Editorial
Br J Sports Med: first published as 10.1136/bjsports-2019-101250 on 30 January 2020. Downloaded from http://bjsm.bmj.com/ on January 30, 2020 at Agence Bibliographique de l
Corticosteroid injections: glass half-­full,
half-­empty or full then empty?
John W Orchard  ‍ ‍
Cortisone is the most common class of
injection in musculoskeletal medicine.
Expert guidelines, such as the 2017 edition
of Therapeutic Guidelines: Rheumatology
(Australia),1 generally recommend corti-
costeroid injections (CSI) as a treatment
for most tendon and joint pain conditions
(including those listed in table 1). I quote,
‘local corticosteroid injections should only
be given by, or under the supervision of,
clinicians with appropriate training and
experience’.1 I find it remarkable that the
guidelines do not spell out that cortisone
injections should only be given where
high-­quality evidence shows that benefits
outweigh the harms; that is, the wide-
spread recommendations to use CSI for
multiple joints and multiple tendons are
‘eminence-­based’ (who should give them)
rather than ‘evidence-­ based’ (when they
should be given).
To be fair, I see that ‘appropriate
training’ could cover ‘knowing the indica-
tions’ for a treatment but at a time where
medical overtreatment is incontrovert-
ible—it exists and no one denies it exists—I
argue that the case for ‘indication-­based
treatment’ should be explicit.
Do cortisone injections harm
tendons?
Systematic reviews have examined
whether cortisone injections are beneficial
or harmful. A typical systematic review
concludes as per the text in box 1. This
conclusion was from a 2002 systematic
review on the use of CSI for tennis elbow,2
and there is strong similarity between
that conclusion and more recent ones for
different conditions.
With respect to tennis elbow, research
since 20022 has been decisive: five high-­
quality randomised controlled trials
(RCTs) show that cortisone injection
outcomes are superior to placebo injec-
tion for tennis elbow in the short-­ term
(2–6 weeks) and that injection results are
inferior compared with placebo injec-
tion or conservative treatment from 3
School of Public Health, University of Sydney, Sydney,
New South Wales, Australia
Correspondence to Dr John W Orchard, School of
Public Health, University of Sydney, Sydney, NSW 2006,
Australia; ​john.​orchard@​sydney.​edu.​au
Box 1 Typic
‘Patients with xxx are frequently treated
with corticosteroid injections…. RCTs
were identified …Almost all studies
had poor internal validity scores. For
short-­term outcomes (<or=6 weeks),
statistically significant and clinically
relevant differences were found for
corticosteroid injection compared to
placebo. For intermediate (6 weeks-6
months) and long-­term outcomes (>or=
6 months), no statistically significant
or clinically relevant results in favour
of corticosteroid injections were found.
More, better designed, conducted and
reported RCTs with intermediate and
long-­term follow-­up are needed’.
to 12 months3–5. Cortisone injections
provide short-­term pain relief but worsen
the condition in the longer term compared
with no treatment or placebo treatment.
The no-­ treatment or placebo groups
improve in the longer term, whereas
cortisone causes temporary pain relief but
seems to blunt the recovery associated
with the no treatment/placebo.
In studies that compared injected blood
products such as platelet-­ rich plasma
Table 1  Comparison of short-­term (mainly benefit) versus long-­term effects (possible harm) of
corticosteroid injection for common indications
Injection indication Short-­term effects
Tennis elbow (tendon) Definite benefit (multiple RCTs) Definite harm (vs placebo/conservative in multiple
up to 4–6 weeks
Knee OA (joint) Possible benefit up to 4–6
weeks
Rotator cuff tendons Possible short-­term benefit
Plantar fasciitis (tendon-­like) Possible short-­term benefit
Gluteal tendon insertions/ Possible short-­term benefit
trochanteric bursitis
Hip OA (joint) Possible short-­term benefit
De Quervain’s tenosynovitis Possible short-­term benefit
(tendon-­like)
Achilles tendinopathy Possible short-­term benefit
Green shading indicates benefit; red shading indicates harm.
RCT, randomised controlled trial.
