Näytönastekatsaukset

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

Näytönastekatsaukset

22.6.2022

Krista Nuotio

Level of evidence: C

Corticosteroid injection therapy may decrease pain score, increase global improvement and pain-free grip strength in short-term (≤ 6 weeks) but not in long-term follow up in patients with lateral tendinopathy when compared to physiotherapy.

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 diagnosis 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 «Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-»3 ≥ 1 clinically relevant outcome measure	Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation (1 study)	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
«Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-»3	SR/MA	30 RCTs (n=2123) comparing the effectiveness of any type of exercise used alone or as an additive intervention compared with another type of conservative intervention in adult patients diagnosed with lateral elbow tendinopathy	Exercise with or without physiotherapy or home exercise programme compared with corticosteroid injection(s) (8 studies)	Pain, Grip strength, Elbow disability	High

RCT=randomized controlled trial, SR=systematic review, MA=meta-analysis, PBO=placebo,

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 performed 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 between studies. For the study reported in this evidence summary (see table Pain score) randomisation using sealed numbered envelopes without strata or blocks. Patient, outcome assessor and care provider not blinded for intervention.
«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
«Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-»3	High risk of bias in most of the individual studies included in SR. Two studies were excluded from quantitative synthesis due to indirectness and heterogeneity of intervention and comparators, and two studies due to attrition bias (29% and 70%, respectively). From the four studies which evaluated pain intensity excluded were one from quantitative synthesis due to significant heterogeneity of the comparators (measurement of pain at rest compared with pain during activities during the day or last week). Three studies evaluated the PFGS at short-term, mid-term and long-term follow-up and were included in quantitative synthesis.

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	RR/MD/SMD (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 (53/53): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation	6 weeks 52 weeks	NR	NR	RR: 0.61 (0.48, 0.78) 1.20 (0.96, 1.51)
«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	N=126 (62/64)	3 weeks 6 weeks 12 weeks 26 weeks 52 weeks	NR	NR	MD: 30 (23, 37) 26 (18, 34) -0.3 (-10, 9) -14 (-23, 5) -11 (-20, -2)
«Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-»3	8 RCTs (n=933)	2–3 months 3–12 months > 12 months	NR	NR	SMD: -0.27 (-0.59, 0.05) -0.69 (-0.91, -0.47) -0.56 (-0.78, -0.34)

I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; SMD=Standardised 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 (n=53): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation	6 weeks 52 weeks	NR NR	NR NR	0.45 (0.29, 0.69) 1.24 (0.81, 1.90)

I= intervention; C=comparison; CI=confidence interval; 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	MD/SMD (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 (53 pts): Corticosteroid injection + local anesthetic vs. Friction massage + Mill's manipulation	6 weeks 52 weeks	NR	NR	SMD: -0.65 (-1.04, 0.25) -0.27 (-0.66, 0.12)
«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	126 pts (62/64)	3 weeks 6 weeks 12 weeks 26 weeks 52 weeks	NR	NR	MD: 30 (23, 38) 27 (18, 35) -11 (-21, -0.3) -17 (-28, -6) -24 (-35, -13)
«Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-»3	8 RCTs (933 patients)	2–5 months 3–12 months > 12 months	NR	NR	MD: 12.15 (1.69, 22.60) 22.45 (3.63, 41.30) 18.00 (11.17, 24.84)

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

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
Karanasios S, Korakakis V, Whiteley R ym. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. Br J Sports Med 2021;55:477-485 «PMID: 33148599»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