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.

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.

Are these results surprising?

Man with painful tennis elbowMost 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

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.

Do these results surprise you? Have you had success – or failure – with cortisone injections for tennis elbow? Share your thoughts and experiences below!

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.

32 Responses to Cortisone injections lead to worse outcomes for tennis elbow

  1. I am currently in physical therapy for an acute case of lateral epicondylitis. Use of my right hand is greatly curtailed due to lack of grip. At the end of this session I am scheduled for a corticosteriod injection. People I have spoken to have reported excellent results with this treatment. I am surprised and confused by these findings.

    • That doesn’t surprise me. Many patients will get significant relief of their pain. But frequently the problem comes back in weeks or months. There has been suspicion for a long time in orthopaedic surgery that cortisone injections actually might be counterproductive, but we haven’t had much data. I don’t tell people that they should never try one, but I do discuss risks and benefits.

      • Dr. Geier, did the authors of the study mentioned above measure the subjects activity level pre vs. post-treatment (placebo)? The reason I ask this is that I believe the activity, not the cortisone shot, is responsible for the high rate of recurrence. If someone obtains relief from the cortisone shot but then returns to the exact same behavior that caused the condition in the first place, then recurrence should be expected. I have had cortisone shots in multiple joints and have had tremendous success. But at the same time, I realized that overuse caused the injury so I modified my behavior (reduced specific activity) and incorporated physical therapy exercises. I am interested in hearing your thoughts on this. Thanks.

        • I can’t remember about activity levels in that study at this point, but those findings are consistent with more and more studies on the topic. I’m not a big fan of cortisone for it personally, so I might be biased. I worry about what the cortisone does to the tendon, especially with multiple injections. Having said that, many surgeons still advocate it.

  2. I have a mild/mod case of lateral epicondylitis, I actually do play tennis and experienced a pain upon a topspin forehand in Oct’12. Since then I have been dx and some ROM exercises, kinesiotape, etc. I have not been playing tennis to “rest” it since then and occasionally wearing a cock up splint for wrist extensors to rest during sleep. I just got a cortisone shot and now wonder the best approach? rest for 2 weeks, cont. to not play tennis, yardwork for healing process? If I use it will it not heal but be a nuisance with pain? Dr.s have varied views. I’m an OT and trying to make since of this, I do believe I damaged the tendon(s) playing tennis with possibly poor muscle mechanics, so need to address that. I will be in Charleston in August, maybe an appt?
    Any present suggestions, Thanks

    • It is really difficult to give you any specific advice. Options generally for lateral epicondylitis include a counterforce strap, physical/occupational therapy, and rest from offending activities. If tennis is painful, many patients often give it up temporarily. Cortisone injections are probably not great ideas if patients have already had one and are still having symptoms. Options for the small percentage of people still with symptoms at that point can include PRP or surgery. Also the extent of the damage of the tendon determined by MRI can play a role in deciding the options as well.

      • thank you, in general, what is the recommended protocol post cortisone shot for lateral epicondylitis? 2 weeks after shot and then up to 4 months after shot. what is the recommended time to resume normal activities, though gradually with movement and strengthening exercises? Assuming no pain.
        thanks for this second opinion,
        from a graduate from MUSC

  3. I have had pain, loss of strength not only in my hand but lower and upper arm including pain in the biceps/triceps area and even into the shoulder and armpit area. The physician stated since the lateral epicondyle region was tender he wanted to do an injection and stated that this would rule out if it was true “tennis elbow”. After reading the findings, and undergoing therapy, I am even more hesitant than I was prior to this, of undergoing an injection.
    I’ve had xrays also, and wondering what my next steps should be in the course of treatment, because although my physician seems to think an injection is warranted to “rule out”, I’m not apt to have one. Can an MRI be utilized to rule out other issues or injuries?

    • MRIs can certainly show edema within the tendon that would represent changes related to lateral epicondylitis. They would also show any other changes, such as partial tendon tears. Often treating the pain with conservative measures, such as a counterforce strap or physical therapy, can help determine if that is the diagnosis for a patient.

  4. I have been suffering with lateral epicondylitis for two weeks now I am in absolute agony and can hardly us my arm when I went to the doctors he told me I have tennis elbow, and gave me the cortisone injection, which has made things worse, I can now hardly lift anything. I honestly think that my diagnoses could be wrong. I just want this sorted as its so painful.

