Tennis elbow and sciatica are not helped by corticosteroid injections

JAMA Vol 309 No 5Tennis elbow (lateral epicondylalgia) is commonly treated with corticosteroid injections but, like many interventions has never been investigated for efficacy . A randomized controlled trial recently published in JAMA (The Journal of the American Medical Association) shows, however, that corticosteroid injections don’t help tennis elbow and can actually make it worse. The authors determined to look into this:

“Corticosteroid injection and physiotherapy, common treatments for lateral epicondylalgia, are frequently combined in clinical practice. However, evidence on their combined efficacy is lacking…To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia.”

To do so they divided their subjects with tennis elbow into cohorts who received either corticosteroid injection, placebo injections corticosteroid injection plus physiotherapy, or placebo injection plus physiotherapy. For outcome measures the looked for significant improvement at 4, 8 and 26 weeks and recurrence after 1 year. All the interventions were disappointing:

Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively); and greater 1-year recurrence (54% vs 12%). The physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively) or recurrence (29% vs 38%). Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively) and no difference between the physiotherapy and no physiotherapy groups (71% vs 69%, respectively). At 4 weeks, there was a significant interaction between corticosteroid injection and physiotherapy, whereby patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%). However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively).”

In other words, the corticosteroid injections resulted in a worse outcome for tennis elbow (and the physiotherapy done was not shown to help). Interestingly the placebo injection, which can be considered a form of ‘sensory-based peripheral stimulation therapy’ (eliciting a therapeutic neurological response) had the best result. The authors conclude:

“Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.”

Annals of Internal MedicineAnd a study published recently in Annals of Internal Medicine finds that corticosteroid injections for sciatica, another unproven therapy, are not really helpful either. The authors set out to…

“…To determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo.”

They examined 23 published randomized, placebo-controlled trials that assessed the efficacy of corticosteroid injections for sciatica, establishing metrics for leg pain, back pain and disability and calculated both short term (less or equal to 3 month) and long term (more or equal to a year) benefits. While the data showed some short-term benefit, it did not persist:

“The pooled results showed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term and also for disability in the short term. The long-term pooled effects were smaller and not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high.”

In other words, there was no evidence for long-term benefit of corticosteroid injections for sciatica. The authors conclude:

“The available evidence suggests that epidural corticosteroid injections offer only short-term relief of leg pain and disability for patients with sciatica. The small size of the treatment effects, however, raises questions about the clinical utility of this procedure in the target population.”

I suggest that clinicians have a look at the clinical trials published (over thirty) investigating the effectiveness of low level laser therapy (LLLT) for tennis elbow and the couple dozen examining the effects on sciatic and other peripheral nerve injuries.