Cortisone injections lead to worse outcomes for tennis elbow

Cortisone injections have been almost routine treatments for patients with lateral epicondylitis – commonly known as tennis elbow. A study published in today’s issue of the Journal of the American Medical Association questions whether cortisone injections are effective and whether they should be used for this problem.

Brooke K. Coombes, PhD et al performed a randomized controlled trial comparing adults undergoing a one-time injection of a corticosteroid versus a placebo injection, with and without a short course of physical therapy. They found that patients who received a single corticosteroid injection had a higher recurrence rate and worse long-term outcomes one year later than did those receiving a placebo injection.

Cortisone shot for tennis elbow

The authors also noted other interesting findings:

    Corticosteroid injections provided a short-term benefit compared to placebo. However six months after receiving the injection, patients were found to have worse outcomes in terms of pain, disability and quality-of-life.
    More than half of patients who received a corticosteroid injection had a recurrence of their lateral epicondylitis, which was much higher than the placebo patients.
    Significantly fewer patients who received a corticosteroid injection claimed to be completely recovered than did those patients who received a placebo injection.
    Eight weeks of physical therapy did not improve patient outcomes long-term, but it did seem to provide short-term benefits to patients who did not receive a corticosteroid injection.

Pain from tennis elbow

Should we be surprised?

Most people reading this post might be surprised, because cortisone injections have been considered standard treatments for tennis elbow for years. In my experience the majority of patients who come to my office for evaluation and treatment of tennis elbow expect or request a cortisone shot.

On the other hand, many of us who specialize in sports medicine probably aren’t or won’t be surprised. In theory, cortisone injections shouldn’t effectively treat lateral epicondylitis. Why?

While the name lateral epicondylitis suggests an inflammatory problem, it actually isn’t one. If you biopsied the diseased tendons, you would find few inflammatory cells. Corticosteroids are anti-inflammatory medications. If there isn’t an inflammatory process present, an injection shouldn’t have an effect. Actually concern that the steroids would weaken the tendon is warranted.

Tennis elbow is actually a tendinopathy – a disease process where there is a small area of degeneration within the tendon. While the cortisone shot might provide short-term relief, it does not actually cause healing within the diseased tendon. The short-term relief might result from the local anesthetics in the injection or a placebo effect itself.

Bottom line about getting a cortisone shot for tennis elbow

What message can patients take home from this study? First, and most importantly, they should avoid a cortisone injection as a first-line treatment for lateral epicondylitis. It is important to point out that most patients recover from this problem without long-term issues. The authors in this study showed that 90% of patients either had complete recovery or significant improvement at one year with a placebo injection – meaning it essentially resolved on its own.

Doctor giving patient a shot

Reference:
Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial. JAMA. February 6, 2013;309(5):461-9.