes等2月6日在《美国医学会杂志》[JAMA 2013，309（5）：461-9]上发表的一项随机对照临床试验表明，对于肱骨外上髁炎（网球肘）患者，注射皮质类固醇和物理治疗1年后的完全恢复和显著改善率低于安慰剂治疗，并且复发率升高。

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.

Importance  

Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking.

Objective  

To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia.

Design, Setting, and Patients  

A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial was conducted at a single university research center and 16 primary care settings in Brisbane, Australia. A total of 165 patients aged 18 years or older with unilateral lateral epicondylalgia of longer than 6 weeks' duration were enrolled between July 2008 and May 2010; 1-year follow-up was completed in May 2011.

Interventions  

Corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41).

Main Outcome Measures  

The 2 primary outcomes were 1-year global rating of change scores for complete recovery or much improvement and 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later) analyzed on an intention-to-treat basis (P < .01). Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks.

Results  

Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; relative risk [RR], 0.86 [99% CI, 0.75-0.99]; P = .01) and greater 1-year recurrence (54% vs 12%; RR, 0.23 [99% CI, 0.10-0.51]; P < .001). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, 0.90-1.19]; P = .56) or recurrence (29% vs 38%; RR, 1.31 [99% CI, 0.73-2.35]; P = .25). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, 0.62-0.99]; P < .001) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively; RR, 1.22 [99% CI, 0.97-1.53]; P = .84). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy (P = .01), whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; RR, 4.00 [99% CI, 1.07-15.00]; P = .004). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, 0.65-1.38]; P = .57).

Conclusion and Relevance  

Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.