Are Cortisone Shots for Tendon Injuries Worth It?

Study: Shots Provide Short-Term Relief but Inferior in Long Term

By Kathleen Doheny
WebMD Health News

Reviewed by Laura J. Martin, MD

Oct. 21, 2010 -- Corticosteroid injections, better known as cortisone shots, provide short-term pain relief for tendon problems such as tennis elbow but may be worse than other treatments later on, according to a new analysis.

"We have shown strong evidence that corticosteroid injection is beneficial in the short term for treatment of tendinopathy, but is worse than other treatment options in the intermediate and long terms," says researcher Bill Vicenzino, PhD, professor of sports physiotherapy at the University of Queensland in St. Lucia, Australia.

''The strong immediate effects [of pain relief] in a high proportion of patients have led to the notion that they are the miracle treatment," Vicenzino tells WebMD.

But he suspected otherwise, since the treatment is sometimes accompanied by poor long-term outcomes. Some experts had begun to question the use of corticosteroids, which reduce inflammation, for overuse disorders of the tendon, which are not accompanied by inflammation.

Tendons are tough, fibrous tissues that connect muscles to bones; in tendinopathy, the tendon becomes painful or torn.

To get some answers, Vicenzino and his colleagues reviewed the results of 41 previously published studies, including 2,672 patients with various tendon problems.

In the 41 published studies, the tendinopathy sites primarily included the elbow and the rotator cuff in the shoulder.

Some studies used corticosteroids for injections, while others used non-steroid-based treatments such as Botox, platelet-rich plasma, sodium hyaluronate, and other substances.

The researchers looked at pain reduction in the short term (about four weeks), intermediate term (about 26 weeks), and long term (one year).

Benefits differed by site, the researchers found.

For tennis elbow, corticosteroid injections provided relief at eight weeks but had negative outcomes at six months and one year.

For rotator cuff tendinopathy, corticosteroid injections provided inconsistent effects, but some of the studies showed a medium beneficial effect compared to placebo.

All studies using non-corticosteroid injections reported adverse events, but only 82% of the 28 using corticosteroids did.

And the adverse effects were generally minor, such as pain and loss of pigment. "We could not find much evidence to indicate that there are many adverse effects of a serious nature," he tells WebMD, speaking of the corticosteroid injections. However, he adds, "the caveat on this is that it is unknown to what extent adverse events are reported or not."

As welcome as the injections are, Vicenzino says skipping the injections appear to be a reasonable option when you consider recovery rates and the chance of recurrence.

"If we look at delaying recovery and [at] recurrence rates, then there is solid evidence, especially for the tennis elbow steroid injections, that they will delay recovery and there will be a high probability of recurrences beyond that if the patient had just adopted a wait-and-see policy [over 12 months]."

While the new non-steroid injections are becoming more popular, Vicenzino says many questions remain about them.

One of them, sodium hyaluronate, ''demonstrated vastly superior results across all time points," he says, and he believes that one should be further studied.

Whatever the injection that may be used, he says, it's not enough. The tendon needs to be ''mechanically stimulated" through exercise or physical therapy, he says, to address the disruption in collagen and at a cellular level that occurs with the tendon injury.

''Chronic tendon injuries are not easy to treat," says John DiFiori, MD, team physician for the University of California Los Angeles Department of Intercollegiate Athletics and chief of sports medicine at UCLA's David Geffen School of Medicine.

One chronic tendon injury is not the same as another, even within the same tendon, he says.

"Cortisone injections can provide short-term pain relief, this study confirms that further," says DiFiori, who reviewed the study for WebMD.

The study findings, he says, suggest that patients "need to be cautious if their physician is recommending an injection and nothing more or multiple injections of corticosteroids," he says.

Agreeing with Vicenzino, DiFiori says that the physical therapy part of treatment is crucial.

''With these tendon injuries you are trying to heal the tendon, trying to get the tendon to be stronger," he says.

Of the newer, non-corticosteroid injections, he says: ''There is not enough data to recommend them."

In a comment accompanying the study, Alexander Scott and Karim Khan of the University of British Columbia point out that the evidence for exercise therapy ''is more encouraging than the evidence for corticosteroid injection."

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SOURCES: Bill Vicenzino, PhD, professor of sports physiotherapy, University of Queensland, St. Lucia, Australia.Coombes, B. The Lancet, published online Oct. 22, 2010.Scott, A. The Lancet, published online Oct. 22, 2010.John DiFiori, MD, professor of family medicine and orthopaedic surgery and chief, division of sports medicine, University of California Los Angeles David Geffen School of Medicine; team physician, UCLA Department of Intercollegiate Athletics.

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