February 6, 2013
Steroid Injections Do Not Help Tennis Elbow In The Long-Term
Lawrence LeBlond for redOrbit.com - Your Universe Online
Aside from the occasional jokes associated with “tennis elbow,” there isn´t much laughter going on with people who suffer from the condition, technically known as chronic unilateral epicondylalgia. And it surely is no pun when people who do suffer from it realize that steroid injections used to treat the condition may actually worsen it in the long run.
A new Australian study has found that common cortisone injections do not cure tennis elbow any better than a drug-free saline shot, and actually increase the chances the painful condition will reappear. They said that patients who get a dummy injection and physical therapy were more likely to completely recover after a year and much less likely to have recurrence than those given the steroidal shot.
While the results of the study concur with previous findings, cortisone injections are still widely recommended by doctors to treat tennis elbow, likely because the shots usually provide short-term relief.
The study, led by Brooke K. Coombs, PhD, of the University of Queensland, found that a few weeks after a steroid shot had been given, patients reported much less pain than those who received the dummy shot. But after a year or more, the dummy group was more likely to report complete recovery than the group that had received the drug injections.
"Use of corticosteroid injections to treat lateral epicondylalgia is increasingly discouraged, partly because evidence of long-term efficacy has not been found, and due to high recurrence rates," according to background information in the article.
"This absolutely confirms that steroid injections are not a good idea," Dr. Allan Mishra, an orthopedic surgeon at Stanford University in Menlo Park, California, told Genevra Pittman of Reuters Health.
"This is important, because people think that it's okay to get a cortisone injection (for tennis elbow), and it's not okay. It puts you at a disadvantage long term in terms of getting better," said Mishra, who was not involved in the Australian study.
The study, appearing in the Feb. 6 issue of JAMA, was conducted to evaluate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both on patients suffering from tennis elbow. The study included 165 patients who had been suffering from the painful condition for longer than six weeks. The patients were enrolled between July 2008 and May 2010, with a one-year follow-up completed in May 2011.
The study participants were randomized to either receive cortisone injection, placebo injection, cortisone plus physiotherapy, or placebo plus physiotherapy. The two primary outcomes were complete recovery/much improvement after one year; and recovery after 4-8 weeks, but with recurrence after one year. Secondary outcomes included complete recovery or much improvement at 4 and 26 weeks.
Coombs and her colleagues found that corticosteroid shots demonstrated that one year out patients had lower complete recovery or much improvement outcomes than those who received the placebo injection (83 percent vs. 96 percent) and significantly greater recurrence (54 percent vs. 12 percent). There was no significant difference between physiotherapy and no physiotherapy outcomes for either group.
Pertaining to secondary outcomes at 26 weeks, the corticosteroid injections demonstrated lower complete recovery or much improvement outcomes compared to the dummy shots (55 percent vs. 85 percent). Physiotherapy and no physiotherapy outcomes were not significantly different in this group as well, with no significant differences on measures of worst pain; resting pain; pain and disability; and quality of life.
"At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy, whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs. no physiotherapy (39 percent vs. 10 percent, respectively). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs. corticosteroid alone (68 percent vs. 71 percent, respectively)," the authors wrote.
"Contrary to our hypothesis and to a generally held clinical view, we found that multimodal physiotherapy provided no beneficial long-term effect on complete recovery or much improvement, recurrence, pain, disability, or quality of life, thereby not supporting the hypothesis that the combined approach is superior. However, physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates (4.9 percent) and 100 percent complete recovery or much improvement at 1 year," the authors concluded.
The results of this research concur with a Danish study which last month showed that neither steroid nor platelet injections improved pain and functioning among people with tennis elbow any better than saline shots. But the authors in that study cautioned that their follow-up period was short and the results may have been much different at six months or a year post-injection.
By following the patients longer, the new study demonstrated that cortisone shots may cause more damage in the long run, leading to possible long-term tendon damage.
Mishra told Pittman that researchers have been looking for better treatment options to better address what is actually causing tendon pain in the first place. He noted that he and his colleagues have been studying the use of platelet-rich plasma injections.
He said that many cases of tennis elbow get better with time and stretching. "I think home-based exercises are probably sufficient for treating this. You'd be better off with that than with a cortisone injection. That's what you should start with, because you might not even need physical therapy.”
The main problem with steroid injections is that they generally only mask the pain, rather than fixing the underlying problem. Patients often go back to their normal activities soon after receiving these shots, many who are doing so much too soon, Dr. Michael Perry, a sports medicine specialist at Northwestern Memorial Hospital in Chicago, said in an interview with HuffPost.