Orchard JW. Br J Sports Med Month 2020 Vol 0 No 0
(PRP) to cortisone injections for tennis
elbow, the PRP injections have gener-
ally provided superior outcomes to CSI
at 6–12 months6. Should a study such as
this conclude that blood product injection
provides long-­term benefit or that corti-
sone injection leads to long-­term harm?
Although there are relatively few placebo-­
controlled RCTs that compare injected
cortisone to injected blood products, the
usual pattern is superior long-­term results
for the blood products.7
Cortisone injections for knee OA
I began with 2002 data relating corti-
sone injections and tennis elbow because
we may be able to learn from history
when we consider cortisone injections
and knee osteoarthritis (OA). After
many low-­ quality studies suggested a
short-­term benefit of cortisone injec-
tion in knee OA,8 a recent high-­ quality
Enseignement Superieur (ABES). Protected by copyright.
well-­powered placebo-­controlled RCT
showed no clinical difference in outcomes
between cortisone injection and placebo
(saline) injection at any stage over the
2-­year follow-­up.9 There was also a small
(−0.1 mm) statistically significant addi-
tional deterioration in articular cartilage
as assessed by imaging in the cortisone
injection group.9 In a propensity-­matched
cohort study,10 compared with non-­users,
HRs of joint structure worsening over 48
months after cortisone injection was 3.02
(95% CI 2.19 to 4.16). Only 5% of control
patients required knee replacement during
follow-­up, compared with 22% of knees
in patients who had received cortisone
injections.10
Although cortisone injections may alle-
viate symptoms (in the short term) for
Long-­term effects
RCTs) at 6 months
Likely harm (vs non-­use or placebo) over 2–4 years,
cohort and some RCT studies
No long-­term benefit, insufficient data to conclude
on long-­term harm
No long-­term benefit, insufficient data to conclude
on long-­term harm
Unlikely to be a long-­term benefit, but not enough
data to conclude on long-­term harm
No long-­term benefit, but emerging data suggest
possible long-­term harm (eg, accelerated OA)11
No long-­term benefit, insufficient data to conclude
on long-­term harm
No long-­term benefit, lack of long- term safety
data but possible association with tendon rupture
   1
 Editorial

patients awaiting Total Knee Replacement effects of CSI, for most indications there
(TKR), the strongest cohort study to date is no demonstrated long-­ term benefit,
shows that a patient may progress more and there are insufficient data to be able
rapidly to knee replacement. Although to adequately assess long-­ term harm/
worse outcomes in the cohort study were risks. The medium-­ term and long-­ term
seen even with a single injection, repeated outcomes are now available for tennis
cortisone injections were associated with elbow and knee OA, and I believe corti-
greater deterioration than a single injec-
sone injections should not be prescribed
tion. A 2019 case series revealed that the for these two conditions as long-­ term
risk of medium-­term to long-­term compli- results are consistently not as good as
cations for both knee and hip OAs treated comparators.
with cortisone injections may be quite The question remains: can we clinicians
high.11 assume that CSI is benign and that there
is no long-­term deleterious effect for the
Systemic cortisone: short-term majority of indications? It might depend
athletic performance versus on whether you have a glass-­half full or
long-term catabolic effects
a glass-­half empty mentality, or whether,
The systemic effects of cortisone roughly after looking at the data, it looks more
follow a similar trajectory, with short-­ like the glass starts off full and ends up
term benefit followed, perhaps, by long-­ empty—the patient ends up worse off.
term risks. In the short-­ term, cortisone
in high doses is a performance-­enhancing Twitter John W Orchard @DrJohnOrchard
Br J Sports Med: first published as 10.1136/bjsports-2019-101250 on 30 January 2020. Downloaded from http://bjsm.bmj.com/ on January 30, 2020 at Agence Bibliographique de l
References
1 Therapeutic Guidelines: Rheumatology. Version 3.
Melbourne: Therapeutic Guidelines Limited; 2017.
331 pages, 2017. Available: https://​tgldcdp.​tg.​org.​au/​
viewTopic?​topicfile=​limb-c​ onditions&​guidelineName=​
Rheumatology#​toc_​d1e415
2 Smidt N, Assendelft WJJ, van der Windt DAWM, et al.
Corticosteroid injections for lateral epicondylitis: a
systematic review. Pain 2002;96:23–40.
