ADVERTISEMENT
Point-Counterpoint: Are Steroid Injections Indicated For Tendon Pathology?
Point-Counterpoint
Point
Stigma does exist towards the use of injectable corticosteroid for tendon
pathology, but does the literature support this concern? Here the author
advocates for careful consideration of circumstances surrounding this
treatment modality, but that the controversy does not have a clear verdict.
By Valerie Marmolejo, DPM, MS, CTBS, MWC
Corticosteroid injection is a common treatment for various foot and ankle pathologies.1 However, its use is controversial when it comes to treating tendon pathology. This controversy exists due to a lack of evidence on its biomechanical effect and conflicting reports on its clinical benefits.1-3 One double-blind RCT showed no reduction in pain or tenderness or return to regular activity following a peritendinous injection of 40 mg methylprednisolone in 28 subjects.4 Another double-blind RCT of peritendinous steroid injection using ultrasound guidance for chronic tendinitis (symptoms greater than 1.5 years) reported significant reduction in tendon diameter and greater reduction in pressure-pain threshold within one week following a single injection of 20 mg triamcinolone compared to placebo group.3 The need for surgery in the treatment group also reduced by 50 percent. The most frequent adverse effect the authors reported was reversible skin atrophy, which resolved by six-months post-application. They noted high frequency of recurrent pain if resuming intense training within a few days of injection, prompting them to recommend graduated rehabilitation over three-to-six months following ultrasound-guided peritendinous corticosteroid injection.3 However, the most significant concern prompting providers to forego such injections for tendon pathology is the risk for rupture.
What Does The Evidence Reveal?
The plantar fascia and Achilles tendon are the two structures in the foot and ankle most often reported as ruptured in conjunction with corticosteroid injection.1-3,5-7 While corticosteroid injection for tendon pathology has developed a stigma because of this, the clinical evidence to support this controversial concern does not exist. Preclinical studies on the effects of local corticosteroid injection around tendons found no difference in cellular infiltration or vascularity to the area or tendon necrosis compared to saline.8,9 A review of 356 cases of tendinopathy reported tendon rupture in 3.5 percent of patient not given steroids and 3.7 percent for those who did receive steroids.10 Another study also found a three percent incidence of tendon rupture in patients administered injectable steroids.11 A retrospective review comparing patients who did and did not receive corticosteroid injection for Achillodynia reported the highest incidence rate, still only at eight percent for patients who receive a 1ml peritendinous injection of hydrocortisone acetate compared to six percent in those who did not.12 Another study also reported an 8.4 percent Achilles tendon rupture rate following corticosteroid injection.13 Even in high-performance athletes, a systematic review of corticosteroid injections’ utilization, efficacy, and adverse effects found no report of minor or major adverse events with game-day use of corticosteroid injections. Evidence supported this treatment as it may allow for early return to play without adverse events, although the studies included were of poor quality secondary to being retrospective, having a small number of subjects, or being physician surveys on corticosteroid use.2
The most common adverse effects reported following corticosteroid injection for foot and ankle pathologies, including tendon and ligament conditions and osteoarthritis, divide into minor and major adverse effects. Minor adverse effects are most common, including pain after injection, disturbance in menstruation or flushing, skin and/or subcutaneous atrophy, mild skin discoloration, numbness and tingling in the hands, cellulitis, transient sympathetic reaction, and ecchymosis. Other minor adverse events occur more rarely, with some having only a single case report. Major adverse reactions are also rare, at times only a single case or small case series. Tendon rupture following corticosteroid injection ranges from three to eight percent in the literature.10-12
How Do Provider Perceptions And Practices Influence The Data?
The low reported rate of tendon rupture following corticosteroid injection may be due to providers avoiding this modality due to stigma of potential rupture. A 13-year review of National Football League (NFL) data found that corticosteroid injections directly into an injury site only occurred 58 times.13 Another report of corticosteroid injection use for a single NFL team over a three-session period found only 38 injections performed in 31 athletes.2
A survey of orthopedic surgeons on the frequency of corticosteroid injections for various foot and ankle pathologies found that 88 and 98 percent of respondents never perform injections for insertional and midsubstance Achilles tendinitis/tendinosis.14 Results found that incidence of rupture per provider following corticosteroid injection for insertional or midsubstance Achilles tendinitis/tendinosis was 0.5 and 0.6, respectively. However, 26 percent and 54 percent of respondents performed corticosteroid injections for posterior tibial and peroneal tendonitis, respectively. Even with this increased reporting of usage, only 0.8 ruptures per provider of the posterior tibial tendon were reported. The authors did not report the rupture rate per provider for the peroneal tendon. In addition, 89 percent of the respondents reported performing corticosteroid injection for plantar fasciitis and there was a plantar fascia rupture rate of 53.7 percent, or 1.5 ruptures per provider.14 Despite this high reported rupture rate, corticosteroid injection remains a mainstay treatment modality for this condition.
