Perceived Pain Severity and Disability After the Recurrence of Tennis Elbow Following a Local Corticosteroid Injection

Document Type : RESEARCH PAPER


1 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 1 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran 2 Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran

3 Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran

4 Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, USA


Background: We hypothesized that there is no difference in the perceived pain and disability when the tennis elbow 
symptoms recur after a CSI. Consequently, we secondarily aimed to assess the approximate time from CSI until 
symptom recurrence. Moreover, we aimed to evaluate factors associated with the time to recurrence.
Methods: This cross-sectional study was performed during 2018-2019. We enrolled 50 consecutive patients who 
presented with the recurrence of tennis elbow symptoms and had a history of a single CSI for this condition. We asked 
the patients to rate the perceived pain and disability by filling the QuickDASH twice, including one by recalling pain and 
function before the CSI and one for the recent recurrent symptoms to assess the patient’s perceived pain and disability 
at the two-time points. 
Results: There was a significant difference in perceived pain VAS and disability QuickDASH between pre-injection and 
recurrence, showing that the patient’s perceived pain and disability were greater when recurred (P<0.001). The mean 
time between CSI and recurrence of symptoms was 6 (4-7) months, which is shorter than the expected spontaneous 
resolution of tennis elbow (> 1 year) to offer other invasive treatments. Time to recurrence had no significant association 
with sex, age, side, education, occupation, pre-injection VAS score, pre-injection QuickDASH, or symptom duration 
using a linear regression model.
Conclusion: Although CSI seems to relieve or mask the pain in the short term, there is a considerable chance of 
recurrence, and patients may perceive more significant pain and disability that may lead to subsequent injection or 
precocious surgery. Time is an effective treatment for this illness. Shared decision-making is paramount, and patients 
have to be counseled regarding the natural history and expected prognosis of different treatments. 
Level of evidence: IV


