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Dr Lorenzo Masci on injections for tendonitis

Injections for tendonitis?

I see many patients with tendonitis – tennis elbow, golfer’s elbow, Achilles tendonitis, patellar tendonitis, hip tendonitis, foot tendonitis and wrist and hand tendonitis. Managing tendonitis is always difficult, partly because we don’t completely understand tendonitis. Partly, also, because our treatments are not great. I wrote a blog explaining how to manage tendonitis. Exercise is the best medicine for patients with tendonitis, but some cases are resistant to exercise and require other treatments.

One option for patients with difficult tendonitis is an injection. We have used cortisone injections for tendonitis since the discovery of cortisone over 70 years ago. Today, doctors perform over 500000 steroid injections for arthritis or tendonitis. Cortisone is a good pain reliever for arthritis and tendonitis, but it has some nasty side effects such weakening of tendons. Recently, other injections such as platelet-rich plasma (PRP) or hyaluronic acid are used to inject into or around tendons to help with pain.

What is the evidence for injections in tendonitis?

According to a recent paper, we are a bit clearer on the positives and negatives of an injection.

First, it is becoming clear that cortisone injections produce short term pain relief but little long term benefit. Also, there are some tendons (tennis elbow) where an injection of cortisone can cause harm. While the evidence for harm is not definite for other tendons, the balance is certainly favouring a negative effect.

Second, platelet-rich plasma (PRP) injections, which shows promising results in arthritis, seem to be less effective in tendonitis. There are a few studies that show a positive effect of platelet-rich plasma (PRP) injections for tennis elbow and plantar fasciitis. However, there is no evidence for benefit in Achilles tendonitis or patellar tendonitis. I outline the evidence for PRP in this recent blog.

A specific type of injection called high-volume injection for Achilles and Patellar tendonitis showed some promise in early studies. However, recent work suggests that the effect is probably short term and limited.

Other injections such needle tenotomy have some evidence for use in tennis elbow. But there is little evidence for other tendons. Recently, a new procedure pioneered by me called tendon scraping is used for some cases of Achilles and Patellar tendonitis with good results.

Finally, injections of tendons are better under direct vision using ultrasound to improve accuracy.

To conclude:

In summary, injections form a small part of the treatment of tendonitis. Exercise treatment should always be the first treatment. I only use an injection in difficult cases. More importantly, I try to avoid injections that cause harm such as cortisone injection.

 

Dr Masci is a Sports and Exercise Medicine doctor with an expertise in the management of general musculoskeletal injuries including tendonitis. An expert in MSK ultrasound with a specialisation in ultrasound-guided injections for joints and tendons, he has written 20 peer-reviewed papers on tendonitis. He is a recognised tendon specialist and has presented on tendonitis at international conferences including Arsenal football conference. Dr Masci consults at OneWelbeck. For enquiries, please contact info@sportdoctorlondon.com or visit his website www.sportdoctorlondon.com