Tennis Elbow - the case against cortisone injection
For over ten years, it has been acknowledged that tendon pain and disease is a non-inflammatory condition(4,5). ‘Tendinopathies’, including tennis elbow, represent an overuse condition with an absence of inflammatory cells. The condition is degenerative rather than inflammatory. Yet anti-inflammatory treatments, including corticosteroid injections, continue to be prescribed. The following is a brief discussion of the arguments against this practice.
Through poorly understood mechanisms(5), corticosteroids are an extremely effective pain killer. Their ability to inhibit pain in the short-term is one of the reasons for their perceived effectiveness in treating tendon disease. However, for chronic tennis elbow, studies have shown mixed results for pain relief (4). At best, pain will improve for 6-12 weeks (2,3,6). Thereafter, symptoms have been found to be worse than for those managed with a “wait and see” approach (1,2,3,6,7,9). Injected patients were significantly worse at 12 months (3).
While cortisone injection for tennis elbow has no clinical benefit, there is good evidence that it delays recovery and is probably harmful to the tendon (4,6,9). Injections into the Achilles tendon were abandoned years ago, after it became evident it was associated with a high incidence of rupture8. This is not surprising, considering that “corticosteroid injection leads to cell death and tendon atrophy”(5). Corticosteroids also inhibit collagen synthesis, and decrease tendon load to failure (5). These are the opposite effects to what is required for tendon healing.
Adverse effects on the tendon are not confined to corticosteroids. NSAID’s are also of no clinical benefit (4,6,7), and probably inhibitory to tendon repair (4,6). While there are other injectable and non-injectable pharmalological agents available (sclerosing therapy, PRP, nitrate patches, botox), the evidence for their use is limited (6). Expert consensus, both from quality research and clinical experience, is that the mainstay of treatment should be a tailored exercise programme (1,2,4,5,6). This is the only treatment with definite evidence of benefit through clinical trials. The patient also needs to understand that tendon repair is usually a slow process, with recovery occurring over several months or longer.
1. Bisset, L et al (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized controlled trial. British Medical Journal, Nov, 4:333 (7575): 939.
2. Bisset, L (2011). Lateral epicondylalgia: evidence for different treatments. Sports Physio, 1, 10-14.
3. Coombes, B et al (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomized controlled trials. Lancet, 376, 1751-1767.
4. Khan, K et al (2002). Time to abandon the “tendinitis” myth. British Medical Journal, 324, 626-627.
5. Khan, K & Cook, J. (2003). The painful non-ruptured tendon: clinical aspects. Clinics in Sports Medicine, 22, 711-725.
6. Orchard, J & Kountouris, A (2011). The management of tennis elbow. British Medical Journal, May, 342 (d2687).
7. Orchard, J (2008). Which sports medicine conditions are NSAID’s and cortisone injections useful for? Sports Health, 26, 2, 11-12.
8. Schepsis, A et al (2002). Achilles tendon disorders in athletes. American Journal of Sports Medicine, 30, 2, 287-305.
9. Scott, A & Khan, K (2010). Corticosteriods: short-term gain for long-term pain? Lancet, 376, 1714-1715.