ArticlesEfficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials
Introduction
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 difficult to manage successfully. These disorders are characterised by angiofibroblastic hyperplasia,1 including hypercellularity, neovascularisation, increased protein synthesis, and disorganisation of matrix, but not inflammation.2, 3, 4 This absence of inflammation, along with poor long-term outcomes5 and adverse effects,6, 7 has led investigators to question the use of corticosteroid injections for treatment8 and has contributed to increased use of other injection types, such as lauromacrogol (polidocanol), platelet-rich plasma, botulinum toxin, and proteinases. The large number of studies about these other injection types underpins the need for a synthesis of the evidence for injection therapies. We aimed to review the clinical efficacy and risk of adverse events of injections (including corticosteroids) for treatment of tendinopathy in the short term, intermediate term, and long term, and in different areas of tendinopathy.
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Search strategy and selection criteria
We did this systematic review and reported it in accordance with Cochrane Collaboration9 and PRISMA10 guidelines. We systematically reviewed eight databases (Medline, Cinahl, Embase, Web of Knowledge, Allied and Complementary Medicine, SPORTDiscus, Cochrane Controlled Trial Register, and Physiotherapy Evidence Database) without language, publication, or date restrictions in March, 2010, with the search terms “tennis elbow”, “Achilles tendon”, “patellar ligament”, “tendinopathy”, “tendon
Results
Figure 1 shows the process of study selection, leading to the inclusion of 41 studies in the systematic review. Quality rating scores ranged from 2 of 13 to 13 of 13 (see webappendix) and were not dependent on anatomical site. 23 articles were excluded from the systematic review because of low modified PEDro scores (<50%). Table 1 shows study populations, interventions, and extracted outcome measures for eligible trials. Table 2, Table 3 show clinical outcomes in the eligible studies. We
Discussion
We have shown strong evidence that corticosteroid injection is beneficial in the short term for treatment of tendinopathy, but is worse than are other treatment options in the intermediate and long terms. Use of corticosteroid injections, which are potent anti-inflammatories,57 poses a clinical dilemma because consistent findings suggest good short-term effects but tendinopathy does not have an inflammatory pathogenesis. Altered release of toxins and inhibition of collagen, extracellular matrix
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