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Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial
  1. Brooke K Coombes1,2,
  2. Luke Connelly3,
  3. Leanne Bisset4,
  4. Bill Vicenzino2
  1. 1The University of Queensland, School of Biomedical Sciences, Brisbane, Queensland, Australia
  2. 2The University of Queensland, School of Health and Rehabilitation Sciences, Physiotherapy, Brisbane, Queensland, Australia
  3. 3Faculty of Medicine and Biomedical Sciences, the University of Queensland, Brisbane, Queensland, Australia
  4. 4Menzies Institute, Griffith University, Gold Coast, Queensland, Australia
  1. Correspondence to Professor Bill Vicenzino, School of Health and Rehabilitation Sciences: Physiotherapy, the University of Queensland, Building 84A, St. Lucia, QLD 4072, Australia; b.vicenzino{at}


Aim To determine the cost-effectiveness of corticosteroid injection, physiotherapy and a combination of these interventions, compared to a reference group receiving a blinded placebo injection.

Methods 165 adults with unilateral lateral epicondylalgia of longer than 6 weeks duration from Brisbane, Australia, were randomised for concealed allocation to saline injection (placebo), corticosteroid injection, saline injection plus physiotherapy (eight sessions of elbow manipulation and exercise) or corticosteroid injection plus physiotherapy. Costs to society and health-related quality of life (estimated by EuroQol-5D) over the 1 year follow-up were used to generate incremental cost per quality-adjusted life year (QALY) ratios for each intervention relative to placebo.

Results Intention-to-treat analysis was possible for 154 (93%) of trial participants. Physiotherapy was more costly, but was the only intervention that produced a statistically significant improvement in quality of life relative to placebo (MD, 95% CI 0.035, 0.003 to 0.068). Similar cost/QALY ratios were found for physiotherapy ($A29 343; GBP18 962) and corticosteroid injection ($A31 750; GBP20 518); however, the probability of being more cost-effective than placebo at values above $A50 000 per quality-adjusted life year was 81% for physiotherapy and 53% for corticosteroid injection. Cost/QALY was far greater for a combination of corticosteroid injection and physiotherapy ($A228 000; GBP147 340).

Summary Physiotherapy was a cost-effective treatment for lateral epicondylalgia. Corticosteroid injection was associated with greater variability, and a lower probability of being cost-effective if a willingness to pay threshold of $A50 000 is assumed. A combination of corticosteroid injection and physiotherapy was ineffective and cost-ineffective. Physiotherapy, not corticosteroid injection, should be considered as a first-line intervention for lateral epicondylalgia.

Trial registration number Trial identifier: ACTRN12609000051246.

  • Tendinopathy
  • Tendinosis
  • Physiotherapy
  • Tennis elbow

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  • Contributors BKC and BV monitored data collection for the whole trial. BC and LC wrote the statistical analysis plan, cleaned and analysed the data. All authors designed data collection tools, drafted and revised the manuscript. BKC and LB had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This study was supported by the Australian National Health and Medical Research Council grant 511238 awarded to BV, LC and LB. A University of Queensland Research Scholarship was received by BKC.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval University of Queensland Medical Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.