  5. I have been carrying this case of golfer’s elbow for about 4 months. I did not want to stop weightlifting so I played through the pain. I only felt pain during triceps and sometimes chest exercises. I used NSAIDs (oral and local) , ice packs to relieve the pain. I also wore an elbow strap to keep pressure on the elbow. I did not stop training though. My condidtion didn’t get better so I decided to go to a doctor.

    The doctor prescribed a more powerful oral NSAID for 2 weeks and complete rest for the upper body. He said if there is no improvement, I will need to take a cortisone shot. I’ve been resting for a week now but don’t feel any improvement. I did some research online and found that many don’t recommend cortisone shots as they do no cure the problem. I am worried it would mask the pain and that I would go back to training full throttle and then injure myself worse.

    What should I do? Fo you recommend I have an MRI scan?

    • I can’t give you specific advice, buy you are correct in that generally I am not big on cortisone shots, for the reasons mentioned in my post. I think physical therapy, counterforce straps, stretching, short-term activity modification and more can be helpful first treatments. I will occasionally do a cortisone shot one time if the other treatments aren’t working, but there are many factors involved.

  6. I have been suffering from tennis elbow on both sides since 5/16/12. I had two sets of cortisone done, first in sept 2012 with great results. I had some initial pain and flare up but the pain was 50-75% better after a month. It lasted a short time, only until late Nov. That is when I received a second set of injections. This time my arm flare was worse, I could not extend my arm fully for week. The pigment is now gone around the site I am left with very indented elbows. The skin is so thin there is nothing left to protect them. On top if these side effects I think the shots made my hair fall out really fast.
    I would not recommend cortisone for tennis elbow as you might end up with irreversible damage. I was recommended to have surgery since it has been well over a yea, and I have tried every thing from arm band, pt, taping, compression sleeves, ice and ultra sound. I also have a back, neck, shoulder and rib that feeds pain down my arms from the nerves. They all contribute to the pain in my arms so I had to have it confirmed via mri before my injections were done. I wish I could go back and not have the injections done. I believe it made things worse in the long run.

  7. I am a Physical Therapist who regularly performs Injection Therapy for Lateral Epicondylitis. I have found that Cortisone injections work well when performed in the early stage of injury and when radiacular symptoms have been ruled out and a confident diagnosis can be made. I think many patients in general practice are wrongly diagnosed. Also, most research studies such as this one look at chronic Lateral Epicondylitis when any inflammatory stage is well past and tendons are in a degenerative state. In these cases, its no surprise there is no long term benefit. I would like to see a study where cortisone is performed in the acute stage of injury and look at the long term effects of this.

    • Thanks for sharing your thoughts and experiences! I agree that more research is needed to find quick, effective treatments.

  8. I have golfers elbow in my right arm and tennis elbow in my left arm I have had this problem for well over a year now I have had about 4 cortisone injections in my left arm which is pain free at the moment however I have had about 6 injections in my right arm my arm is still in a lot of pain I asked the doctor are you supposed to have this many and he said well it will help I have heard that you should only have 3 I wonder is this going to damage my tendons because it does not seem to be helping I have lost a lot of grip in my hand I cannot put any pressure on with my hand at all

  9. I have a partial rotator cuff tear with my primary symptoms being bicep tendonitis. I’ve been given contradictory advice that cortisone injections would either mask symptoms as you stated or others stating injections would help with inflammation long enough for me to strengthen the area to avoid the need for surgery later. I definitely don’t want to do something that will weaken the area in the long term by exasperating the problem through exercises that may actually make the situation worse. Physical therapy hasn’t helped and I’m not a candidate for surgery yet according to doctors who looked at my MRI. Any ideas? Thank you ahead of time for your insights.

    • This post and the thoughts about cortisone injections pertain specifically to tennis elbow (lateral epicondylitis). It is potentially an option for some patients with shoulder issues along with other nonoperative treatments. It might be a question appropriate for your orthopaedic surgeon to help find treatments appropriate for your particular problem.

  10. I had lateral epicondyle release with partial ostectomy on both arms after undergoing PT and cortisone injections. I had 3 injections in right arm with minimal relief and 1 injection in left arm with no relief in a span of 1 year. I have a job that is very repetitive and my concern is that if I go back to it am I going to be in the same shape before the surgery’s. I can not modify the way I do my job. Any suggestions?

