Corticosteroid and Other Injections in the Management of Tendinopathies
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OBJECTIVE: To determine the efficacy and risk of adverse effects of peritendinous corticosteroid and other injections in the management of tendinopathy. DATA SOURCES: In March 2010, using terms describing common tendinopathies and injections, including steroids, local anesthetics, sclerosing solutions, aprotinin, platelet-rich plasma, botulinum toxins, and glycosaminoglycans, 8 databases were searched without language, publication, or date restrictions. Reference lists were scanned for additional articles. STUDY SELECTION: Criteria for inclusion were randomized controlled trials that compared ≥1 peritendinous injection with placebo or other nonsurgical intervention. Study methods were independently assessed by 2 reviewers (reliability, κ = 0.85) on a modified PEDro scale, and scores were required to be ≥50% for inclusion. Studies with a high proportion of patients with adhesive capsulitis, full-thickness rotator cuff tears, or rheumatologic disease were excluded. Of 2954 studies screened, 174 full-text articles were evaluated for inclusion by 1 investigator and confirmed by a second. Of 64 studies that were initially included, the 41 that scored >50% on the PEDro scale were retained. DATA EXTRACTION: Information about injection type and comparison treatments, site of the tendinopathy, duration of follow-up (short term, <12 weeks; long term, ≥52 weeks), outcomes (pain, function, and patient-rated overall improvement), and frequency of adverse events was extracted. Study results were pooled when the data were sufficiently homogeneous. MAIN RESULTS: Clinically diagnosed lateral epicondylalgia: In 3 trials that compared corticosteroid injections with no intervention, corticosteroid injections were effective in the short term in pain reduction [standard mean difference (SMD), 1.44; 95% confidence interval (CI), 1.17-1.71], in improving function (SMD, 1.50; 95% CI, 1.22-1.77), and in overall improvement [relative risk (RR), 3.47; 95% CI, 2.11-5.69]. In the intermediate and long term, corticosteroid injections were less effective than no intervention. In comparison with placebo injection (4 studies), there was limited evidence for the effectiveness of corticosteroid injection in relieving pain. In comparison with physiotherapy (4 studies), corticosteroid injection was more effective in the short term for improving function (SMD, 1.29; 95% CI, 1.03-1.55) and in overall improvement (RR, 2.37; 95% CI, 1.75-3.21), and there was strong evidence among heterogeneous studies for reducing pain. Intermediate and long-term results were worse in pain and function for the corticosteroid injection intervention. Corticosteroid injections were more effective than orthotic devices for the wrist or elbow for overall improvement in the short term but not in the long term (2 studies). Effectiveness did not differ in comparisons of high- versus low-corticosteroid dosage, and between triamcinolone and hydrocortisone. Pain and function improved more with corticosteroid than with platelet-rich plasma injection in the short term but were worse in the long term. Rotator cuff tendinopathy: In the short term, corticosteroid injection improved pain (SMD, 0.68; 95% CI, 0.35-1.01) and function (SMD, 0.62; 95% CI, 0.29-0.95) more than placebo (3 studies). In comparisons with nonsteroidal anti-inflammatory drugs (NSAIDs) and with NSAIDs plus placebo injection, no differences in pain or function were found (3 studies) or when NSAIDs were administered in addition to corticosteroid and placebo injections (4 studies). Corticosteroid injection and physiotherapy did not differ in effectiveness (2 studies), although 1 study found short-term greater overall improvement and function after corticosteroid injection. Adverse effects were reported in 82% of corticosteroid injection trials. In comparison with placebo injections, corticosteroid injections were associated with an increased risk of atrophy for Achilles and patellar tendons but not elbow tendons. In trials of injections of sclerosant, platelet-rich plasma, proteinase, glycosaminoglycan polysulfate, sodium hyaluronate, prolotherapy, and botulinum toxin compared with placebo injection or other therapies, only sodium hyaluronate compared with placebo showed consistently better results in the short and long term in overall improvement and pain reduction of lateral epicondylalgia (1 study). Adverse effects were reported for all these injections except sclerosant and platelet-rich plasma. CONCLUSIONS: Corticosteroid injection is beneficial in the short term for the treatment of tendinopathies but may be worse than other treatments in the intermediate and long terms. No clear evidence of benefit of other injections was shown, except for sodium hyaluronate in the short and long term.
