CRD summary

The authors concluded that there was strong evidence that corticosteroid injections were beneficial in short-term treatment of tendinopathy (although the effect varied between sites), but other treatment options were more effective in the intermediate and long term. This was a well-conducted piece of research and the authors' conclusions appear likely to be reliable.

Authors' objectives

To assess the safety and efficacy of injections (including corticosteroids) for the treatment of tendinopathy.

Searching

MEDLINE, CINAHL, EMBASE, Web of Knowledge, AMED, SPORTDiscus, Cochrane Central Register of Controlled Trials (CENTRAL) and PEDro were searched up to March 2010 for articles in any language. Search terms were reported. Reference lists were searched for additional studies.

Study selection

Randomised controlled trials (RCTs) that compared one or more peritendinous injections versus a placebo or other non-surgical intervention for treatment of tendinopathy were eligible for inclusion. Studies of a high number of adhesive capsulitis, full thickness tears or rheumatological disease were excluded. Outcomes of interest were pain, function, patient-rated overall improvement and adverse events.

Included trials were of patients with lateral epicondylalgia, rotator-cuff tendinopathy, medial epicondylalgia and Achilles and patellar tendinopathy. Most trials administered between one and three of the following injections (at varying intervals): corticosteroid, prolotherapy, glycosaminoglycan polysulphate, proteinase, sodium hyaluronate, platelet-rich plasma, botulinum toxin and non-steroidal anti-inflammatory drug (NSAID). Comparators included placebo injection (saline or local anaesthetic), no intervention (observation or wait and see), NSAIDs, physiotherapy, electrotherapy or orthotic devices. Visual analogue scales were commonly used to assess pain; various other scales and scores were used. Various cointerventions (including lidocaine and exercises) were used in a number of studies.

One reviewer screened studies for inclusion and these were checked by a second reviewer.

Assessment of study quality

Two reviewers independently assessed trial quality using a modified PEDro scale. Studies that scored at least 7 were included in the review. Maximum score was 13. Disagreements were resolved by consensus.

Data extraction

One reviewer extracted data on overall improvement and adverse events to calculate relative risks (RRs) and extracted data on pain and function to calculate mean differences and their 95% confidence intervals (CIs). Number needed to harm (NNH) was calculated for adverse events. Data extraction was checked by a second reviewer. Where insufficient data were provided, primary authors were contacted for further details.

Methods of synthesis

Where appropriate, a random-effects model was used to pool relative risks and 95% CIs and calculate standardised mean differences (SMDs), grouped by site of tendinopathy (lateral or medial epicondyle, rotator-cuff, Achilles and patellar), type of comparison and length of follow-up. Length of follow-up was short term (four weeks, range zero to 12 weeks), intermediate (26 weeks, range 13 to 26 weeks) and long term (one year, ≥52 weeks). Statistical heterogeneity was assessed using the Ι² statistic.

Outcomes that were statistically heterogeneous were presented as a narrative synthesis based on strength of evidence: strong (consistent findings between many high-quality RCTs), moderate (one high-quality RCT), conflicting (inconsistent findings between many RCTs) or no evidence.

Publication bias was not formally assessed due to the small number of trials for pooling.

Results of the review

Forty-one RCTs (2,672 patients, range 21 to 331) were included in the review. Study quality ranged between 7 and 13 out of 13.

Corticosteroid injections for lateral epicondylalgia (12 RCTs, 1,171 patients):

Corticosteroids showed statistically significant improvements on all outcomes in short-term treatment of lateral epicondylalgia compared to no intervention: pain (SMD 1.44, 95% CI 1.17 to 1.71; three RCTs, Ι²=0%), function (SMD 1.50, 95% CI 1.22 to 1.77; three RCTs; Ι²=0%) and overall improvement (RR 3.47, 95% CI 2.11 to 5.69; two RCTs; Ι²=50%).

