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GPs ‘should use short courses of steroid injections’

By Lilian Anekwe

GPs are being advised to only use short courses of steroid injections to treat tendinopathies, after a systematic review found using them for longer can produce worse results than no treatment.

Instead, GPs could consider other non-steroid injectable treatments, hyaluronic acid and botulinum toxin for tennis elbow and some other tendinopathies, the Australian researchers advised.

Their review – published in The Lancet – looked at 41 trials involving 2,672 patients and estimated the standardised mean differences between treatments and placebo.

The primary outcome of clinical efficacy was pain reduction in the short-term treatment that lasted a mean of four weeks, intermediate term lasting 26 weeks or long-term treatment for 52 weeks.

The benefits of steroid treatment were consistent and showed a reduction in pain in the short term compared with other interventions, but the benefits were unclear over longer periods.

For example, steroid injections had a large effect on pain reduction in a pooled analysis of treatment for tennis elbow, with an mean difference of 1.44 compared with no intervention in the short term, but not at intermediate or long term, where the mean difference was -0.40 and -0.31, respectively.

But patients who received injections of hyaluronic acid showed improvements in pain in the short term with a mean difference of 3.91 compared with placebo, 2.89 in the intermediate term and 3.91 in the long term.

Prolotherapy - where a non-pharmacological irritant solution is injected in the region of tendons or ligaments to promote inflammation and healing - was also effective in the intermediate term, with a standardised mean difference of 2.62 for the treatment of tennis elbow.

Study leader Professor Bill Vicenzino, head of the division of physiotherapy at the University of Queensland, said: ‘Use of corticosteroid injections, which are potent anti-inflammatories, poses a clinical dilemma because consistent findings suggest good short-term effects but tendinopathy does not have an inflammatory pathogenesis.'

‘Different types of injection led to different clinical effectiveness and adverse events between tendon sites, despite similar pathological changes.'

Professor Martin Underwood, professor of primary care at the University of Warwick and a GP musculoskeletal researcher, said: ‘It´s papers like this that mean I do far fewer of these injections than I used to.'

‘The benefits can be quite big but what's crucial is that you tell the patient that it may make no difference to their long term condition and also that we don´t know what the risks might be of repeated injections.'

The Lancet, online 22 October

Steroid injections for tendinopathies are less effective in the longer term What works for tendinopathies?

Tennis elbow
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), but no intervention was favoured at intermediate term (SMD –0•40) and long term (SMD –0•31).
Botulinum toxin was also effective in the short term (1•23), and prolotherapy in the intermediate term (2•62) for treatment of lateral epicondylalgia.

Rotator cuff tendinopathy
By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate in the short (SMD 3•91), intermediate (2•89), and long term (3•91terms).

Source: The Lancet, online 22 October


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