Näytönastekatsaukset

Corticosteroid injection therapy in patients with lateral tendinopathy: effectiveness compared to placebo

Näytönastekatsaukset

22.6.2022

Krista Nuotio

Level of evidence: C

Corticosteroid injection therapy may decrease pain [mean difference approximately 31 (23, 40)], increase global improvement [relative risk in different studies from 0.11 (0.04, 0.33) to 0.36 (0.18, 0.71)] and increase pain-free grip strength [mean difference approx. 33 (22, 42)] in short-term (≤ 6 weeks) but not in intermediate or long-term follow up in patients with lateral tendinopathy when compared to placebo.

Corticosteroid injection may worsen the long-term prognosis of lateral tendinopathy. The quality of evidence is low, but the applicability is good.

Table 1. Description of the included studies
Reference	Study type	Population	Intervention and comparison	Outcomes	Risk of bias
«Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1	SR (13 RCTs)	RCTs «Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1 Patients had a clinical dg of lateral epicondylitis «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2 At least one treatment was ≥ 1 corticosteroid injection «Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 »3 ≥ 1 clinically relevant outcome measure	Corticosteroid injection therapy vs. PBO injections (2 studies) or injection with local anaesthetic (5 studies) or another conservative treatment (5 studies) or another corticosteroid injection (3 studies)	Pain, Global improvement, grip strength	High
«Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2	RCT	patients ≥ 18 years (n=185) with pain at the lateral side of the elbow, increasing with pressure on the lateral epicondyle and with resisted dorsiflexion of the wrist; recruited by general practitioners	Corticosteroid injections (n=62) vs. Physiotherapy 6 weeks (n=64) vs. wait-and-see policy (n=59)	General improvement, severity of the main complaint, pain, elbow disability, patient satisfaction, grip strength.	Moderate
«Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 »3	SR/NMA	RCTs «Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1 adults (≥ 18 years) «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2 diagnosis with lateral epicondylalgia «Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 »3 at least two injection therapies for lateral epicondylagia evaluated, including PBO or a ‘wait and see' strategy «Bisset L, Beller E, Jull G ym. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939 »4 results of pain relief or functional recovery reported.	Injection therapies, corticosteroid (9 RCTs, n=774) vs. PBO or a "wait and see" strategy	Pain score (VAS, NRS)	Moderate

RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis; NMA=Network meta-analysis, PBO=placebo, VAS=visual analoque scale, NRS=the Numerical Rating Scale

Table 2. Additional comments for included studies
Reference	Comments
«Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1	SR collected studies published before 1999. Risk of bias is high due to inadequate control, reporting of co-interventions, and blinding of care provider. In addition, randomisation procedure, baseline similarity, number of withdrawal and drop-outs were poorly repoted. There were large heterogeneity in study designs.
«Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2	If necessary, paracetamol or NSAID were prescribed to patients. Research physiotherapists making the outcome assessment were blinded but in practice they were in some cases aware of the treatment group. Co-interventions
«Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 »3	15 RCTs reported randomisation details, and the allocations were properly concealed in 11 of them. The blinding was insufficient in some of the studies. Different measurements for pain score. These different measurements were adjusted to a 0–10 scale. No comprehensive scoring system for evaluating elbow function was used. The treatment schedules and dosages varied in different studies. The follow-up varied substantially, but although the time point that was nearest to 6 months (26 weeks) was adopted, this difference might affect the results.

SR=systematic review

Results

Table 3. Pain score, 2–52 weeks
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	MD/WMD (95% CI)
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision.
«Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2	121 patients (62/59)	3 weeks 6 weeks 12 weeks 26 weeks 52 weeks	NR	NR	MD: 30 (23, 36) 32 (24, 40) 8 (-1, 18) -7 (-17, 2) -4 (-13, 6)
«Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 »3	9 RCTs, (399/375)	7–26 weeks	NR	NR	WMD: 0.12 (-0.65, 0.90)

I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; WMD=Weighted mean difference

Table 4. Global improvement, 2–52 weeks
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative risk (95% CI)
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision.
«Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1	1 RCT comparing to PBO (n=29), 1 RCT comparing to elbowband (n=18) or splintage (n=18)	2 weeks	NR	NR
		Elbowband			0.36 (0.18, 0.71)
		Splintage			0.33 (0.17, 0.65)
		Unclear (≤ 6 weeks)			0.11 (0.04, 0.33)
		13 weeks
		Elbow support			0.76 (0.32, 1.80)
		Splintage			0.52 (0.24, 1.16)
		26 weeks
		Elbow support			1.83 (0.58, 5.77)
		Splintage			3.00 (0.73, 12.27)
		52 weeks
		Elbow support			0.92 (0.27, 3.07)
		Splintage			1.22 (0.32, 4.65)

I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; WMD=Weighted mean difference; NR=not reported

Table 5. Grip strength, 2–52 weeks
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Mean difference (95% CI)
Level of evidence: low. The quality of evidence is downgraded due to the risk of bias of included studies as well as indirectness and imprecision.
«Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2	121 pts (62/59)	3 weeks 6 weeks 12 weeks 26 weeks 52 weeks	NR	NR	34 (26, 42) 31 (22, 39) -6 (-17, 5) -11 (-22, -0.4) -14 (-25, -3)

I= intervention; C=comparison; CI=confidence interval; NR=not reported

Adverse events

Short-term (< 6 weeks) adverse events of corticosteroid injections were mostly mild such as facial flushes (3%), post injection pain (11–58%), increased pain > 1 day (16%), red swollen elbow (3%), change of skin colour (11%), local skin atrophy (17–40%) or skin irritation (5%) and other minor or temporary adverse reactions (13%) «Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2, «Bisset L, Beller E, Jull G ym. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939 »4. Smidt and coworkers reported any adverse event in 58% patients in the cortisone injection group compared to 17% in the wait-and-see group «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2. Two studies reported high recurrence rate (37–72%) in the cortisone injection group after 6–12 weeks compared with physiotherapy or wait-and-see «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2, «Bisset L, Beller E, Jull G ym. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939 »4. No serious adverse events were reported «Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 »1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 »2, «Bisset L, Beller E, Jull G ym. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939 »4.

References

Smidt N, Assendelft WJ, van der Windt DA ym. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23-40 «PMID: 11932058»PubMed
Smidt N, van der Windt DA, Assendelft WJ ym. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62 «PMID: 11879861»PubMed
Dong W, Goost H, Lin XB ym. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016;50:900-8 «PMID: 26392595»PubMed
Bisset L, Beller E, Jull G ym. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939 «PMID: 17012266»PubMed