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Corticosteroid injections: glass half-full, half-empty or full then empty?
  1. John W Orchard
  1. School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr John W Orchard, School of Public Health, University of Sydney, Sydney, NSW 2006, Australia; john.orchard{at}

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Cortisone is the most common class of injection in musculoskeletal medicine. Expert guidelines, such as the 2017 edition of Therapeutic Guidelines: Rheumatology (Australia),1 generally recommend corticosteroid injections (CSI) as a treatment for most tendon and joint pain conditions (including those listed in table 1). I quote, ‘local corticosteroid injections should only be given by, or under the supervision of, clinicians with appropriate training and experience’.1 I find it remarkable that the guidelines do not spell out that cortisone injections should only be given where high-quality evidence shows that benefits outweigh the harms; that is, the widespread recommendations to use CSI for multiple joints and multiple tendons are ‘eminence-based’ (who should give them) rather than ‘evidence-based’ (when they should be given).

View this table:
Table 1

Comparison of short-term (mainly benefit) versus long-term effects (possible harm) of corticosteroid injection for common indications

To be fair, I see that ‘appropriate training’ could cover ‘knowing the indications’ for a treatment but at a time where medical overtreatment is incontrovertible—it exists and no one denies it exists—I argue that the case for ‘indication-based treatment’ should be explicit.

Do cortisone injections harm tendons?

Systematic reviews have examined whether cortisone injections are beneficial or harmful. A typical systematic review concludes as per the text in box 1. This conclusion was from a 2002 systematic review on the use of CSI for tennis …

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  • Contributors Single author paper.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JWO is a Sport and Exercise Medicine Physician affiliated with Australasian College of Sport and Exercise Medicine Physicians.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.