Stick a needle in me, I’m done. Or am I?

UpToDate.com

When I was pregnant I developed tennis elbow, or lateral epicondylitis, in my left arm. It persisted until long after I was pregnant and drove me to distraction. The pain eventually drove me to sticking a needle full of cortisone in my arm, after which I felt much better.  But was I better?  Ever since that fateful jab, I’ve had recurring problems with that devilish elbow.

The conventional wisdom has long been that acute pain in our tendons, or tendinopathy, was the result of dreaded inflammation. Corticosteroids (not anabolic steroids) are just about the most potent anti-inflammatory we have and for certain tendon pain syndromes – like tennis elbow – the standard of care has been to jab a needle near the tendon, infuse the medicine, and let it work its magic.  

Not so fast, Captain Cortisone!  A major review of steroid injections for tennis elbow and other tendinopathies published recently in The Lancet dispels this notion. Inflammation, it would seem, plays much less of a role than we thought; tendon wear and tear probably plays more.  The authors concluded that steroid injections numb the pain in the short term but do nothing to make the underlying problem better.  In fact, 6 and 12 months down the road, patients who’d had injections had more pain and disability than patients who hadn’t received the shots.  The authors suggest that suppression of local healing processes by the steroids probably causes this effect.  In other words, steroids get in the way of your tendon’s ability to repair itself. 

Does this mean that we have nothing to offer?  Not at all.  We’ve always had effective ways of managing the pain and helping to support your sore joints as they heal up.  Non-steroid anti-inflammatory pills like Ibuprofen (Advil, Motrin) and Naproxen (Aleve) can help a lot, and in severe or chronic injuries, physical therapy can work real magic.  There are also some cool new “injectables” under investigation now, including botulinum toxin and hypertonic glucose.  That’s right folks… botox and sugar for your elbows.   

The take-home message?  Bring us your troublesome tennis elbow, your aching Achilles, or your ripped rotator cuff.  We’ll get it sorted out, and we’ll probably do it without poking you with any needles.

Victoria Rentel, MD
Student Health Services
The Ohio State University

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomized controlled trials. Coombs, BK; Bisset, L; Vincenzo B. The Lancet, In Press, Corrected Proof, Online October 21, 2010.

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