Individual trials showed that compared to physiotherapy, corticosteroids statistically significantly improved: pain (three RCTs that could not be pooled due to significant statistical heterogeneity, Ι²=68%), function (SMD 1.29, 95% CI 1.03 to 1.55; three RCTs; Ι²=0%) and overall improvement (RR 2.37, 95% CI 1.75 to 3.21; three RCTs; Ι²=43%).

By contrast, significant negative effects in favour of no intervention and physiotherapy groups were reported at intermediate and long-term follow-up. There were no statistically significant differences between corticosteroids and placebo for any outcome in the short and intermediate term.

Corticosteroid injections for rotator-cuff tendinopathy (10 RCTs, 780 patients): Corticosteroids showed statistically significant short-term improvements compared with placebo for pain (SMD 0.68, 95% CI 0.35 to 1.01; three RCTs; Ι²=0%) and function (SMD 0.62, 95% CI 0.29 to 0.95; three RCTs; Ι²=0%). No statistically significant differences were found for other comparisons.

Non-corticosteroid injections (15 RCTs; results reported for 12 RCTs): Three RCTs of patients with lateral epicondylalgia showed statistically significant improvements with non-corticosteroids versus placebo: sodium hyaluronate in the short, intermediate and long term for overall improvement and pain (one RCT); botulinum toxin for pain in the short term (one RCT); and prolotherapy for pain in the intermediate but not short term.

Other results for comparisons that included only one RCT were reported in the review.

A statistically significantly greater risk of atrophy was reported in one RCT using corticosteroid injection. Two RCTs reported statistically significantly greater risk of itching or burning with aprotinin. One RCT reported greater overall risk of adverse events with botulinum toxin.

Authors' conclusions

There was strong evidence that corticosteroid injections were beneficial in short term treatment of tendinopathy (although the effect varied between sites), but other treatment options were more effective in the intermediate and long term.

CRD commentary

The review question and inclusion criteria were clearly defined. A comprehensive search of the literature was undertaken, although it was unclear whether attempts were made to locate unpublished data. Publication bias was not formally assessed due to the small number of studies. Each stage of the review process was undertaken in duplicate, which reduced potential for reviewer error and bias. Appropriate criteria were used to assess the quality of the included studies; only high-quality studies were included in the review. The authors acknowledged that this may have excluded useful clinical information, but noted that the quality of trials did not substantially alter the findings (data not presented). Appropriate methods were used to combine the studies and investigate statistical heterogeneity. Sample sizes were generally small and, as the authors acknowledged, only a few trials were included for any given comparison.

This was a well-conducted piece of research; the authors' conclusions reflect the evidence available and appear likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that the findings challenged the continued use of corticosteroid injections as long-term use of corticosteroids was less effective than most conservative interventions for tendinopathy. The authors also stated that as many of the included trials were restricted to subgroup populations with tendinopathy, generalisability of the findings to clinical practice needed careful judgement.

Research: The authors stated that further large high-quality studies were needed that included standardisation of cointerventions, long-term follow-up and systematic reporting of recurrence and adverse events. Further research was also needed to assess whether physiotherapy reduced the high rates of recurrence associated with corticosteroid injection.

Funding

Translation services and the PhD scholarship of one author were funded by the National Health and Medical Research Council of Australia.

Bibliographic details

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(9754): 1751-1767. [PubMed: 20970844]

Original Paper URL

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61160-9/abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Anti-Inflammatory Agents /administration & dosage /adverse effects; Aprotinin /administration & dosage /adverse effects; Botulinum Toxins /administration & dosage /adverse effects; Glucocorticoids /administration & dosage /adverse effects; Glycosaminoglycans /administration & dosage /adverse effects; Humans; Hyaluronic Acid /administration & dosage /adverse effects; Injections; Patellar Ligament; Platelet-Rich Plasma; Polyethylene Glycols /administration & dosage /adverse effects; Randomized Controlled Trials as Topic; Rotator Cuff; Tendinopathy /drug therapy; Tennis Elbow /drug therapy

AccessionNumber

12010007121

Database entry date

03/11/2010

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.