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Injections for tendinopathy: mixed outcomes by site, injection agent, and duration of effect

Clinical Question:
Are steroid injections effective in managing patients with tendinopathy?

Bottom Line:
If these authors found all the relevant studies, corticosteroid injections provide significant short-term improvement for epicondylitis but are of mixed utility for other tendinopathies. For intermediate and long-term outcomes, corticosteroid injections are often less effective than other therapies. Other agents, such as hyaluronate, botulinum, and prolotherapy, are also effective for epicondylitis, but the data are more limited. The data for other tendinopathies are unclear. (LOE = 1a-)

Reference:
Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376(9754):1751-1767.  [PMID:20970844]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Self-funded or unfunded

Setting:
Various (meta-analysis)

Synopsis:
These authors systematically searched multiple databases, including a registry of clinical trials, for randomized trials comparing peritendinous steroid injections with placebo or other nonsurgical interventions, They did not include studies that used intramuscular injections. They did not restrict the location of the tendinopathy. Since only one author initially screened studies for inclusion and another confirmed them, it is possible that relevant studies might have been missed. Two authors independently evaluated the quality of the included studies and discrepancies were resolved by consensus. Any study that didn't score at least 50% on their quality measure was excluded. Ultimately, they included 41 trials with 2672 patients: 28 studies used steroids and 13 used other agents; 18 evaluated epicondylitis, 16 rotator cuff tendinopathy, 7 Achilles tendinopathy, and 3 patella tendinopathy. Only 11 of the trials evaluated long-term outcomes. In the trials of corticosteroid injections for epicondylitis, steroids reduced pain in the short term, but no interventions were helpful in the intermediate or long term. Steroid injections for rotator cuff tendinopathy were better at short-term pain relief than placebo, but there was no difference between steroid injections and oral anti-inflammatory medications or between steroids and physiotherapy. The authors found 14 trials of injections of other agents (eg, prolotherapy, platelet-rich plasma, hyaluronate, botulinum, and so forth). Nonsteroid injections with hyaluronate, prolotherapy, and botulinum for epicondylitis were more effective than placebo in improving pain. Generally the data were very limited for other injections and injection sites, and these interventions were not very effective for pain relief or for improving function. Although most studies did not report adverse events, the most worrisome event, tendon rupture, occurred in less than 1% of patients receiving steroid injections compared with none in the control group.

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