With Elbows, Cortisone Shots May Hurt More Than Help
Go to the doctor with an aching elbow, and the prescription may well be a cortisone shot. Ah, relief!
But that short-term gain may make for long-term pain. There's mounting evidence that cortisone shots, long the first response for the painful tendon problem known as tennis elbow, increases the risk of continued problems or relapse one year out.
That may come as a surprise to those who have availed themselves of this seemingly miraculous quick fix.
The latest study, published in JAMA, the Journal of the American Medical Association, found that 83 percent of people who got a cortisone shot for tennis elbow had recovered or improved one year later. Sounds good, right? Well, 96 percent who got placebo shots did just as well. The study included 165 people in Brisbane, Australia.
And about half of the people getting cortisone shots had symptoms return within a year, compared to 12 percent who didn't get the treatment.
Those results are similar to other studies of tendon damage in elbows, shoulders, and Achilles tendons found steroids less helpful long term than taking a "wait and see" approach. The researchers from the University of Queensland who did this study also wanted to see if physical therapy would counteract the lack of long-term improvement. It didn't.
"The recommendation from this study is not to combine physiotherapy and corticosteroid injections, or to do corticosteriod injection," Bill Vicenzino, chair in sports physiotherapy and a co-author of the study, said in an email.
Vicenzino says that advice doesn't apply to acute tendon injuries, like snapping an ACL in the knee. Cortisone shots can help reduce the pain caused by those sorts of acute injuries, though, they are sometimes used to excess by athletes eager to get back on the field.
The pain of tennis elbow (official name, lateral epicondylalgia) seems to be caused by damage to the tendons that attach the forearm muscles to the elbow, but not by inflammation. It's becoming more common, and can be caused by repetitive gripping of a computer mouse, smartphone, or other gizmo, not just a tennis racket.
It's not clear why cortisone, a steroid, would quickly relieve the pain from that sort of tendon damage. It may be due to cortisone's effect on chemicals produced by the damaged tendon — or by placebo effect. Doctors have long recommended that patients have no more than three cortisone shots in a body part per year, but there's no firm data on whether that's too much, or not enough.
"The harder you drill into the data, the more it seems we may be better off doing nothing," says Leon Benson, an upper-extremity surgeon at the Illinois Bone and Joint Institute in Glenview, Ill. "If you do nothing at all for this condition, it will eventually go away."
But eventually can mean three years, for tennis elbow. So Benson says he'll continue to recommend cortisone shots to his patients, along with pain relievers like Advil, and physical therapy. "The interest in treating this is for patients to have better quality of life sooner rather than later."
That's a different point of view than that of Mary Ann Wilmarth, chief of physical therapy at Harvard University Health Systems. "If you can get through the short term without [a shot], you may be better off," she told Shots.
The JAMA study found that physical therapy helped improve symptoms four weeks out, but showed no more benefits than placebo a year after treatment. But the therapy participants took half as much pain medication, and didn't have the problems with recurrence seen with cortisone shots.
It's disheartening to see a lack of positive physical therapy results, Wilmarth says. "But there were actually better results with PT than with corticosteroids."