1. Vaquero-Picado A, Barco R, Antuña SA. Lateral 
epicondylitis of the elbow. EFORT Open 
Reviews 2016;1(11):391-7. doi: 10.1302/2058-
2. Kachooei AR, Talaei-Khoei M, Faghfouri A, Ring 
D. Factors associated with operative treatment of 
enthesopathy of the extensor carpi radialis brevis 
origin. J Shoulder Elbow Surg 2016;25(4):666-70. 
doi: 10.1016/j.jse.2015.12.019.
3. Sanders Jr TL, Maradit Kremers H, Bryan AJ, Ransom JE, 
Smith J, Morrey BF. The epidemiology and health care 
burden of tennis elbow: a population-based study. The 
American journal of sports medicine 2015;43(5):1066-
71. doi: 10.1177/0363546514568087.
4. Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee 
M, Tytherleigh-Strong G, Rushton N. Lateral 
epicondylitis: a review of pathology and management. 
The bone & joint journal 2013;95(9):1158-64. doi: 
5. Hollander JL. Intra-articular hydrocortisone in 
arthritis and allied conditions; a summary of two 
years’ clinical experience. The Journal of bone and  joint surgery American volume 1953;35-a(4):983-90.
6. Cyriax J, Troisier O. Hydrocortone and soft-tissue 
lesions. British medical journal 1953;2(4843):966-8. 
doi: 10.1136/bmj.2.4843.966.
7. Murley AH. Tennis-elbow treated with hydrocortisone acetate. Lancet (London, England) 
1954;267(6831):223-5. doi: 10.1016/s0140-6736 
8. Crisp EJ, Kendall PH. Hydrocortisone in lesions of soft 
tissue. Lancet (London, England) 1955;268(6862):476-
9. doi: 10.1016/s0140-6736(55)90263-4.
9. Claessen F, Heesters BA, Chan JJ, Kachooei AR, Ring D. A 
Meta-Analysis of the Effect of Corticosteroid Injection 
for Enthesopathy of the Extensor Carpi Radialis 
Brevis Origin. J Hand Surg Am 2016;41(10):988-98.
e2. doi: 10.1016/j.jhsa.2016.07.097.
10.Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. 
Effect of corticosteroid injection, physiotherapy, or 
both on clinical outcomes in patients with unilateral 
lateral epicondylalgia: a randomized controlled 
trial. Jama 2013;309(5):461-9. doi: 10.1001/jama. 
11.Krogh TP, Fredberg U, Stengaard-Pedersen K, 
Christensen R, Jensen P, Ellingsen T. Treatment of lateral 
epicondylitis with platelet-rich plasma, glucocorticoid, 
or saline: a randomized, double-blind, placebocontrolled trial. Am J Sports Med 2013;41(3):625-35. 
doi: 10.1177/0363546512472975.
12.Tahririan MA, Moayednia A, Momeni A, Yousefi 
A, Vahdatpour B. A randomized clinical trial on 
comparison of corticosteroid injection with or without 
splinting versus saline injection with or without 
splinting in patients with lateral epicondylitis. J Res 
Med Sci 2014;19(9):813-8.
13.Carey TS. ACP Journal Club. Corticosteroid injection 
worsened recovery and recurrence of tennis elbow; 
physiotherapy had no effect. Annals of internal 
medicine 2013;158(10):Jc8. doi: 10.7326/0003-
14.Osborne H. Stop injecting corticosteroid into patients 
with tennis elbow, they are much more likely to get 
better by themselves! J Sci Med Sport 2010;13(4):380-
1. doi: 10.1016/j.jsams.2009.09.009.
15.Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino 
B. Mobilisation with movement and exercise, 
corticosteroid injection, or wait and see for tennis 
elbow: randomised trial. BMJ 2006;333(7575):939. 
doi: 10.1136/bmj.38961.584653.AE.
16.Smidt N, van der Windt DA, Assendelft WJ, Devillé 
WL, Korthals-de Bos IB, Bouter LM. Corticosteroid 
injections, physiotherapy, or a wait-and-see policy 
for lateral epicondylitis: a randomised controlled 
trial. Lancet 2002;359(9307):657-62. doi: 10.1016/
17.Orchard JW, Vicenzino B. Cortisone injections 
for tennis elbow should be an “avoid”, rather 
than a recommended procedure. Med J Aust 
2017;207(10):453. doi: 10.5694/mja17.00445.
18.Orchard J. Corticosteroid injection for lateral 
epicondylalgia is helpful in the short term, but harmful 
in the longer term; data for non-corticosteroid 
injections and other tendinopathies are limited. 
Evid Based Med 2011;16(4):116-7. doi: 10.1136/
19.Drake ML, Ring DC. Enthesopathy of the Extensor 
Carpi Radialis Brevis Origin: Effective Communication 
Strategies. J Am Acad Orthop Surg 2016;24(6):365-9. 
doi: 10.5435/JAAOS-D-15-00233.
20.Dimitroff SJ, Kardan O, Necka EA, Decety J, Berman 
MG, Norman GJ. Physiological dynamics of stress 
contagion. Sci Rep 2017;7(1):6168. doi: 10.1038/
21.Kroslak M, Murrell GAC. Surgical Treatment of 
Lateral Epicondylitis: A Prospective, Randomized, 
Double-Blinded, Placebo-Controlled Clinical 
Trial. Am J Sports Med 2018;46(5):1106-13. doi: 
22.Dean BJ, Lostis E, Oakley T, Rombach I, Morrey ME, 
Carr AJ. The risks and benefits of glucocorticoid 
treatment for tendinopathy: a systematic review of 
the effects of local glucocorticoid on tendon. Semin 
Arthritis Rheum 2014;43(4):570-6. doi: 10.1016/j.
23.Titchener AG, Booker SJ, Bhamber NS, Tambe AA, Clark 
DI. Corticosteroid and platelet-rich plasma injection 
therapy in tennis elbow (lateral epicondylalgia): a 
survey of current U.K. specialist practice and a call for 
clinical guidelines. Br J Sports Med 2015;49(21):1410-
3. doi: 10.1136/bjsports-2013-092674.
24.Paavola M, Kannus P, Jarvinen TA, Jarvinen TL, Jozsa 
L, Jarvinen M. Treatment of tendon disorders. Is 
there a role for corticosteroid injection? Foot and 
ankle clinics 2002;7(3):501-13. doi: 10.1016/s1083-
25.Hsieh LF, Kuo YC, Lee CC, Liu YF, Liu YC, Huang V. 
Comparison between corticosteroid and lidocaine 
injection in the treatment of tennis elbow: a 
randomized, double-blinded, controlled trial. Am J 
Phys Med Rehabil 2018;97(2):83-9. doi: 10.1097/
26.Herquelot E, Bodin J, Roquelaure Y, et al. Natural 
history of lateral epicondylitis among French Workers. 
InPREMUS 2013-8th International Conference on 
Prevention of Work-related Muscoloskeletal Disorder 
27.Herquelot E, Guéguen A, Roquelaure Y, et al. 
Work-related risk factors for incidence of lateral 
epicondylitis in a large working population. Scand J 
Work Environ Health 2013:578-88. doi: 10.5271/
28.Tajika T, Kobayashi T, Yamamoto A, Kaneko T, 
Takagishi K. Prevalence and risk factors of lateral 
epicondylitis in a mountain village in Japan. J 
Orthop Surg (Hong Kong) 2014;22(2):240-3. doi: 
29.Waugh EJ, Jaglal SB, Davis AM, Tomlinson G, Verrier 
MC. Factors associated with prognosis of lateral 
epicondylitis after 8 weeks of physical therapy. Arch 
Phys Med Rehabil 2004;85(2):308-18. doi: 10.1016/
30.Lewis M, Hay EM, Paterson SM, Croft P. Effects of 
manual work on recovery from lateral epicondylitis Scand J Work Environ Health 2002;28(2):109-16. doi: 
31.Pransky G, Benjamin K, Hill-Fotouhi C, Fletcher 
KE, Himmelstein J. Occupational upper extremity 
conditions: a detailed analysis of work-related 
outcomes. J Occup Rehabil 2002;12(3):131-8. doi: