Study critiques cortisone injections for tennis elbow

A recent article in the Journal of the American Medical Association raised questions about the practice of treating tennis elbow with steroids.

Anti-inflammatory steroid injections, commonly referred to as “cortisone shots,” were evaluated by Bill Vicenzino and colleagues at the University of Queensland, Australia. The researchers assigned 165 adults to four treatment strategies, composed of cortisone injection versus placebo injection, with and without physical therapy for each group. Patient improvement was about the same in all four treatment groups, after a year. Cortisone shots and physical therapy fared no better than more conservative remedies, such as stretching and rest. Some experts are now questioning the ubiquitous practice of treating tendinitis, including tennis elbow, with cortisone shots.

In tennis elbow, the tendons that extend the wrist are under strain where they attach to the forearm bone structure. The result is pain and swelling on the lateral forearm.

The term “tennis elbow” is a bit of a misnomer. I have seen the same condition in office workers, especially typists. The common denominator is an over-use of the forearm muscles, often in the setting of underlying weakness and poor biomechanics. Tennis elbow is one of many forms of tendinitis. Golfer’s elbow, for example, tends to strike duffers on the inner aspect of the elbow. Weekend warriors, reporting excessive exertion in sports or chores, are particularly at risk. If you exercise, it is better to “start low and go slow.”

Adrenal hormones, including cortisol, revolutionized the practice of medicine over the past half-century. Indeed, it would be hard to imagine practicing rheumatology, internal medicine, allergy, or dermatology without these amazing compounds. No wonder Edward Kendall and Phillip Hench won the Nobel Prize in Physiology and Medicine in 1950, in recognition for their seminal work defining the therapeutic uses of cortisone and other compounds from the body’s adrenal glands.

Hench, an early rheumatologist, treated patients with rheumatoid arthritis with “Compound E,” an adrenal steroid. Soon, the patients were improved to the point of practically throwing away their canes and braces. Unfortunately, researchers subsequently noted that large doses of these steroid hormones also caused thinning of the bones, high blood pressure and diabetes.

Today, cortisone shots and pills are prescribed, with caution, in selected cases. This evolutionary process is common in medical thinking. New treatments are often enthusiastically introduced, only to be criticized after toxic side effects are discovered. After a few years, the treatments may remain in the therapeutic armamentarium, or may be abandoned entirely.

There are different preparations of cortisone and related compounds. Some are administered orally, others by intravenous, topical, or tissue injection routes. Severe allergic reactions, for example, may necessitate intravenous treatments. Oral agents, such as prednisone, are commonly suitable for treatment of arthritis, poison oak, or other inflammatory conditions.

As medical research evolves, however, newer treatments for arthritis sometimes eliminate the need to prescribe cortisone-related compounds. Kendall and Hench, I think, would approve. Newer treatments are often less toxic than cortisone. Tendinitis research, in fact, now is gravitating toward biological remedies. For example, injection of “platelet-rich plasma” may strengthen healthy tissues, diminishing pain. Our current use of cortisone shots may eventually become old-fashioned, as new treatments emerge.

Certain areas are not safe for steroid injections. For example, the Achilles’ tendon, above the heel, can rupture if injected with steroids. A group of antibiotics called Fluoroquinolones may predispose to tendon inflammation, and even rupture. Why? No one knows. I am reminded of the old joke about taking medical examinations. The questions stay the same, year after year. The answers, however, are usually different. As philosophers have noted, the more things change, the more they stay the same.

Scott Anderson, M.D., Ph.D. (stamdphd@comcast.net) is clinical professor of medicine, division of rheumatology, UC Davis. This column is informational, and does not constitute medical advice.