Steroid InjectionsIf you have arthritis, anavar quads may have considered a cortisone shot as part of your treatment plan. These shots are not pain relievers. Cortisone is a type of steroid, a drug steroid injection into shoulder tendon lowers inflammation, which is something that can lead to less pain. Cortisone injections can be used to treat inflammation of small areas of the body, such as inflammation of a specific joint deca qv 300 tendon. A single injection can avoid certain side effects, notably stomach irritation, that can happen with other anti-inflammation drugs.
Cortisone Injection (Corticosteroid Injection)
To assess the efficacy and safety of steroid injections for patients with tendonitis of the shoulder or elbow. Pooled effect size ES was calculated by meta-analysis using the Mantel—Haenszel method.
In all, 20 RCTs were analysed patients treated by injections and patients treated by controls; shoulders and elbows. Sensitivity analyses indicated similar results whatever the localisation, type of steroid and type of comparator except for NSAIDs: Steroid injections appeared more effective than pooled other treatments in acute or subacute tendonitis.
The main side effects were transient pain after injection Steroid injections are well tolerated and more effective for tendonitis in the short-term than pooled other treatments, though similar to NSAIDs. No long-term benefit was shown. Tendon lesions represent a large proportion of rheumatic issues resulting in pain and disability, and absence from work.
There are a great variety of potential treatments, surgical intervention being the most radical. In usual practice, pain-relieving medications, non-steroidal anti-inflammatory drugs NSAIDs , steroid injections and physical therapy are the most frequent options. Because of conflicting results, two meta-analyses were conducted several years ago, one in 8 and one in by the Cochrane group; 6 however, this second analysis included various shoulder disorders rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses.
Moreover the conclusion was not clear cut. In , Smidt et al 9 concluded that although the available evidence shows superior short-term effects of corticosteroid injections for lateral epicondylitis, it was not possible to draw firm conclusions on the effectiveness of injections, due to the lack of high quality studies.
Therefore it appeared important to perform a new systematic review, including diagnostic considerations and recent trials. The objective of the present study was to assess the efficacy on pain and functional disability, and to assess the safety of, steroid injections for patients with tendonitis of the shoulder and elbow in published randomised controlled trials RCTs. This meta-analysis was conducted according to the Cochrane Collaboration guidelines. A systematic literature search was performed in PubMed Medline, EMBASE and Cochrane library databases up to April without limitation of years of publication or journal, using the following keywords: In addition, reference lists of the papers initially detected were manually searched to identify additional relevant reports.
The trials were initially selected on the basis of their titles and abstract, then on the full texts. Articles reporting no interpretable results data required included mean SD for any of the three outcome measures pain, function and safety were not analysed. One investigator CGV selected the articles and collected the data using a predetermined form. The following methodological features were collected: The Jadad scale was applied, 11 which contains two questions for randomisation and masking and one question evaluating the reporting of withdrawals and dropouts.
Each question entails a yes or no response option. In total, 5 points can be awarded, with higher scores indicating higher quality. For each trial, demographic characteristics sex, mean age , tendinosis features and duration, type of steroid with doses and number of injections , type of comparator and duration of follow-up were collected. In order to evaluate safety, data were extracted from each study in active and control groups regarding the number and the type of all adverse events reported.
In each trial the effect size ES or the standardised response mean SRM were determined to assess the magnitude of treatment effect. The ES is calculated as the ratio of the treatment effect mean differences in treatment group minus differences in control group to the pooled standard deviation of these differences.
This calculation entails the use of means for baseline and final data with a measure of variability such as SD. Every effort was made to calculate the ES in all studies. If the SD was given in only one group it was used as baseline SD for both groups. However, if no measure of variability was given the ES could not be extrapolated and we calculated the SRM mean change divided by SD of the change when available. Primary analyses examined pooled ES and pooled SRM of steroid injections versus controls for pain intensity and physical function.
Sensitivity analyses were calculated within subgroups of studies decided a priori joint involved, duration of pain, type of steroid and type of comparator to assess the robustness of the main conclusions. The number needed to harm NNH was used to assess steroid injections safety. Harm was primarily defined by the occurrence of one or more adverse events.
The NNH is the number of patients that should be treated to observe the occurrence of one extra adverse event in the treatment group compared to the control group. The advantage of the NNH is that it reflects an absolute risk increase, and because it is related to the control event rate, it reflects the true baseline or underlying risk of the study population.
Initially, potentially relevant articles were screened. From them, were excluded. Finally, after manually searching the reference lists, 20 randomised trials were included: Thus, this systematic review included patients; A total of The mean SD age of these patients was Patient characteristics are detailed in table 1 and trial characteristics in the Supplementary material. Characteristics of patients with tendonitis included in a meta-analysis of randomised controlled trials of steroid injections for shoulder and elbow tendonitis.
The methodological quality was correct: Of the 16 trials for efficacy, 9 included a flowchart or described precisely the patient selection process and outcome, 14 used a concealed random allocation and 11 presented differences in change with confidence intervals, 2 with interquartile range and 2 with standard error of the mean.
