CRD summary

This review concluded that steroid injections were well tolerated and effective in treating tendonitis at short-term follow-up compared with placebo and other commonly used therapies; there was no benefit of steroid injections compared with non-steroidal anti-inflammatory drugs. No long-term benefit was observed. Given the methodological flaws in the review process, the authors' conclusions may not be reliable.

Authors' objectives

To assess the efficacy and safety of steroid injections in the treatment of shoulder and elbow tendonitis.

Searching

The following databases were searched for English or French language studies up to April 2008: PubMed, EMBASE and the Cochrane Library. Search terms were reported. Reference lists of retrieved publications were also screened.

Study selection

Randomised controlled trials (RCTs) that compared steroid injections with placebo, ''wait and see'', non steroidal anti-inflammatory drugs (NSAIDs) or physiotherapy, in patients with epicondylitis, rotator cuff tendonitis or subacromial impingement, were eligible for inclusion. Eligible outcomes were pain, physical function and adverse events.

The majority of included patients had an elbow lesion. The included patients had the following disease conditions: acute condition (less than 12 weeks symptom duration), chronic condition (12 weeks and over symptom duration), or heterogeneous condition (with variable symptom duration). The mean age of included patients was 47.5 years and 38% of included patients were female.

One reviewer assessed studies for inclusion.

Assessment of study quality

The quality of trials was assessed using the Jadad scale, a five-point scale evaluating randomisation, blinding and withdrawal. Intention-to-treat analysis was used as an additional criterion in assessing trial quality.

The authors did not state how many reviewers performed the validity assessment.

Data extraction

Data were extracted on the means and standard deviations (SDs). If the standard deviation was only given in one treatment group, it was used as the baseline standard deviation for both intervention and control groups. The effect sizes (ESs) or the standardised response means (SRMs), with 95% confidence intervals (CIs), were calculated. Rates of adverse events were also extracted.

One reviewer performed the data extraction.

Methods of synthesis

The studies were combined in a meta-analysis, using a random-effects model in the presence of significant heterogeneity. The pooled Effect sizes and standardised response means, with 95% confidence intervals, were calculated. The magnitude of effect size was assessed using the Cohen Categories. A standardised response mean value of greater than 0.8 was considered as large. Sensitivity/subgroup analyses were performed to assess the robustness of results in terms of the location of joint involved, disease duration, types of steroids and types of comparators. Statistical heterogeneity was assessed using the X² test and I² statistic.

Results of the review

Twenty RCTs (n=1,731 patients) were included in the meta analysis. The included trials were generally of good quality, with the mean Jadad score of 3.1 (ranging from 1 to 5 points). Thirteen RCTs performed intention-to-treat analyses.

Short-term follow-up (at week four to eight): Compared with controls, steroid injection was associated with a significant short-term improvement of pain (ES 1.30, 95% CI 0.55 to 2.04; SRM 0.96, 95% CI 0.63 to 1.30) and physical function (ES 0.66, 95% CI 0.03 to 1.30; SRM 1.06, 95% CI 0.45 to 1.66). Based on the evaluation of the effect size, the effect was moderate to large for these outcomes.

Long-term follow-up (at week 48): Compared with controls, steroid injection was associated with a significant long-term increase of pain (SRM -0.28, 95% CI -0.53 to -0.03) and a reduction of physical function (SRM -0.47 (95% CI -0.72 to -0.22). There were no significant differences in the outcomes of pain effect size and physical function effect size between the two groups.

Significant heterogeneity was observed in the four to eight week outcomes of pain effect size (I² not reported; p<0.001), pain standardised response mean (I²=65.7%; p=0.003) and physical function standardised response mean (I²=87.8%; p<0.001). Results of statistical heterogeneity in the week 48 outcomes were not presented.

Sensitivity/subgroup analyses showed that steroid injections were not significantly better than non-steroidal anti-inflammatory

drugs at short-term follow-up; steroid injections were significantly more effective in acute or sub-acute tendonitis than in chronic tendonitis (p<0.001). Sensitivity analysis did not materially affect the results in terms of location of joint involved and types of steroids.

The main adverse events of steroid injections were transient pain after injection (10.7% of corticosteroid injections) and skin modification (4.0%).

Results evaluating the efficacy of steroid injections at week one to three and 12 to 24 were also reported.

Authors' conclusions

Steroid injections were well tolerated and effective in treating tendonitis at short-term follow-up compared with placebo and other commonly used therapies (physiotherapy, wait and see); there was no benefit of steroid injections compared with non-steroidal anti-inflammatory drugs. No long-term benefit was observed.

CRD commentary

The review inclusion criteria were clear. Relevant sources were searched. Efforts were made to find published studies but not unpublished studies, introducing the potential for publication bias. Language restrictions were applied to the search, which introduced the risk of language bias. There were no sufficient attempts to minimise the bias and errors in the review process, as only one reviewer performed the study selection and data extraction.

Relevant criteria were used to assess the study quality. Statistical heterogeneity was assessed and appropriate methods were used to pool the results. In light of the high degree of statistical heterogeneity identified, the pooled estimates were of limited value.

The absence of two reviewers at the study selection and data extraction phases represented substantial limitations for evaluating the reliability of the review. The authors' conclusion reflected the evidence presented, but they may not be reliable given the methodological concerns outlined above.

Implications of the review for practice and research

Practice: The authors stated that this review may lead doctors to give steroid injections mostly in acute or subacute tendonitis, and systematically prescribe non-steroidal anti-inflammatory drugs (if there are no contraindications) in the treatment of tendonitis before performing steroid injections.

Research: The authors did not state any implications for research.

Funding

A grant from Abbott France for organising a meta-analysis methods workshop.

Bibliographic details

Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases 2009; 68(12): 1843-1849. [PMC free article: PMC2770107] [PubMed: 19054817]

Original Paper URL

http://ard.bmj.com/content/68/12/1843.abstract

Other URL

http://ukpmc.ac.uk/classic/articlerender.cgi?artid=1861600&rendertype=abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Elbow Joint; Female; Glucocorticoids /administration & dosage /adverse effects /therapeutic use; Humans; Injections, Intra-Articular; Male; Middle Aged; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Shoulder Joint; Tendinopathy /drug therapy; Treatment Outcome

AccessionNumber

12010000642

Database entry date

16/06/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.