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Available online at www.sciencedirect.comJournal of Science and Medicine in Sport 13 (2010) 380–381EditorialStop injecting corticosteroid into patients with tennis elbow, they aremuch more likely to get better by themselves!Keywords: Tendonopathy; Injection; Elbow; CorticosteroidTennis elbow is a common1 presentation to familytury ago2 and more recently.1 Few studies followed patientspractitioners and various medical specialists. Injectable cor-beyond 6 months and none of these studies showed posi-ticosteroids have been used and continue to be used as one oftive outcomes for corticosteroid injections beyond 6 months.1the mainstays of treatment for tennis elbow. This is in spiteSpurious conclusions in the literature also lead to confusion.of the fact that shortcomings have existed regarding its useFor example injecting hypertonic glucose11 no more provessince one of the earliest published clinical trials.2 Seven ofthat tendonopathy is a disorder of insulin metabolism, thanthirteen patients injected had recurrence of symptoms dur-injecting corticosteroid into tendonopathy means that it ising follow-up studies of at least 6 months with only 38%an inﬂammatory disorder.12 Recent clinical trials9 supportobtaining permanent relief.the high rate of recurrence following corticosteroid injectionFirst described by Morris3 confusion surrounding thenoted last century.2nomenclature and underlying pathology have remained aTwo recent clinical trials with extended follow up tocommon theme in the literature through the ages.4,5 Many12 months give a much clearer picture of the pitfalls ofcurrently practicing doctors, including general practitioners,corticosteroid injections.9,10 These studies had very similarspecialists and new medical graduates continue to be taughtmethodology where patients either received corticosteroidthat tennis elbow is inﬂammatory. It is now more than 30 yearsinjections (127 patients), physiotherapy (127 patients) or asince tendonosis was described6 and yet universities acrosswait and see approach (119 patients). The results at 6 weeksAustralasia are still teaching undergraduates in Medicinewere consistent with the literature, 78% of patients havingthat the pathology of tennis elbow is tendonitis.7 They con-had an injection had a successful outcome compared withtinue to be taught that patients with tendon conditions willonly 29% of those waiting. At 1 year of follow up thingsbeneﬁt from non-steroidal anti-inﬂammatories and corticos-changed completely with many injected patients having hadteroid injections.7 Evidence over the last quarter of a centuryrelapses (49%) and only 68% having a successful outcomestrongly points to conditions such as tennis elbow being acompared with 87% of those who just waited and 92% ofdegenerative condition of the tendon, not an inﬂammatorythose who had physiotherapy. In other words up to 22% ofdisorder.5,6patients who would have otherwise improved with a wait andInjections of corticosteroid into rabbit tendon has beensee approach, failed to do so because of the corticosteroidshown to cause tendon necrosis within 45 min of injection.8injection.9,13Logic would suggest that this is therefore a bad thing to doUsing the remission rates from these two long term trials13to encourage tendon healing.we can make an analogy to the introduction of a therapeuticEditorials have asked “when will the myth beagent. If a new anti-cancer drug were to show early (6 weeks)abandoned?”.5 Clinicians continue to use corticosteroids asbeneﬁts with remission rates of 78% for the drug comparedtheir peers teach them, backed up by numerous papers demon-with 29% for placebo, there would be great excitement. Ifstrating that it is a highly effective treatment—but only iffollow up data showed remission rates at 1 year of 87% inyou consider outcomes 6 weeks post-injection.1,9,10 The lit-the placebo group compared with 69% in the new drug grouperature is however equally clear that there are high rates ofwith signiﬁcant statistical and clinical signiﬁcance the newrecurrence of symptoms. This was ﬁrst noted over half a cen-drug would never make it to market.1440-2440/$ – see front matter © 2009 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.jsams.2009.09.009Editorial / Journal of Science and Medicine in Sport 13 (2010) 380–381381It is time for clinicians to ﬁnally update themselves on8. Balasubramaniam P, Prathap K. The effect of injection of hydro-the nature of tendonopathy and to embrace, along with med-cortisone into rabbit calcaneal tendons. J Bone Joint Surg Brical educators, that corticosteroid injections for tennis elbow1972;54-B(4):729–34.9. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-deworsen the long term outcomes of patients. CorticosteroidBos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-injections should not be used to treat most patients with tennisand-see policy for lateral epicondylitis: a randomised controlled trial.elbow with symptom duration of less than 12 months.Lancet 2002;359(9307):657–62.10. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobili-sation with movement and exercise, corticosteroid injection, or waitand see for tennis elbow: randomised trial. BMJ 2006;333(7575):References939.11. Yelland MJ, Sweeting KR, Lyftogt JA, Ng S, Scuffham PA, Evans1. Smidt N, Assendelft WJ, van der Windt DA, Hay EM, BuchbinderKA. Prolotherapy injections and eccentric loading exercises for painfulR, Bouter LM. Corticosteroid injections for lateral epicondylitis: aAchilles tendinosis: a randomised trial. Br J Sports Med 2009,systematic review. Pain 2002;96(1–2):23–40.bjsm.2009.057968.2. Young HH, Ward LE, Henderson ED. The use of hydrocortisone acetate12. Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, Bliddal H. Effect(compound F acetate) in the treatment of some common orthopaedicof glucocorticosteroid injections in tennis elbow veriﬁed on colourconditions. J Bone Joint Surg Am 1954;36-A(3):602–9.Doppler ultrasonography: evidence of inﬂammation. Br J Sports Med3. Morris H. The rider’s sprain. Lancet 1882;120(3074):133–4.2008;42(12):978–82.4. Cyriax J, Troisier O. Hydrocortone and soft-tissue lesions. Br Med J13. Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks1953;2(4843):966–8.P, et al. Conservative treatments for tennis elbow do subgroups of5. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandonpatients respond differently? Rheumatology (Oxford) 2007;46(10):the “tendinitis” myth. BMJ 2002;324(7338):626–7.1601–5.6. Puddu G, Ippolito E, Postacchini F. A classiﬁcation of achilles tendondisease. Am J Sports Med 1976;4(4):145–50.Sport and Exercise Medicine, University of Otago,7. Osborne HR. Personal communication with recent medical graduatesof University of Notre Dame, Fremantle, Australia and University ofPO Box 913, New ZealandOtago, New Zealand.E-mail address: firstname.lastname@example.org.