Efficacy and safety of corticosteroid injections for management of tendinopathy: A systematic review of randomised controlled trials

Lancet November 20, 2010; Vol. 376; pp. 1751 – 67 Brooke K Coombes, Leanne Bisset, Bill Vicenzino FROM ABSTRACT: Background Few evidence-based treatment guidelines for tendinopathy exist. We undertook asystematic review of randomised trials to establish clinical efficacy and risk ofadverse events for treatment by injection. Methods We searched eight databases without language, publication, or date restrictions. Weincluded randomized trials assessing efficacy of one or more peritendinousinjections with placebo or non-surgical interventions for tendinopathy, scoring morethan 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk andstandardised mean differences. The primary outcome of clinical efficacy was protocol-defined pain score in the shortterm (4 weeks, range 0 – 12), intermediate term (26 weeks, 13 – 26), or long term(≥52 weeks). Findings 3824 trials were identified and 41 met inclusion criteria, providing data for 2672participants. We showed consistent findings between many high-quality randomisedcontrolled trials that corticosteroid injections reduced pain in the short termcompared with other interventions, but this effect was reversed at intermediate and long terms. THESE AUTHORS ALSO NOTE: 1) Overuse disorders of tendon or tendinopathies affect active young people(20 – 30 years old) and middle-aged people (40 – 60 years old) and are often difficultto manage successfully. 2) These disorders are characterized by angiofibroblastic hyperplasia, includinghypercellularity, neovascularisation, increased protein synthesis, anddisorganisation of matrix, but not inflammation. [The Fibrosis of Repair] 3) This absence of inflammation, along with poor long-term outcomes andadverse effects, has led investigators to question the use of corticosteroid injectionsfor treatment. RESULTS 4) Compared with non-injection interventions, there was strong evidence forbenefit of corticosteroid injections in the short term across all outcome measuresfor treatment of lateral epicondylalgia. 5) Strong evidence suggests that corticosteroid injections are less beneficialthan are other interventions for treatment of lateral epicondylalgia at 26 weeks. 6) Inferior reductions in pain were reported after corticosteroid injectioncompared with no intervention, NSAIDs, physiotherapy, and platelet-rich plasmainjections. 7) Repeated corticosteroid injections (average of 4 injections, range of 3-6 in18 months) were associated with a poorer long-term effect on reduction in painthan were interventions with one injection. DISCUSSION 8) We have shown strong evidence that corticosteroid injection is beneficial inthe short term for treatment of tendinopathy, but is worse than other treatmentoptions in the intermediate and long terms. 9) Use of corticosteroid injections, which are potent anti-inflammatories, posesa clinical dilemma because consistent findings suggest good short-term effects buttendinopathy does not have an inflammatory pathogenesis. Altered release oftoxins and inhibition of collagen, extracellular matrix molecules, and granulationtissue might provide a biological basis for this effect. 10) Our systematic review challenges continued use of corticosteroid injectionsby providing strong evidence that they are worse in the long term than are mostconservative interventions for tendinopathy. 11) Injection into the tendon might weaken its structure and increase probabilityof rupture. 12) Moderate evidence of harmful effects of repeated corticosteroid injection onpain was noted. COMMENT FROM DAN MURPHY Many of our patients are advised to have their tendinopathies treated withcorticosteroid injection, and consequently they ask us for advice. This systematicreview of randomized controlled trials indicates that these injections are beneficialin the short term (at 8 weeks), but are worse than conservative treatments in theintermediate (26 weeks) and long (≥52 weeks) terms. In addition, Injection intothe tendon might weaken its structure and increase probability of rupture.