Volume 207 - Issue 10
Cortisone injections for tennis elbow should be an “avoid”, rather than a recommended procedure
Authors: John W Orchard and Bill Vicenzino
Med J Aust 2017; 207 (10): 453. || doi: 10.5694/mja17.00445
Published online: 20 November 2017
Published online: 20 November 2017
To the Editor:
We are strong supporters of Choosing Wisely, which promotes appropriate use of medical procedures and evidence-based medicine. We bring to your attention an example of a recommendation published in the 2017 edition of the Australian Therapeutic Guidelines for rheumatology,1 which is contrary to level 1 evidence (ie, multiple randomised control trials) and the Choosing Wisely ethos. The guidelines suggest that local corticosteroid injections may be considered for lateral epicondylitis (tennis elbow) and repeated if needed. The recommendation uses the less than prudent justification: “local corticosteroid injection can provide pain relief for 6–12 weeks”.1
There are now at least five high quality randomised control trials of corticosteroid injection for tennis elbow with 6 or more months follow-up, and collectively they show harm of corticosteroid compared with placebo injection or conservative treatment for time periods greater than 3 months. We reference three of these trials,2-4 and others show consistent results. There are no high quality published trials showing benefit of corticosteroid over placebo injection at time periods greater than 3 months, and one review, in fact, showed an association of poorer long term outcome with repeated injections.5 It is not reasonable, nor should it be good clinical practice, to justify a possible medium term harm by reference to a much shorter term benefit.
Based on current evidence, corticosteroid injection for tennis elbow should become a Choosing Wisely “avoid” procedure. Practice guidelines such as the Australian Therapeutic Guidelines for rheumatology ought to more carefully consider level 1 evidence to avoid supporting a prevailing traditional treatment option that is not evidence-based. In treatments with potential benefits and harms that have been tested by randomised control trials, recommendations should only support those treatments with a high quality trial evidence of benefits outweighing harms.
Competing interests
No relevant disclosures.
References
- Therapeutic Guidelines. Management of lateral and medial epicondylar tendinopathies [website]. Melbourne: Therapeutic Guidelines; 2017. https://tgldcdp.tg.org.au/viewTopic?topicfile=limb-conditions&guidelineName=Rheumatology#toc_d1e415 (accessed Sept 2017).
- Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359: 657-662.
- Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333: 939.
- Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013; 309: 461-469.
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; 376: 1751-1767.