3 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.
4 Coombes BK, Bisset L, Brooks P, et al. Effect of
corticosteroid injection, physiotherapy, or both on
clinical outcomes in patients with unilateral lateral
Epicondylalgia. JAMA 2013;309:461–9.
5 Olaussen M, Holmedal Øystein, Mdala I, et al.
Corticosteroid or placebo injection combined with
deep transverse friction massage, Mills manipulation,
stretching and eccentric exercise for acute lateral
epicondylitis: a randomised, controlled trial. BMC
Musculoskelet Disord 2015;16:122.
6 Branson R, Naidu K, du Toit C, et al. Comparison
of corticosteroid, autologous blood or sclerosant
injections for chronic tennis elbow. J Sci Med Sport

Enseignement Superieur (ABES). Protected by copyright.

substance, with five out of seven RCTs Contributors  Single author paper.
placebo-­controlled athletic trials showing
Funding  The author has not declared a specific grant
improved performance (mainly time to for this research from any funding agency in the public,
exhaustion).12 In the longer term, there commercial or not-­for-­profit sectors.
is an association of oral corticosteroid use Competing interests  JWO is a Sport and Exercise
with increased risk of sepsis, deep venous Medicine Physician affiliated with Australasian College
thrombosis (DVT)and fractures.13 This is of Sport and Exercise Medicine Physicians.
consistent with what every medical student Patient consent for publication  Not required.
knows about Cushing’s syndrome: that
Provenance and peer review  Not commissioned;
excess of corticosteroid eventually leads externally peer reviewed.
to catabolic effects (tissue weakening) in
© Author(s) (or their employer(s)) 2020. No commercial
multiple systems, including muscle, bone re-­use. See rights and permissions. Published by BMJ.
and joints in the musculoskeletal system.
A picture emerges (table 1) of consistent
likely short-­term benefit for CSI perhaps
for most musculoskeletal conditions, To cite Orchard JW. Br J Sports Med Epub ahead of
although it should be noted that even print: [please include Day Month Year]. doi:10.1136/
bjsports-2019-101250
many RCTs are at high-­risk of bias. This
means that some of the reported benefits Accepted 15 January 2020
from CSI in RCTs could be from placebo/ Br J Sports Med 2020;0:1–2.
non-­specific effects if the trial design was doi:10.1136/bjsports-2019-101250
not able to adequately blind participants ORCID iD
or assessors from group allocation, for John W Orchard http://​orcid.​org/​0000-​0003-​3530-​
example. With respect to the long-­ term 1711
2017;20:528–33.
7 Fitzpatrick J, Bulsara MK, O’Donnell J, et al. Leucocyte-­
Rich platelet-­rich plasma treatment of gluteus Medius
and Minimus tendinopathy: a double-­blind randomized
controlled trial with 2-­year follow-­up. Am J Sports Med
2019;47:1130–7.
8 Juni P, Hari R, Rutjes AW, et al. Intra-­Articular
corticosteroid for knee osteoarthritis. Cochrane
Database Syst Rev 2015;10:Cd005328.
9 McAlindon TE, LaValley MP, Harvey WF, et al. Effect of
intra-­articular triamcinolone vs saline on knee cartilage
volume and pain in patients with knee osteoarthritis.
JAMA 2017;317:1967–75.
10 Zeng C, Lane NE, Hunter DJ, et al. Intra-­Articular
corticosteroids and the risk of knee osteoarthritis
progression: results from the osteoarthritis initiative.
Osteoarthritis Cartilage 2019;27:855–62.
11 Kompel AJ, Roemer FW, Murakami AM, et al. Intra-­
Articular corticosteroid injections in the hip and
knee: perhaps not as safe as we thought? Radiology
2019;293:656–63.
12 Tacey A, Parker L, Garnham A, et al. The effect of
acute and short term glucocorticoid administration
on exercise capacity and metabolism. J Sci Med Sport
2017;20:543–8.
13 Waljee AK, Rogers MAM, Lin P, et al. Short term use of
oral corticosteroids and related harms among adults in
the United States: population based cohort study. BMJ
2017;357:j1415–j15.

2 Orchard JW. Br J Sports Med Month 2020 Vol 0 No 0