    • Honestly I don’t have any specific suggestions since I am not involved in your care. Generally if a patient works hard to let the surgery heal and regain motion and strength, he can return to his former activities.

  11. I had shot April 2013. Shot was effective for 2 months. Pain came back. Got another shot 2 weeks ago. The shot did not work. I can’t use my arm. I have no strength. it hurts to even move my fingers. My whole arm is effected. I take anti inflammatories on a daily basis and the pain still persisting. My injury happened on the job in December of last year. I went to the Kaiser the doctor said if I still have pain come back in two weeks. So I did, went back and they did nothing. Then in April I finally got the shot. And I just had another one two weeks later. I think something else is wrong.

  12. I have made a living as a potter for 35 years, and the last few years have suffered with left lateral epicondylitis – made worse I believe, by a torn right rotator cuff 3 years ago. Last spring I had the cortisone injection, which I found incredibly and brutally painful for the first week. After it settled down, it was wonderful for about 5 months. In October, while working hard as ever, I literally felt it “go” again. I am opposed to ever receiving another cortisone injection, so I met with a surgeon in December to discuss lateral epicondyle release. Everything I’ve read tells me that 80% – 90% of patients with epicondylitis can recover without the surgery. I have tried to rest it, and not worked since November, but it doesn’t seem to be much better. The strap that I wore for about 6 weeks only made it feel worse, and for the last month or so, I am wearing the “Futuro Infinity” brace, which provides minimal comfort. As it has been 4 months now, I am agonizing over whether to do the surgery, or just hope the elbow heals sooner rather than later. I would appreciated your advice on this matter.

    • It sounds like you have tried many of the nonoperative options for lateral epicondylitis. Some patient try PRP for chronic tendinopathy. Physical therapy can help many patients. Surgery can be an option if nothing works. I can’t give you advice on what you should do, though.

  13. I had a cortisone shot on friday for “tennis elow” it did not help the slightest bit. infact things are way worse. before the sot I could marginally use my arm, with pain but bearable. since the shot I can do nothing. I cannot straighten my arm or even hold a pen :( please avise what other options there are?

    • I can’t say without being involved in your care. You might contact your orthopaedic surgeon for advice.

  14. I was having pain in my elbow from march this year, till now, had the shot on my elbow 3 days ago, but after the shot i felt the heavy in my whole arm, now i cant even straighten my arm or move it around,It is so painful that i couldnt even comb my hair nor touch it, omg this is so painful:(

  15. I have been suffering from tennis elbow since April of this year. I am an IT Desktop Analyst so I am hauling and setting computer equipment as well as typing on a daily basis. I have been seeing a hand therapist now for 6 sessions with no relief at all. Going through several different exercises, icing, using a couple different braces as well as kinesio tape with no relief from the pain at all. Even with resting it, my arm is still extremely painful with severe burning. I have heard about cortisone shots not being a good option as they only provide temporary relief, but I’m at a loss as far as what my next options are. I struggle with my daily routine getting ready in the morning as well as doing my job. Please help!

    • Physical therapy with or without modalities, home exercises, use of a counterforce strap, platelet-rich plasma, and surgery can all be options in place of or along with a cortisone injection for patients with lateral epicondylitis..

  16. After having type 1 diabetes and given birth 10 months ago I some how got tennis elbow in my left arm 5 months ago, the pain was to the point where I couldn’t take it anymore and was advised by my GP to have the cortisone injection, upon getting an ultrasound the GP showed me the area that had information while at the same time as the injection (owch). Following tht I had a lot of pain not just in the area of injection but my whole arm was and has been aching since, it’s been 2 days now and I feel that it’s much worse than before. I was shocked to read that cortisone injection ha such crap results, any advice on what my next step is?

    • I really can’t offer specific medical advice on this site. You might discuss options with your orthopaedic surgeon.

  17. I have had tennis elbow for 7 months (since Dec 2013) with a knot at the outside tip of my elbow . I have treated with NSAIDS, had a cortisone shot in March, another in May, and am now doing OT for the last week. The therapy seems to be making it worse so far – my question is whether or not this is a normal course for this condition. Not sure where things are going, but it is becoming a big nuisance to just do things I need to do around the house. What’s next?

    • You might discuss your case with your orthopaedic surgeon to determine next steps, like PRP injections, brace and surgery.

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