Elsevier

The Lancet

Volume 376, Issue 9754, 20–26 November 2010, Pages 1751-1767
The Lancet

Articles
Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

https://doi.org/10.1016/S0140-6736(10)61160-9Get rights and content

Summary

Background

Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.

Methods

We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0–12), intermediate term (26 weeks, 13–26), or long term (52 weeks, ≥52). Adverse events were also reported.

Findings

3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17–1·71, p<0·0001), but no intervention was favoured at intermediate term (−0·40, −0·67 to −0·14, p<0·003) and long term (−0·31, −0·61 to −0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54–4·28, p<0·0001], intermediate [2·89, 2·58–3·20, p<0·0001], and long [3·91, 3·55–4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67–1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36–3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise.

Interpretation

Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy.

Funding

None.

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.

Section snippets

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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