Of the 20 RCTs analysed, 16 provided the required data to calculate the efficacy on pain intensity for participants who received steroid injections and for who received a comparator. Eight studies concerned shoulder tendinosis and eight epicondylitis. The data on function were extracted from 7 RCTs: The characteristics of these trials are summarised in the Supplementary material and the ES or SRM for pain intensity and physical function at different end points week 1 to 3, week 4 to 8, week 12 to 24 and week 48 are detailed in table 2.
Effect size and standardised response mean of controlled trials comparing steroid injections with placebo or other comparator for pain intensity and physical function in patients with tendonitis. Significant results are in bold type.
At longer-term follow-up no difference for pain could be detected, and steroid injections appeared less effective particularly on functional disability than pooled other treatments.
Function standardised response mean SRM at weeks 4—8 versus all comparators. Pooled effect size ES and pooled standardised response mean SRM for steroid injections in tendonitis according to the comparator. The heterogeneity was substantial for pain, and to a lesser extent for function, at week 1—3 and at week 4—8 for example pain ES: The other results were homogeneous. In the assessment of heterogeneity, sensitivity analyses showed no changes in the conclusions according to the localisation, or the type of steroid data not shown.
Steroid injections were more efficient in the short-term week 1 to 3 and week 4 to 8 than different comparators table 3. However the pooled ES versus NSAIDs were not significant in the short-term; long-term results were significant but are issued from a single study.
This meta-analysis suggested that steroid injections are more effective in acute or subacute tendonitis duration of symptoms below 12 weeks than in chronic disease: In all, 19 studies no. There were no treatment discontinuations for toxicity. The NNH for steroid injection versus other commonly used treatments was 26 ie, 26 patients would need to be treated to observe the occurrence of 1 extra adverse event in the injection group compared to all the comparators, and versus placebo it was 9; however, the confidence intervals were not significant.
The NNH values versus each comparator and calculated for each adverse event are provided in table 4. Adverse events AE reported for steroid injections versus placebo or other comparator. This meta-analysis indicated short-term effectiveness 1—3 weeks and 4—8 weeks of steroid injections in shoulder and elbow tendinosis on pain and functional disability, but at longer-term follow-up no difference for pain could be detected and steroid injections appeared less effective for function than pooled other treatments.
Compared to NSAIDs however, steroid injections did not appear statistically more efficacious in the short term. There is little consensus on the optimum timing of corticosteroid injections in tendonitis, relative to the symptom duration.
Some experts advocate injections when the patient does not respond to a certain period of rest 2 or 3 months , 34 whereas others argue that injectable steroids should be deferred as long as possible. Therefore our results indicate that the optimum timing for steroid injections may be in the early weeks of tendonitis symptoms.
Despite the high level of interest in the aetiologies, diagnosis and treatment of tendonitis in the literature, there are relatively few randomised controlled trials and the outcomes used are heterogeneous. Physical function was rarely assessed by the same score in different studies. In some studies the ES or the SRM could not be extrapolated either due to lack of data or to inappropriate outcomes eg, qualitative evaluation. Another limitation of this review is possible publication bias ie, negative trials are often unpublished, which may have overestimated the beneficial effect of corticosteroid injections.
Several reviews on the utility of steroid injections in shoulder pain have been performed and conflicting results found, but the studies analysed assessed a wide variety of conditions and disorders including frozen shoulder and there was often no pooling of results. Concerning epicondylitis, Labelle et al 39 concluded that there was insufficient scientific evidence to support the use of corticosteroid injections. The pooled analysis indicated short-term effectiveness of steroid injections.
However, this review differs from these earlier works in several important respects. Firstly, it included diagnostic considerations and attempted to differentiate studies based upon the nature of the populations being studied, recognising that the benefits of treatment may vary for different underlying causes of shoulder or elbow pain.
This analysis was thus centred on tendinosis. Thirdly, effect sizes were calculated for the different reported outcome measures in different trials.
This enabled a direct comparison between studies using the same scale, whatever the outcome measure. If the ES could not be calculated, another pooled measure of effect, the SRM, was calculated when available in order not to lose information. In spite of these measures, statistical testing revealed heterogeneity during the first weeks.
The a priori defined sensitivity analyses showed no changes in the main conclusions with the localisation, duration of pain, or type of corticoid. Some other possible reasons for this heterogeneity are variation in study quality but only three Jadad scores were lower than 3 , differences in the type of patients included or the composition of the various injection fluids, variation in the number and interval of injections four studies allowed up to two injections and two studies up to three injections and different methods of outcome measurement.
In addition, diagnostic accuracy is always a difficulty in particular for shoulder disorders: Accuracy of placement of the needle for injections may also be an issue. Although steroid injections were more efficacious in the first weeks than pooled comparators, importantly, steroid injections did not demonstrate superiority in the first weeks either for pain or for functional disability compared to NSAIDs. This is an important finding since NSAIDs are a widely used and relatively safe therapeutic option in tendonitis, leading to questions regarding the role of steroid injections in these pathologies.
In usual care, steroid injections are in fact most often performed after NSAIDs have been prescribed but without sufficient efficacy.
It should be noted that none of the studies included in this meta-analysis did in fact test this treatment strategy. Adverse clinical effects of steroid injections were systematically investigated in this meta-analysis. This study indicates steroid injections are well tolerated, with infrequent and minor side effects.