Stop injecting corticosteroid into patients with tennis elbow, they are much more likely to get better by themselves!

Tennis elbow is a common1 presentation to family practitioners and various medical specialists. Injectable corticosteroids have been used and continue to be used as one of the mainstays of treatment for tennis elbow. This is in spite of the fact that shortcomings have existed regarding its use since one of the earliest published clinical trials.2 Seven of thirteen patients injected had recurrence of symptoms during follow-up studies of at least 6 months with only 38% obtaining permanent relief.

First described by Morris3 confusion surrounding the nomenclature and underlying pathology have remained a common theme in the literature through the ages.4, 5 Many currently practicing doctors, including general practitioners, specialists and new medical graduates continue to be taught that tennis elbow is inflammatory. It is now more than 30 years since tendonosis was described6 and yet universities across Australasia are still teaching undergraduates in Medicine that the pathology of tennis elbow is tendonitis.7 They continue to be taught that patients with tendon conditions will benefit from non-steroidal anti-inflammatories and corticosteroid injections.7 Evidence over the last quarter of a century strongly points to conditions such as tennis elbow being a degenerative condition of the tendon, not an inflammatory disorder.5, 6

Injections of corticosteroid into rabbit tendon has been shown to cause tendon necrosis within 45min of injection.8 Logic would suggest that this is therefore a bad thing to do to encourage tendon healing.

Editorials have asked “when will the myth be abandoned?”.5 Clinicians continue to use corticosteroids as their peers teach them, backed up by numerous papers demonstrating that it is a highly effective treatment—but only if you consider outcomes 6 weeks post-injection.1, 9, 10 The literature is however equally clear that there are high rates of recurrence of symptoms. This was first noted over half a century ago2 and more recently.1 Few studies followed patients beyond 6 months and none of these studies showed positive outcomes for corticosteroid injections beyond 6 months.1 Spurious conclusions in the literature also lead to confusion. For example injecting hypertonic glucose11 no more proves that tendonopathy is a disorder of insulin metabolism, than injecting corticosteroid into tendonopathy means that it is an inflammatory disorder.12 Recent clinical trials9 support the high rate of recurrence following corticosteroid injection noted last century.2

Two recent clinical trials with extended follow up to 12 months give a much clearer picture of the pitfalls of corticosteroid injections.9, 10 These studies had very similar methodology where patients either received corticosteroid injections (127 patients), physiotherapy (127 patients) or a wait and see approach (119 patients). The results at 6 weeks were consistent with the literature, 78% of patients having had an injection had a successful outcome compared with only 29% of those waiting. At 1 year of follow up things changed completely with many injected patients having had relapses (49%) and only 68% having a successful outcome compared with 87% of those who just waited and 92% of those who had physiotherapy. In other words up to 22% of patients who would have otherwise improved with a wait and see approach, failed to do so because of the corticosteroid injection.9, 13

Using the remission rates from these two long term trials13 we can make an analogy to the introduction of a therapeutic agent. If a new anti-cancer drug were to show early (6 weeks) benefits with remission rates of 78% for the drug compared with 29% for placebo, there would be great excitement. If follow up data showed remission rates at 1 year of 87% in the placebo group compared with 69% in the new drug group with significant statistical and clinical significance the new drug would never make it to market.

It is time for clinicians to finally update themselves on the nature of tendonopathy and to embrace, along with medical educators, that corticosteroid injections for tennis elbow worsen the long term outcomes of patients. Corticosteroid injections should not be used to treat most patients with tennis elbow with symptom duration of less than 12 months.