Corticosteroid injection may worsen the long-term prognosis of lateral tendinopathy. The quality of evidence is low, but the applicability is good.
Reference | Study type | Population | Intervention and comparison | Outcomes | Risk of bias |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | SR (13 RCTs) | RCTs «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 Patients had a clinical dg of lateral epicondylitis «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 At least one treatment was ≥ 1 corticosteroid injection «Dong W, Goost H, Lin XB ym. Injection therapies fo...»3 ≥ 1 clinically relevant outcome measure |
Corticosteroid injection therapy vs. PBO injections (2 studies) or injection with local anaesthetic (5 studies) or another conservative treatment (5 studies) or another corticosteroid injection (3 studies) |
Pain, Global improvement, grip strength | High |
«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»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 |
«Dong W, Goost H, Lin XB ym. Injection therapies fo...»3 | SR/NMA | RCTs «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 adults (≥ 18 years) «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 diagnosis with lateral epicondylalgia «Dong W, Goost H, Lin XB ym. Injection therapies fo...»3 at least two injection therapies for lateral epicondylagia evaluated, including PBO or a ‘wait and see' strategy «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4 results of pain relief or functional recovery reported. |
Injection therapies, corticosteroid (9 RCTs, n=774) vs. PBO or a "wait and see" strategy |
Pain score (VAS, NRS) | Moderate |
RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis; NMA=Network meta-analysis, PBO=placebo, VAS=visual analoque scale, NRS=the Numerical Rating Scale
Reference | Comments |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 |
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«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 |
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«Dong W, Goost H, Lin XB ym. Injection therapies fo...»3 |
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SR=systematic review
Results
Reference | Number of studies and number of patients (I/C) | Follow-up time | Absolute number of events (%) I | Absolute number of events (%) C | MD/WMD (95% CI) |
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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. |
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«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 | 121 patients (62/59) | 3 weeks 6 weeks 12 weeks 26 weeks 52 weeks |
NR | NR | MD: 30 (23, 36) 32 (24, 40) 8 (-1, 18) -7 (-17, 2) -4 (-13, 6) |
«Dong W, Goost H, Lin XB ym. Injection therapies fo...»3 | 9 RCTs, (399/375) | 7–26 weeks | NR | NR | WMD: 0.12 (-0.65, 0.90) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; WMD=Weighted mean difference
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) |
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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. |
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«Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1 | 1 RCT comparing to PBO (n=29), 1 RCT comparing to elbowband (n=18) or splintage (n=18) | 2 weeks | NR | NR | |
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0.36 (0.18, 0.71) | ||||
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0.33 (0.17, 0.65) | ||||
Unclear (≤ 6 weeks) | 0.11 (0.04, 0.33) | ||||
13 weeks | |||||
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0.76 (0.32, 1.80) | ||||
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0.52 (0.24, 1.16) | ||||
26 weeks | |||||
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1.83 (0.58, 5.77) | ||||
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3.00 (0.73, 12.27) | ||||
52 weeks | |||||
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0.92 (0.27, 3.07) | ||||
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1.22 (0.32, 4.65) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported; MD=Mean difference; WMD=Weighted mean difference; NR=not reported
Reference | Number of studies and number of patients (I/C) | Follow-up time | Absolute number of events (%) I | Absolute number of events (%) C | Mean difference (95% CI) |
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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. |
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«Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2 | 121 pts (62/59) | 3 weeks 6 weeks 12 weeks 26 weeks 52 weeks |
NR | NR | 34 (26, 42) 31 (22, 39) -6 (-17, 5) -11 (-22, -0.4) -14 (-25, -3) |
I= intervention; C=comparison; CI=confidence interval; NR=not reported
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. Corti...»1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»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. Corti...»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. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4. No serious adverse events were reported «Smidt N, Assendelft WJ, van der Windt DA ym. Corti...»1, «Smidt N, van der Windt DA, Assendelft WJ ym. Corti...»2, «Bisset L, Beller E, Jull G ym. Mobilisation with m...»4.