Criteria for inclusion were randomized controlled trials that compared ≥1 peritendinous injection with placebo or other nonsurgical intervention. Study methods were independently assessed by 2 reviewers (reliability, κ = 0.85) on a modified PEDro scale, and scores were required to be ≥50% for inclusion. Studies with a high proportion of patients with
adhesive capsulitis, full-thickness
rotator cuff tears, or rheumatologic disease were excluded. Of 2954 studies screened, 174 full-text articles were evaluated for inclusion by 1 investigator and confirmed by a second. Of 64 studies that were initially included, the 41 that scored >50% on the PEDro scale were retained.
DATA EXTRACTION: Information about injection type and comparison treatments, site of the
tendinopathy, duration of follow-up (short term, <12 weeks; long term, ≥52 weeks), outcomes (
pain, function, and patient-rated overall improvement), and frequency of adverse events was extracted. Study results were pooled when the data were sufficiently homogeneous.
MAIN RESULTS: Clinically diagnosed lateral epicondylalgia: In 3 trials that compared
corticosteroid injections with no intervention,
corticosteroid injections were effective in the short term in
pain reduction [standard mean difference (SMD), 1.44; 95% confidence interval (CI), 1.17-1.71], in improving function (SMD, 1.50; 95% CI, 1.22-1.77), and in overall improvement [relative risk (RR), 3.47; 95% CI, 2.11-5.69]. In the intermediate and long term,
corticosteroid injections were less effective than no intervention. In comparison with placebo injection (4 studies), there was limited evidence for the effectiveness of
corticosteroid injection in relieving
pain. In comparison with physiotherapy (4 studies),
corticosteroid injection was more effective in the short term for improving function (SMD, 1.29; 95% CI, 1.03-1.55) and in overall improvement (RR, 2.37; 95% CI, 1.75-3.21), and there was strong evidence among heterogeneous studies for reducing
pain. Intermediate and long-term results were worse in
pain and function for the
corticosteroid injection intervention.
Corticosteroid injections were more effective than
orthotic devices for the wrist or elbow for overall improvement in the short term but not in the long term (2 studies). Effectiveness did not differ in comparisons of high- versus low-
corticosteroid dosage, and between
triamcinolone and
hydrocortisone.
Pain and function improved more with
corticosteroid than with platelet-rich plasma injection in the short term but were worse in the long term. Rotator cuff
tendinopathy: In the short term,
corticosteroid injection improved
pain (SMD, 0.68; 95% CI, 0.35-1.01) and function (SMD, 0.62; 95% CI, 0.29-0.95) more than placebo (3 studies). In comparisons with nonsteroidal anti-inflammatory drugs (
NSAIDs) and with
NSAIDs plus placebo injection, no differences in
pain or function were found (3 studies) or when
NSAIDs were administered in addition to
corticosteroid and placebo
injections (4 studies).
Corticosteroid injection and physiotherapy did not differ in effectiveness (2 studies), although 1 study found short-term greater overall improvement and function after
corticosteroid injection. Adverse effects were reported in 82% of
corticosteroid injection trials. In comparison with placebo
injections,
corticosteroid injections were associated with an increased risk of
atrophy for Achilles and patellar tendons but not elbow tendons. In trials of
injections of
sclerosant, platelet-rich plasma,
proteinase,
glycosaminoglycan polysulfate,
sodium hyaluronate,
prolotherapy, and
botulinum toxin compared with placebo injection or other
therapies, only
sodium hyaluronate compared with placebo showed consistently better results in the short and long term in overall improvement and
pain reduction of lateral epicondylalgia (1 study). Adverse effects were reported for all these
injections except
sclerosant and platelet-rich plasma.
CONCLUSIONS: