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New Treatment for Tennis Elbow

Posted on: 02/15/2012
Steroid injections are no longer routinely recommended for lateral epicondylitis (tennis elbow). Instead, physical therapists offer an alternative treatment in the form of something called iontophoresis.

In this article, the use of steroid injection is compared with iontophoresis delivered in two different ways. Iontophoresis uses a small electric current to drive steroid medication through the skin. It is a noninvasive method of reducing the pain of tennis elbow.

Iontophoresis has traditionally been administered in a hands-on process by the physical therapist. The procedure could take anywhere from 20 minutes up to an hour. But now a new battery powered skin patch has been developed that leaves the therapist free to spend treatment time on other aspects of rehabilitation.

Eighty-two (82) patients participated in this study. Each one had a diagnosis of lateral epicondylitis. They were divided into three groups. Group one had the self-contained skin patch placed over the lateral elbow (side away from the body). The patch was left on for two days.

Group 2 received an injection of the same medication used in group one (10 mg dexamethasone). One injection was given into the extensor tendon-muscle along the lateral elbow. Group 3 received a 10 mg injection of a steroid (triamcinolone) to the same extensor area of tendon-muscle.

Steroid injection has fallen out of favor for the treatment of lateral epicondylitis but is still used by some physicians. The disadvantages of steroid injection include only short-term pain relief and disruption of the body's natural healing process.

Steroid injections do not change the underlying pathology. And in the case of degenerative rather than inflammatory epicondylitis, steroids can actually delay healing. Since iontophoresis and steroid injections are all antiinflammatories, the question has been raised: why use them if there’s only a short-term benefit with potential drawbacks?

The authors explain that pain relief (even if temporary) is valuable. Turning off pain signals at the tendon-bone interface can help break the pain cycle. This gives the patient an opportunity to rehab under the guidance of the therapist.

It is also possible that it's not the medication itself that is the problem but rather the method of delivery. That's what makes this study valuable: comparing three different delivery methods of the same or similar medication.

Results showed that the two groups treated with iontophoresis got better faster than the steroid injection group. The best clinical outcomes were in the skin patch iontophoresis delivery. But at the end of six months, pain relief, grip strength, and hand function were the same for all three groups.

There were some treatment failures but they were evenly distributed in all three groups. The patients in the iontophoresis group received by skin patch were able to return-to-work sooner and with fewer restrictions compared with the other two groups. Overall, battery delivered iontophoresis provided faster results than the injection groups. This may be evidence that the method of drug delivery is an important factor as suspected.

Future studies are needed to compare patients who receive no treatment with those who are given a placebo iontophoresis treatment. It's important to sort out the real reason(s) why some patients improve while others don't (or improve at a slower rate).

Is it truly the method of drug delivery or just a matter of time, the electrical stimulation, or the hand therapy? There are questions the authors intend to pursue further in future research efforts to find the fastest, most effective treatment for lateral epicondylitis.

Amalia Stefanou, MD, et al. A Randomized Study Comparing Corticosteroid Injection to Corticosteroid Iontophoresis for Lateral Epicondylitis. In The Journal of Hand Surgery. January 2012. Vol. 37A. No. 1. Pp. 104-109.

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