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Rapid response to:


Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

BMJ 2009; 338 doi: (Published 14 April 2009) Cite this as: BMJ 2009;338:b1088

Rapid Response:

Time for a re-think on the role of corticosteroid injections?

Although Cohen et al[1] did not study the efficacy of corticosteroid
injections against a comparator treatment, their report and the rapid
responses prompted thereafter do focus the spotlight on the role of
corticosteroid injections for like musculoskeletal soft tissue problems
(i.e., lacking in inflammatory markers, chronic (long term) pain states[2-
7]). They rightly concluded that a single study like theirs is not enough
to change practice, yet a broad snapshot of the related evidence base
reveals that there is mounting evidence that raises concern regarding the
mid- to long-term effects of corticosteroid injections and brings into
question their role in the management of musculoskeletal pain states.

A number of studies, which are often cited in support of
corticosteroid injections, have substantiated the frequently made clinical
observation of a rapid and substantial improvement in a range of soft
tissue injuries following these injections (e.g., [7-14]). However, like
the paper of Cohen et al, many of these studies also report poor mid to
long-term outcomes – indicative of delayed recovery, which is also
frequently observed in clinical practice. The report of success rates in
the order of 40-60% at 3 and 6 months, which are often inferior to control
(e.g., adoption of a wait and see policy), across a number of studies[8
,10 ,11 ,14], countries[9 ,12 ,13] and for a range of musculoskeletal pain
sites [7 ,11 ,13] should now be considered as sufficient evidence to
caution against the use of corticosteroid injections for these conditions.
Paralleling this delay in recovery are very high recurrence rates (~72% of
patients reporting success at 6 weeks reported otherwise at 3-12 months),
which out strip recurrence rates (<_10 in="in" control="control" and="and" physical="physical" therapies="therapies" e.g.="e.g." exercise="exercise" manual="manual" therapy="therapy" electrophysical="electrophysical" agents8.="agents8." corroborating="corroborating" the="the" delay="delay" recovery="recovery" higher="higher" recurrence="recurrence" rates="rates" is="is" use="use" of="of" other="other" treatments="treatments" co-interventions="co-interventions" by="by" those="those" receiving="receiving" corticosteroid="corticosteroid" injections="injections" when="when" compared="compared" to="to" physiotherapy="physiotherapy" control8="control8" _11.="_11." individual="individual" papers="papers" like="like" that="that" cohen="cohen" et="et" al="al" may="may" not="not" themselves="themselves" be="be" sufficient="sufficient" evidence="evidence" change="change" practice="practice" but="but" taken="taken" context="context" findings="findings" reported="reported" these="these" cognate="cognate" _15="_15" should="should" raise="raise" concerns="concerns" regarding="regarding" injections.="injections." it="it" now="now" timely="timely" caution="caution" against="against" for="for" chronic="chronic" soft="soft" tissue="tissue" injuries="injuries" are="are" likely="likely" inflammatory="inflammatory" nature.="nature." along="along" with="with" short-term="short-term" gains="gains" patients="patients" informed="informed" real="real" prospect="prospect" long-term="long-term" problems="problems" such="such" as="as" delayed="delayed" rates.="rates." p="p"/> 1. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M,
et al. Comparison of fluoroscopically guided and blind corticosteroid
injections for greater trochanteric pain syndrome: multicentre randomised
controlled trial. BMJ 2009;338:b1088.

2. Coombes BK, Bisset L, vicenzino B. An integrative model of lateral
epicondylalgia. British Journal of Sports Medicine 2008.

3. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the
"tendinitis" myth. Bmj 2002;324(7338):626-7.

4. Hamilton B, Purdam CR. Patellar tendinosis as an adaptive process: a
new hypothesis. British Journal of Sports Medicine 2004;38(6):758-61.

5. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some
aspects of basic science and clinical management. British Journal of
Sports Medicine 2002;36(4):239-49.

6. Lewis JS. Rotator cuff tendinopathy: A review. British Journal of
Sports Medicine 2008.

7. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of
tendon disorders. Rheumatology (Oxford) 2006;45(5):508-21.

8. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B.
Mobilisation with movement and exercise, corticosteroid injection, or wait
and see for tennis elbow: randomised trial. BMJ 2006;333(7575):939.

9. Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, et
al. Conservative treatments for tennis elbow do subgroups of patients
respond differently? Rheumatology (Oxford) 2007;46(10):1601-5.

10. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised
controlled trial of local corticosteroid injection and naproxen for
treatment of lateral epicondylitis of elbow in primary care. BMJ

11. Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic
randomised controlled trial of local corticosteroid injection and
physiotherapy for the treatment of new episodes of unilateral shoulder
pain in primary care. Ann Rheum Dis 2003;62(5):394-9.

12. Smidt N, Lewis M, Hay EM, Van der Windt DA, Bouter LM, Croft P. A
comparison of two primary care trials on tennis elbow: issues of external
validity. Ann Rheum Dis 2005;64(10):1406-9.

13. Smidt N, van der Windt DA. Tennis elbow in primary care. Bmj

Competing interests:
None declared

Competing interests: No competing interests

12 May 2009
Bill Vicenzino
Chair in Sports Physiotherapy and Head of Physiotherapy
University of Queensland, 4072