While the fear of tendon rupture following corticosteroid injection remains, this potential risk may relate to other factors as opposed to simply the corticosteroid injection itself. These factors include the steroid used and the amount administered, intratendinous versus peritendinous injection, the extent of injury present at the time of injection, time since injury, and post-injection activities.2,3,7-9,12,14,15 The absorption rate of the steroid used may contribute to the potential for rupture. Evidence shows that periarticular injection of methylprednisone acetate remains with the plasma for a mean of 16 days following injection.15
Unfortunately, literature on other corticosteroids is non-existent. Peritendinous injection of corticosteroid, with or without ultrasound guidance, may be more advantageous to avoid rupture than intratendinous injection.2,3 Direct injection into a damaged tendon increased the risk of rupture in one preclinical trial.16 The three most significant factors prior to corticosteroid injection for tendon pathology are: extent of injury at the time of injection; time since injury; and post-injection activities. Corticosteroids work to reduce inflammation. They will not help repair degeneration.12 Studies show corticosteroid injection as most beneficial in the early phase of injury to help reduce inflammation-related pain and aid in healing.8,9,17,18
A preclinical trial of corticosteroid injection to a damaged Achilles tendon in the early phase of healing resulted in increased peak force due to improved tissue organization as the tendon healed.18 When tendon degeneration or defect is present, rupture following corticosteroid injection may be a red herring of a tendon already damaged to the extent that predisposed the risk of rupture.7,8 Several authors also advocate for immobilization immediately following corticosteroid injection.8,9,14 Reduced pain and rapid return to repetitive loading activity may potentiate rupture risk.8 There is no recommendation for a definitive time of immobilization, however, recommendations do exist for gradual return to activity following corticosteroid injection.3,14
In Conclusion
While one article cannot change decades of concern for the potential of tendon rupture following corticosteroid injection, this debate, at a minimum, should assist providers on establishing informed consent regarding the most common potential post-injection adverse events and serve as a basis to consider when, where, and how active patients should be if their provider employs this treatment modality.
Dr. Marmolejo is the Western Region Clinical Wound Specialist with LifeNet Health and a freelance medical writer with Scriptum Medica.
Counterpoint
Here the author points out deficits in the available literature, along with showcasing pertinent animal literature and meta-analyses that cannot completely support steroid injection as a go-to treatment option in tendon pathology.
By Erin E. Klein, DPM, FACFAS, DABPM
The process of healing tissue in the human body requires a complex series of events that in turn requires specific molecular components to occur in a specific order to repair damaged tissue. Basic science suggests that the repair of tissue damage starts with an inflammatory stage followed by a reparative phase and a remodeling phase. This process can take weeks to years. Because of the complex series of events required to repair tissue in the human body (including tendons), acute tendon damage can progress to chronic tendon problems. Despite the widespread literature on how to treat tendon pathology, the etiology, pathophysiology, and healing mechanisms of this tissue are only partly known.1 Interestingly, the origin of pain in chronic tendon problems is also only partially known.1
It is thought that injection of steroids suppresses inflammation, reduces or breaks up adhesions, prevents the production of certain types of collagen, prevents the production of certain matrix molecules and granulation tissue, possibly preventing or reducing pain.1 Corticosteroids may also mediate the production and release of noxious chemicals by the tendon that may stimulate local nociceptors.1
What Does The Available Research Reveal?
Designing a study that includes steroid injections for tendons in humans has the potential to be ethically challenging and may cause harm. Further complicating the subject, many studies lack a standardized injection method, standardized substance of injection, and standardized analysis. However, animal studies allow for histologic analysis that is not ethically possible in human studies, so understanding the basic science and animal-based literature on this topic may be helpful.
