Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med 2011 Nov;21(6):540-1.
Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67. Epub 2010 Oct 21.
Overuse disorders of tendons, or tendinopathies, affect many people and can be frustrating for both the patient and provider. Since most studies question the presence of inflammation in the affected tendons, the use of corticosteroids has been questioned and more studies have investigated other types of injections. Coombes et al reviewed the literature to determine the efficacy and risk of adverse effects of peritendinous corticosteroids and other injections. This article was recently revisited by Hart in the Clinical Journal of Sports Medicine. The criteria for inclusion into this review were randomized controlled trials that compared greater than one peritendinous injection with placebo or other nonsurgical intervention. From these studies, the data extracted included duration of follow-up, outcomes (pain, function), and frequency of adverse events. Follow-up was defined as short term (< 12 weeks), intermediate term (12 to 52 weeks), and long term (> 52 weeks).Twelve trials assessed the efficacy of corticosteroid injections for lateral epicondylalgia. When compared to no intervention, physiotherapy, or orthotic devices, corticosteroid injections were more effective in the short-term for pain reduction, function, and overall improvement, but were less effective in the long term. The same was found in trials comparing non-operative management to platelet-rich plasma injection. Also, a history of repeated corticosteroid injections (range of 3 to 6 in 6 to 18 months) was associated with a poorer long-term effect on pain reduction than interventions with one injection. There were 12 trials included in this review that examined rotator cuff tendinopathy. Corticosteroid injections improved pain and function in the short term compared to placebo. There was no difference in effectiveness compared to NSAID’s and physiotherapy, except one study that showed short-term benefit compared to physiotherapy. Only one study has enough data for lower leg tendinopathies (patellar and Achilles). There was a benefit in the short term for corticosteroids when compared to placebo, but not in the long term. Multiple other types of injections were assessed as well, including platelet-rich plasma, aprotinin, sclerosant, glycosaminoglycan polysulfate, sodium hyaluronate, prolotherapy, and botulinum toxin. No clear evidence of benefit was found with any of these injections except for sodium hyaluronate. Sodium hyaluronate injections provide much better pain relief in the short and long term when compared to placebo injection for lateral epicondylalgia.
Hart states in his commentary, “There is little robust evidence to guide the management of tendinopathies, although they are among the commonest of soft tissue conditions.” This review can help providers show their patients that corticosteroid injections might not be the best option for these conditions in the long-term, especially with repeated use. It’s important to tell patients that the other treatments, such as physical therapy and orthotic devices for lateral epicondylalgia, offer the best chance for long-term pain relief, before using a corticosteroid injection. If patients get proper patient education on expectations from treatments, this may help at follow-up visits. More studies are needed to assess the other injections that were looked at in this study. What are other strategies you have used for patients that continue to ask for repeated corticosteroid injections?
Written by: Kris Fayock & Marc Harwood
Reviewed: Jeffrey Driban
Hart L (2011). Corticosteroid and other injections in the management of tendinopathies: a review. Clinical Journal of Sport Medicine, 21 (6), 540-1 PMID: 22064721
Coombes BK, Bisset L, & Vicenzino B (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet, 376 (9754), 1751-67 PMID: 20970844