Treatment of Lateral Epicondylitis with Botulinum Toxin

A Randomized, Double-Blind, Placebo-Controlled Trial

  1. Shiu Man Wong, MB BCh;
  2. Andrew C.F. Hui, MBBS;
  3. Po-Yee Tong, BSc;
  4. Dawn W.F. Poon, BSc;
  5. Evelyn Yu, BSc; and
  6. Lawrence K.S. Wong, MD
  1. From North District Hospital, The Chinese University of Hong Kong, and Prince of Wales Hospital, Hong Kong, China.

    Abstract

    Background: Lateral epicondylitis is a common condition for which botulinum toxin has been reported to have a therapeutic role in uncontrolled studies.

    Objective: To determine if an injection of botulinum toxin is more effective than placebo for reducing pain in adults with lateral epicondylitis.

    Design: Randomized, double-blind, placebo-controlled trial conducted from September 2002 to December 2004.

    Setting: Outpatient clinics at a university hospital and a district hospital in Hong Kong.

    Participants: 60 patients with lateral epicondylitis.

    Measurements: The primary outcome was change in subjective pain as measured by a 100-mm visual analogue scale (VAS) ranging from 0 (no pain) to 10 (worst pain ever) at 4 weeks and 12 weeks. All patients completed post-treatment follow-up.

    Interventions: A single injection of 60 units of botulinum toxin type A or normal saline placebo.

    Results: Mean VAS scores for the botulinum group at baseline and at 4 weeks were 65.5 mm and 25.3 mm, respectively; respective scores for the placebo group were 66.2 mm and 50.5 mm (between-group difference of changes, 24.4 mm [95% CI, 13.0 to 35.8 mm]; P < 0.001). At week 12, mean VAS scores were 23.5 mm for the botulinum group and 43.5 mm for the placebo group (between-group difference of changes, 19.3 mm [CI, 5.6 to 32.9 mm]; P = 0.006). Grip strength was not statistically significantly different between groups at any time. Mild paresis of the fingers occurred in 4 patients in the botulinum group at 4 weeks. One patient's symptoms persisted until week 12, whereas none of the patients receiving placebo had the same complaint. At 4 weeks, 10 patients in the botulinum group and 6 patients in the placebo group experienced weak finger extension on the same side as the injection site.

    Limitations: The trial was small, and most participants were women. The blinding protocol may have been ineffective because the 4 participants who experienced paresis of the fingers could have correctly assumed that they received an active treatment.

    Conclusions: Botulinum toxin injection may improve pain over a 3-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension.

    Article and Author Information

    • ClinicalTrials.gov Identifier: NCT00119704

    • Grant Support: By a donation from New World Development Ltd.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Shiu Man Wong, MB BCh, PacifiCare, 12th Floor, Oterprise Square, 26 Nathan Road, Tsim Sha Tsui, Hong Kong, China; e-mail, jsmwong{at}hkstar.com.

    • Current Author Addresses: Dr. S.M. Wong: Department of Medicine, North District Hospital, 9 Po Kin Road, Sheung Shui, Hong Kong, China.

    • Drs. Hui and L.K.S. Wong, Ms. Tong, and Ms. Yu: Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.

    • Ms. Poon: Department of Occupational Therapy, Prince of Wales Hospital, Shatin, Hong Kong, China.

    • Author Contributions: Conception and design: S.M. Wong, A.C.F. Hui, L.K.S. Wong.

    • Analysis and interpretation of the data: S.M. Wong, A.C.F. Hui, L.K.S. Wong.

    • Drafting of the article: S.M. Wong, A.C.F. Hui.

    • Critical revision of the article for important intellectual content: S.M. Wong, A.C.F. Hui, L.K.S. Wong.

    • Final approval of the article: S.M. Wong.

    • Provision of study materials or patients: S.M. Wong, P.-Y. Tong, D.W.F. Poon.

    • Statistical expertise: S.M. Wong, P.-Y. Tong, E. Yu.

    • Obtaining of funding: S.M. Wong.

    • Administrative, technical, or logistic support: S.M. Wong, P.-Y. Tong, D.W.F. Poon.

    • Collection and assembly of data: S.M. Wong, P.-Y. Tong, D.W.F. Poon.

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