What are the risks of using steroids for treatment of lateral epicondylitis?

From the Guidelines

Steroid injections for lateral epicondylitis carry significant risks, including tendon weakening or rupture, and may worsen long-term outcomes, making them a less favorable treatment option compared to other approaches like physical therapy. The main risks associated with steroid injections for lateral epicondylitis include tendon weakening or rupture, particularly with repeated injections, as steroids can degrade collagen and impair tendon healing 1. Patients commonly experience post-injection pain flare that typically lasts 24-48 hours. Skin changes such as depigmentation or atrophy may occur at the injection site. Many patients (up to 50%) experience symptom recurrence after initial improvement, often with symptoms worse than before treatment. Facial flushing, temporary blood glucose elevation in diabetics, and rare infection risks are also possible complications.

Some key points to consider when evaluating the risks of steroid injections for lateral epicondylitis include:

• Tendon weakening or rupture: Steroids can degrade collagen and impair tendon healing, increasing the risk of tendon rupture, particularly with repeated injections 1.
• Post-injection pain flare: Patients may experience a temporary increase in pain after the injection, typically lasting 24-48 hours.
• Skin changes: Depigmentation or atrophy may occur at the injection site.
• Symptom recurrence: Many patients experience symptom recurrence after initial improvement, often with symptoms worse than before treatment.
• Systemic complications: Facial flushing, temporary blood glucose elevation in diabetics, and rare infection risks are also possible complications.

While a single corticosteroid injection (typically methylprednisolone 20-40mg or equivalent with lidocaine) may provide short-term pain relief for 4-6 weeks, evidence suggests this approach may worsen long-term outcomes compared to other treatments like physical therapy 1. These risks increase with multiple injections, and current evidence suggests limiting steroid use for tennis elbow to cases where conservative measures have failed and providing only short-term relief is the goal. It is essential to weigh the potential benefits of steroid injections against the potential risks and consider alternative treatment options, such as physical therapy, to minimize the risk of adverse outcomes.

From the FDA Drug Label

Corticosteroids, including triamcinolone acetonide injection, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection The rate of infectious complications increases with increasing corticosteroid dosages.

The risks of using steroids, such as triamcinolone acetonide, for treatment of lateral epicondylitis include:

• Immune system suppression: increasing the risk of infection
• Infection risk: reducing resistance to new infections, exacerbating existing infections, and increasing the risk of disseminated infections
• Reactivation of latent infections: such as tuberculosis, hepatitis B, and varicella
• Adrenal insufficiency: due to suppression of the hypothalamic-pituitary-adrenal axis
• Cardio-renal effects: elevation of blood pressure, salt and water retention, and increased excretion of potassium
• Local atrophy: likely to occur if not administered via deep intramuscular injection 2

From the Research

Risks of Using Steroids for Treatment of Lateral Epicondylitis

• The use of corticosteroid injections for the treatment of lateral epicondylitis has been shown to have short-term benefits, but the long-term effects are not well established 3, 4.
• Studies have found that corticosteroid injections can provide short-term pain relief, but they may not be effective in the long term 3, 5.
• The use of corticosteroid injections has been associated with a range of risks, including:
  • Short-term benefits that may not last 3, 4
  • Lack of long-term efficacy 3, 5
  • Potential for adverse effects, such as skin atrophy and tendon rupture 4
  • Uncertainty about the optimal timing, dosage, and injection technique 4
• Alternative treatments, such as platelet-rich plasma (PRP) injections, may be more effective in the long term 5.
• The trend of using corticosteroid injections for the treatment of lateral epicondylitis has been declining in recent years, possibly due to the increasing evidence of their ineffectiveness 6.
• Rehabilitation should be considered as the first line of treatment for patients with a short duration of symptoms, rather than corticosteroid injections 7.