A New York Times article asks the provocative question “Do steroid injections actually make things worse?”—referring to the treatment of chronic tendon problems such as tennis elbow, rotator cuff symptoms, jumper’s knee, and pain in the Achilles tendon.
The medical establishment has traditionally supported the view that steroid injections for tennis elbow can deliver remarkable short-term pain relief without compromising long-term outcomes. However, in light of recent evidence, this appears to be an erroneous conclusion.
The new review found that the early pain relief provided by the injections comes at a substantial long-term cost. All too often steroid injections appear to compromise the healing process. The pain relief at one month frequently gives way to increasing pain and disability at six months and one year. Exercise, physical therapy, and doing nothing may all lead to better long-term outcomes.
So does the new review kill steroid injections as a treatment for tennis elbow? Not at all. But as the Times article pointed out, the new evidence will allow patients to carefully assess both the benefits and risks of steroid injections as well as other therapies. And they will be able choose a treatment that aligns with their own goals and tolerance for risk.
As the journalist explained, the new systematic review could not find conclusive evidence about the short- or long-term benefits of steroid injections for other chronic tendon problems. But this is also an important conclusion. Those who choose steroid injections for rotator cuff problems, jumper’s knee, and Achilles’ symptoms can do so in the knowledge that they are opting for an uNPRoven therapy.
The New York Times article is not perfect. It did not fully address all of our criteria. It did not comprehensively characterize the pain outcomes for tennis elbow in easy-to-understand statistics—and did not provide any information on the costs of various approaches. But these omissions relate largely to the way the systematic review expressed its composite results rather than a lack of work on the journalist’s part.
There were some live quotes in the article—with commentary from the senior author of the systematic review and one of the editorialists. Ideally, one would have liked to see additional commentary from someone not involved in either publication. However, finding someone familiar with all the evidence on steroid injections for tendon problems on short notice is a tall order. So by almost any standard this is an impressive article.
Modern medicine is slowly emerging from a long period of misunderstanding about the nature of chronic tendon problems such as tennis elbow, rotator cuff “tendinitis”, and pain at the Achilles tendon.
For decades, researchers and healthcare providers held the erroneous belief that these tendon overuse issues stemmed largely from long-term inflammation of the tendons. As the New York Times article noted, this is why many of these tendon problems were given the suffix “itis”, meaning inflammation.
Many traditional treatments for tendon problems, from ice to NSAIDs to steroid injections, were prescribed on the erroneous premise that they would dampen inflammation in the tendons.
However, research over the past decade suggests strongly that most of these tendon problems do not relate fundamentally to inflammation. Rather, they appear to stem from degeneration and mechanical breakdown of the tendons. And it is not clear why any anti-inflammatory treatment would provide a specific therapeutic benefit.
The revision of traditional thinking about these chronic tendon problems requires a careful look at the effectiveness and safety of both traditional and experimental treatment approaches. There is currently is no “magic bullet” for these chronic tendon problems. As a result, the identification of more promising treatments is a major research priority.
The new research highlights information that should provide a fresh longer-term view for patients suffering from pain associated with tendonopathies. For working individuals, such problems can affect work and the need to try to get back to work quickly may lead them to consider steroid injections. This study reminds us that such a short-term view has to be balanced by a longer term perspective. Job modification and non-injection based treatments may be a reasonable approach for many such workers.
The New York Times article did not discuss the costs of steroid injections or other treatments. It would have been useful if the article could have pointed out that the long-term costs of steroid injections haven’t been documented.
The article might have provided better quantitative estimates of the impact of steroid injections on tennis elbow—in terms of the degree of pain relief. However, the systematic review didn’t report its results in quantitative terms that would be easily understood by the general public. And the journalist did solicit some quantitative estimates of treatment impact from one of the researchers she quoted.
The article provided adequate detail on the main harms associated with steroid injections: disruption of the long-term healing process and relapse into pain and disability. It might have been useful to also mention other potential side effects and potential harms related to steroid injections.
The journalist seemed to have an excellent grasp of the evidence under discussion.
There is no suggestion of disease-mongering in this article. These tendon problems are common and painful. They disrupt leisure-time activity and work.
The journalist based the article on two main sources: a systematic review and an editorial from The Lancet. She quoted one of the review authors and one of the editorialists at length. It would have been educational to hear the views of a researcher not involved with either publication. However, this article included a diversity of viewpoints and rates a “satisfactory” on this criterion.
The article mentioned multiple treatment alternatives.
The story explained the history of steroid injections, hinting at trends in availability. Steroid injections are widely available in both primary care and specialty settings. .
The article specified that steroid injections have been employed for roughly half a century.
This article did not rely on a press release.