What are the risks of recurrence and complications associated with injections for treating tennis elbow, including non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections?

Risks of Elbow Injections and Recurrence of Tennis Elbow

Corticosteroid injections for tennis elbow provide short-term pain relief but have high recurrence rates (47/65 cases) and poorer long-term outcomes compared to other treatments, making them a risky option for managing lateral epicondylosis. 1

Risks of Corticosteroid Injections

• Corticosteroid injections may provide more effective short-term relief than NSAIDs in the acute phase of tennis elbow, but do not change long-term outcomes of pain 2
• High recurrence rates occur after initial improvement with corticosteroid injections, with studies showing that 47 out of 65 successful cases subsequently regressed 1
• Corticosteroids may inhibit healing and reduce the tensile strength of the tendon tissue, potentially predisposing to spontaneous rupture 2
• There are no evidence-based guidelines supporting the use of local corticosteroid injections in tendinopathy, and there may be deleterious effects when injected into the tendon substance 2
• Repeated glucocorticoid injections may increase potential risks such as articular cartilage changes and sepsis, though serious adverse events are rare 2
• Corticosteroid injections can cause local atrophy at the injection site 3

Risks of NSAID Injections and Oral NSAIDs

• NSAIDs carry cardiovascular risks including increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke 4
• Gastrointestinal complications are common with NSAID use, including bleeding, ulceration, and perforation of the stomach or intestines 2, 4
• NSAID use has been associated with approximately 100,000 hospitalizations annually in the United States 2
• Elderly patients are at greater risk for serious gastrointestinal events with NSAID use 4
• The average relative risk of developing a serious GI complication is 3-5 times greater among NSAID users than among nonusers 2

Recurrence of Tennis Elbow

• Tennis elbow (lateral epicondylosis) is a common overuse syndrome affecting 1-3% of adults annually 5
• Approximately 80% of cases resolve with conservative treatment, but recurrence is common with certain interventions 5
• Physiotherapy combining elbow manipulation and exercise shows superior long-term outcomes compared to corticosteroid injections 1
• Patients who received physiotherapy sought less additional treatment (such as NSAIDs) than those who had corticosteroid injections 1
• The condition commonly occurs in persons who play racquet sports and in occupations requiring repetitive wrist flexion and extension 2
• Tennis elbow affects men and women equally and is most common after 40 years of age 2

Treatment Algorithm to Minimize Recurrence

1. First-line treatment: Conservative management with rest, physical therapy, and eccentric strengthening exercises 5, 1

   • Avoid activities that require repetitive wrist extension 2
   • Consider bracing or orthotics to unload the tendon 2, 5

2. For pain management:

   • Topical NSAIDs may provide pain relief with fewer systemic side effects than oral NSAIDs 2
   • Short-term oral NSAIDs may be used if necessary, but with caution regarding GI and cardiovascular risks 2, 4
   • Ice therapy for 10-minute periods through a wet towel can provide short-term pain relief 2

3. If conservative treatment fails after 6 weeks:

   • Consider physiotherapy combining elbow manipulation and exercise rather than corticosteroid injections due to better long-term outcomes 1
   • If corticosteroid injection is chosen, patients should be informed about the high recurrence rate and poorer long-term outcomes 1

4. For persistent cases (>6 months):

   • Consider referral for surgical evaluation if pain persists despite well-managed conservative treatment 2
   • Arthroscopic release with debridement is a surgical option for refractory cases 5

Common Pitfalls and How to Avoid Them

• Overreliance on corticosteroid injections: Despite short-term effectiveness, their long-term outcomes are poor with high recurrence rates 1
• Premature return to aggravating activities: Ensure adequate healing time before resuming activities that involve repetitive wrist extension 2
• Neglecting physical therapy: Eccentric strengthening exercises are crucial for long-term recovery and prevention of recurrence 1
• Multiple corticosteroid injections: Repeated injections may lead to tissue weakening and increased risk of tendon rupture 2
• Focusing only on pain relief: Treatment should address both pain management and functional restoration to prevent recurrence 1