Non-steroidal anti-inflammatory drugs (NSAIDs) for treating tennis elbow pain in adults

This summary of a Cochrane review presents what we know from research about the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on lateral elbow pain, also known as tennis elbow. The review, which included 13 trials involving 664 participants, shows the following:

In people with lateral elbow pain:

- Topical NSAIDs (applied to the skin in a gel) may improve treatment success.

- We are uncertain whether topical NSAIDs improve pain because of the low quality of the evidence.

- NSAIDs applied to the skin may result in a skin rash.

- We are uncertain whether NSAIDs taken orally in tablet form improve pain or function because of the low quality of the evidence.

- NSAIDs in tablet form probably result in increased stomach pain and diarrhoea, but we are not certain of the precise estimates because of the low quality of the evidence.

Function and quality of life were not reported.

We do not have precise information about side effects and complications, particularly for rare but serious side effects. NSAIDs may cause stomach, kidney or heart problems, and NSAIDs applied to the skin may cause rash.

What is lateral elbow pain and what are NSAIDs?

Lateral elbow pain, or tennis elbow, can occur for no reason or can be caused by too much stress on the tendon at the elbow. This condition can cause the outside of the elbow (lateral epicondyle) and the upper forearm to become painful and tender to touch. Pain can last for 6 months to 2 years, and may get better on its own. Many treatments have been used to treat elbow pain, but it is not clear whether these treatments work, or if the pain simply goes away on its own.

Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. ibuprofen, diclofenac, celecoxib) can be used to manage the pain. NSAIDs can be applied directly to the skin in the form of a gel, or can be taken in tablet form.

Best estimate of what happens to people with lateral elbow pain who use NSAIDs

Pain (higher scores mean worse or more severe pain):
- People who used NSAID gel compared with a placebo gel rated their pain 1.6 points lower on a scale of 0 to 10 after 4 weeks (16% absolute improvement).

- People who applied NSAID gel rated their pain to be 2.14 on a scale of 0 to 10 after 4 weeks.

- People who applied placebo gel rated their pain to be 3.78 on a scale of 0 to 10.

Successful treatment:

- 24 more people out of 100 reported improvement in their condition with topical NSAIDs (24% absolute improvement).

- 73 out of 100 people who applied NSAID gel improved.

- 49 out of 100 people who applied placebo gel improved.

Side effects:
- 1 more person using NSAID gel out of 100 had minor side effects such as skin rash at the site of application (0% absolute difference, ranging from 5% fewer to 6% more).

- 2 out of 100 using NSAID gel had side effects,

- 1 out of 100 people using placebo gel had side effects.

Authors' conclusions: 

There remains limited evidence from which to draw firm conclusions about the benefits or harms of topical or oral NSAIDs in treating lateral elbow pain. Although data from five placebo-controlled trials suggest that topical NSAIDs may be beneficial in improving pain (for up to 4 weeks), non-normal distribution of data and other methodological issues precluded firm conclusions. Some people may expect a mild transient skin rash. Evidence about the benefits of oral NSAIDs has been conflicting, although oral NSAID use may result in gastrointestinal adverse effects in some people. No direct comparisons between oral and topical NSAIDs were available. Some trials demonstrated greater benefit from glucocorticoid injection than from NSAIDs in the short term, but this was not apparent in all studies and was not apparent by 6 months in the only study that included longer-term outcomes.

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Background: 

Lateral elbow pain, or tennis elbow, is a common condition that causes pain in the elbow and forearm. Although self-limiting, it can be associated with significant disability and often results in work absence. It is often treated with topical and oral non-steroidal anti-inflammatory drugs (NSAIDs). This is an update of a review first published in 2002 (search date October 11, 2012).

Objectives: 

To assess the benefits and harms of topical and oral NSAIDs for treating people with lateral elbow pain.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE and SciSearch up to October 11, 2012. No language restriction was applied.

Selection criteria: 

Studies were included if they were randomised or quasi-randomised controlled trials (RCTs or CCTs) that compared topical or oral NSAIDs with placebo or another intervention, or compared two NSAIDs in adults with lateral elbow pain. Outcomes of interest were pain, function, quality of life, pain-free grip strength, overall treatment success, work loss and adverse effects.

Data collection and analysis: 

Two review authors independently selected the studies for inclusion, extracted the data, and performed a risk of bias assessment.

Main results: 

Fifteen trials, involving 759 participants and reporting 17 comparisons, were included in the review. Four new trials identified from the updated search were included, along with 11 of 14 trials included in the original review (three trials included in the previous review were found not to meet inclusion criteria). Of eight trials that studied topical NSAIDs (301 participants), five compared topical NSAIDs with placebo, one compared manipulative therapy and topical NSAIDs with manipulative therapy alone, one compared leech therapy with topical NSAIDs and one compared two different topical NSAIDs. Of seven trials that investigated oral NSAIDs (437 participants), two compared oral NSAIDs with placebo, one compared oral NSAIDs and bandaging with bandaging alone, three compared oral NSAIDs with glucocorticoid injection, one compared oral NSAIDs with a vasodilator and two compared two different oral NSAIDs. No trials directly compared topical NSAIDs with oral NSAIDs. Few trials used intention-to-treat analysis, and the sample size of most was small. The median follow-up was 2 weeks (range 1 week to 1 year).

Low-quality evidence was obtained from three trials (153 participants) suggesting that topical NSAIDs were significantly more effective than placebo with respect to pain in the short term (mean difference -1.64, 95% confidence interval (CI) -2.42 to -0.86) and number needed to treat to benefit (7 (95% CI 3 to 21) on a 0 to 10 scale). Low-quality evidence was obtained from one trial (85 participants) indicating that significantly more participants report fair, good or excellent effectiveness with topical NSAIDs versus placebo at 28 days (14 days of therapy) (risk ratio (RR) 1.49, 95% CI 1.04 to 2.14). No participants withdrew as the result of adverse events, but some studies reported mild adverse effects such as rash in 2.5% of those exposed to topical NSAIDs compared with 1.3% of those exposed to placebo.

Low-quality and conflicting evidence regarding the benefits of oral NSAIDs obtained from two trials could not be pooled. One trial found significantly greater improvement in pain compared with placebo, and the other trial found no between-group differences; neither trial found differences in function. One trial reported a withdrawal due to adverse effects for a participant in the NSAIDs group. Use of oral NSAIDs was associated with increased risk of gastrointestinal side effects compared with placebo in one trial in the review. Another trial reported discontinuation of treatment due to gastrointestinal side effects in four participants taking NSAIDs, and another participant developed an allergic reaction in response to oral NSAIDs.

Very scant and conflicting evidence regarding the comparative effects of oral NSAIDs and glucocorticoid injection was obtained. One trial reported a significant improvement in pain with glucocorticoid injection, and another found no between-group differences; treatment success was similar between groups (RR of fair, good or excellent effectiveness 0.74; 95% CI 0.43 to 1.26). Transient pain may occur following injection.

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