Injections for tendinopathy: Are they worth it?

  • Monday 08 July 2019

I see many patients with tendinopathy - tennis elbow, golfer's elbow, Achilles tendon, patellar tendon, trochanteric bursitis and wrist and hand tendons.

Tendon problems are always difficult, partly because we don't completely understand the pathology of tendinopathy and partly because our treatments are not great and, in some cases, cause harm.

One treatment option for patients with tendon problems is injection therapy. Cortisone injections have been used for tendon pain since the discovery of cortisone in the 1940s. Today, over 500000 cortisone injections are performed on patients for joint and tendon problems. As I mentioned in my previous blog, cortisone is a good pain reliever for arthritis and tendinopathy; but it has some nasty side effects that include accelerating arthritis and weakening tissues such as tendons or ligaments. Recently, other substances have been used to inject into or around tendons to reduce pain and improve function.

What is the evidence for injection therapy in tendinopathy such as tennis elbow, golfer's elbow, Achilles tendons, patellar tendons and shoulder tendons?

I had the privilege to be co-author in a narrative review on injection therapy in tendons. I have attached the link here: Click to view the PDF.

In summary, there are the conclusions of the recommendations:

  • 1. It is becoming increasing clear that cortisone injections produce short term improvements in symptoms but no medium to long term benefit and in some tendons produce actual harm. In particular, a few excellent studies on tennis elbow have shown unequivocally that patients who have a cortisone injection for tennis elbow do worse than those who have physio or do nothing. So, if I give someone a cortisone injection, then the chances are that they'll do worse than a "do nothing" approach. While the evidence for harm is equivocal for other tendons, the balance of evidence is certainly favouring a negative long-term effect.
  • 2. Regenerative medicine injections such as platelet-rich plasma, which are showing some promising evidence in osteoarthritis, seem to be less effect in tendon disease. Currently, there are only a few studies that show a positive effect of PRP injections in tennis elbow, trochanteric bursitis and plantar fasciopathy and no or conflicting evidence for other tendons such as Achilles tendon, patellar tendon, shoulder tendons.
  • 3. A specific type of injection called HVI or high-volume injection for Achilles and Patellar tendons has shown some promise in earlier studies. However, recent studies suggest that the effect of HVI is probably related to the cortisone effect and not the effect of the high volume. Therefore, given you are adding cortisone to this injection, there is some concern that this injection will follow the results of cortisone injection ie. Short term improvement but medium-term harm.
  • 4. Other injections such as prolotherapy, sclerosants and dry needling/needle fenestration have little evidence to support use in tennis elbow, golfer's elbow, rotator cuff tendons, Achilles and patellar tendons, trochanteric bursitis and Plantar fasciopathy.

So, in summary, a comprehensive rehab programme should be the core treatment for patients with tendon problems. In cases that are slow to respond to exercise therapy, my choice is to use treatments that are less invasive and have a lower side effect profile. I only use injection therapy in difficult cases that fail to respond to other non-invasive less risky measures - and I try to avoid substances that could cause harm such as cortisone.

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