Optimisating corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A randomised control trial with placebo comparison.

All participants in the study will be warned that pain-provoking activities should be avoided, especially if the provoked pain persists for longer than several minutes. They will also be advised that complete rest is extremely detrimental to musculoskeletal disorders and that activity that does not create pain in the elbow should be encouraged. There will be four groups: (a) corticosteroid injection only, (b) corticosteroid injection plus physiotherapy, (c) saline injection, and (d) saline injection and physiotherapy. The corticosteroid injection and physiotherapy are described here and saline below in the comparator condition. Corticosteroid injection: This involves the placement of the corticosteroid injection into the most-tender palpable point(s) of the lateral elbow in the region of the lateral humeral epicondyle. The single injection consists of a 1 ml quantity of 1% lignocaine with 10mg of triaminolone acetonide in 1 ml. Participants will be advised to gradually return to normal activities and not to aggressively pursue return of normal activities even if they were pain free. Prior to the injection the practitioner will perform a routine clinical examination as would be regarded best clinical practice. The protocol has been previously followed in Bisset et al (2006, BMJ 333(7575): 939-41). Physiotherapy: Physiotherapy will be as recently evaluated by Bisset et al (2006, BMJ 333(7575): 939-41), which consists of specific elbow manipulation know as mobilisation with movement and a customized therapeutic exercise program (Vicenzino 2003 Manual Therapy 8(2): 66-79) under the guidance of a physiotherapist over 8 thirty minute sessions in 8 weeks (Vicenzino and Bisset 2007, EBM 12: 37-8). Participants are required to perform a home program of exercises and self manipulation twice daily, each session lasting approximately 20 minutes for the duration of the study. The program will be taught by the therapist and progressed at the physiotherapy treatment sessions, as per a standardised protocol, which is based on the status of the condition and its response to the previously prescribed exercise and self manipulation. Program adherence will be facilitated by attendance at the regular therapist sessions, as well as the provision of exercise equipment (e.g., elasticised resistance exercise band(s)) and an exercise booklet. Timing of measures: The injection will be performed within 10 days of randomisation. Participants receiving physiotherapy will commence their first session prior to injection and second session one week following injection, with the remaining 6 sessions completed by 8 weeks post randomisation. Hence participants receiving injection alone will complete their treatment with 10 days, while those receiving injection with physiotherapy will complete treatment by 8 weeks.