Corticosteroid injections in tendinopathy: why we will continue to follow guidelines.
Our doctors provide steroid injections for amenable, appropriately diagnosed problems such as frozen shoulder or shoulder bursitis. From time to time, we have a request for an injection into a tendon.
We may agree to the injection where there is a clear rationale for providing acute pain relief and usually a well-documented history of reasonable rehabilitation failing. This is an exception; usually, our position is not to provide steroid injections into tendons.
Visser et al(1) recently published a viewpoint that caught our attention (not so much for the Terminator hook). The article incorporates a brief quality appraisal of recent evidence and presents a coherent opinion reinforcing why we will continue to recommend against most tendon steroid injections.
Some time ago, thirty or forty years in fact, what we now term tendinopathy was called tendinitis, suggesting an inflammatory condition affecting tendons. This was not unreasonable, given inflammatory cytokines can, in fact, be present in pathological tendons.
Thus, treating an inflammatory condition required an anti-inflammatory solution; in fact, steroid injections into tendons worked and still work for acute pain relief.
As we know, thinking has changed with the times regarding tendon pathology.
Jill Cook and her colleagues are well recognised as leading authorities with their work describing tendon pathology (e.g., 2), including aetiology and treatment. They have moved thinking away from the itis version of tendon pathology, suggesting instead that the inflammatory cytokines are pleiotropic and, when seen in pathological tendons may not be pro-inflammatory.
Visser et al(1) noted two new RCTs(3-4), which propose that steroid injections may be effective in treating tendon pathology and wondered if it was time to reconsider the routine use of tendon steroid injections in light of this new evidence.
An example of the Achilles tendon with fusiform thickening including microcystic change, collagen fascicular discontinuity, and increased vascularity.
Key points from their article include:
1. A 2010 systematic review(5) recommended against routine use of steroid injections in the management of tendon pathology, and subsequent clinical practice guidelines(6) continue to adhere to this evidence.
2. Two more recent studies show benefits following steroid injection, however:
- There are important methodological flaws introducing risk of bias.
- notwithstanding these errors, the benefit decreased at 3-month and 12-month follow-up points, whereas the placebo group improved.
- While rates are low, there are reports of tendon rupture after tendinous steroid injection and
- The risk increases between two and five times compared to controls, with this risk increasing with the number of tendon injections.
- Ultrasound-guided peri tendinous injections were no more or less effective than unguided injections. They still show good short-term improvements but not good long-term, suggesting ultrasound guidance on balance appears not to affect outcomes.
The authors conclude that given the methodological limitations, the lack of good long-term outcomes, potential deleterious effects, the quality of evidence preceding recommending against tendon steroid injections, there is no need to move away from current guidelines. So, for now, we will continue not to recommend routine steroid injection of the tendon.
References:
1. Visser T, van Linschoten R, Vicenzo B, Weir A, de Vos R. Terminating corticosteroid injection in tendinopathy? Hasta la vista, baby. J Orthop Sports Phys Ther 2023;53(11):1-4. Epub: 28 July 2023. doi:10.2519/jospt.2023.118752.
2. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016 Oct;50(19):1187–91.
3. Johannsen F, Olesen JL, Øhlenschläger TF, et al. Effect of ultrasonography-guided corticosteroid injection vs placebo added to exercise therapy for Achilles tendinopathy: a randomized clinical trial. JAMA Netw Open. 2022;5:e2219661. https://doiorg/10.1001/jamanetworkopen.2022.19661
4. Johannsen FE, Herzog RB, Malmgaard-Clausen NM, Hoegberget-Kalisz M, Magnusson SP, Kjaer M. Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training. Knee Surg Sports Traumatol Arthrosc. 2019;27:5- 12. https://doi.org/10.1007/s00167-018-5234-6.5.
5. 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;376:1751- 1767. https://doi.org/10.1016/S0140-6736(10)61160-9.
6. de Vos R-J, Vlist van der AC, Zwerver J, et al. Dutch multidisciplinary guideline on Achilles tendinopathy. Br J Sports Med. 2021;55:1125- 1134. https://doi.org/10.1136/bjsports-2020-103867.