Guttu and colleagues performed a four-arm study injecting the gastrocnemius muscle of adult male rats.2 The injection of saline, procaine, and steroid produced the least reaction (possibly because of the dilution of the solution with the saline). The injection of procaine and a steroid produced focal inflammation at 24 hours but no other effects after that time. The injection of bupivacaine produced moderate focal necrosis and a mild inflammatory response at 24 hours; however, at the three-week post-injection mark, the muscle had returned to normal. This finding would suggest that the gastrocnemius muscle of rats undergoes a similar healing process to the human body. The fourth group of rats underwent injection with bupivacaine and steroid. At 24 hours post-injection, there was a heavy inflammatory response, and extensive muscle necrosis noted. This persisted throughout the four-week monitoring phase after the injection. At the endpoint of the study, the researchers noted some muscle regeneration.2
How can we apply this study to the human body? It is my contention that the following conclusions are possible from the study by Guttu and colleagues:2
• Injecting substances that should calm inflammation into the gastrocnemius can produce the very inflammation that it should be reducing; and
• There is the potential for harm (ie muscle necrosis) with injection of a substance that is typically thought of as helpful or beneficial.
Muto and team performed a similar study by injecting saline (control group), triamcinolone, and prednisolone into the Achilles tendon of adult male rats.3 They performed histological analysis at one- and three-weeks post-injection. Researchers noted no changes in the saline/control group. At one-week post-injection, they found that the tendon strength for both the triamcinolone and prednisolone groups were less than the control group. There was histologic collagen attenuation and increased expression of MMP-3 and apoptotic cells in the corticosteroid group. The authors concluded that these changes appeared to have involvement in tendon degeneration or rupture after corticosteroid injection.3
How can we apply this study to the human body?
• One should recognize that there may be deleterious histological changes that can occur if one injects steroid into the tendon tissue.
Hugate and coworkers performed a rabbit-based study comparing the effects of saline to steroid when injected into the Achilles tendon (one group) and the retrocalcaneal bursa (second group).4 They found that specimens from limbs that had intratendinous injection of steroid were histologically equivalent to specimens that had intrabursal injections. The specimens from injected limbs demonstrated significantly decreased failure stress, decreased total energy absorbed, and decreased total strain.4 This suggests that the steroid injection changed the biomechanical properties of the tissue to fail and at lower loads than other tendons.
How can we apply this study to the human body?
• It is possible (even likely, based on this study) that injecting steroid into the tendon causes damage that may lead to earlier rupture.
• It is possible that injecting into peritendinous areas (ie, the retrocalcaneal bursa) may lead to tendon alterations similar to intratendinous injections.
What Else Can We Learn From The Animal Research?
The animal-based literature on corticosteroid injections is important to understand, as it is not medically ethical to inject a patient with steroid and then plan to either biopsy their tendon (creating more damage, weakness, problems, etc) or sacrifice non-painful foot and ankle structures to do a histological analysis. Therefore, in my observation, the human and clinical science for corticosteroid injections relies on studies that focus less on histologic changes and more on clinically observable changes (both positive and negative). With that being said, many studies lack standardization (injection site, injection technique, ultrasound guidance, intratendinous injection versus peritendinous injection, post-injection protocol, outcome measures), making comparison difficult. For this reason, systematic reviews of the literature would be best to review this topic.
Nichols published a systematic review of the complications associated with corticosteroid injection in athletic injuries.5 Tendon and fascial ruptures were found to be the most commonly reported complication of injection, while tibial stress fracture and multifocal necrosis were found to be associated with systemic corticosteroid use. A systematic review of corticosteroid injections for plantar fasciitis found that 130 of 155 patients who experienced a plantar fascial rupture had treatment with corticosteroid injections prior to rupture.6 Ruptures occurred at a much higher percentage than patients in that systemic review who experienced a ‘spontaneous’ rupture (n=3).6 One cannot infer or discuss causation with these facts, and it is difficult to discuss if the plantar fascial ruptures were part of the disease process, secondary to the corticosteroid injection, or both.
Irby and colleagues performed a systematic review of other systematic reviews of treatments for tendinopathy.7 These authors concluded that eccentric muscle strengthening was the treatment that most frequently and most consistently demonstrated improvement in pain and muscle function. Corticosteroids were deemed potentially helpful for short-term, acute issues but the authors deemed them ineffective and contraindicated for longer-term management of tendon-related problems.
In Conclusion
Overall, however, there is a considerable paucity of reliable, convincing literature that would allow for discussion of a true risk-versus-benefit ratio of a corticosteroid injection for a tendon problem in the lower extremity. For this reason, and after review of said literature, it is not clear that, and I am personally not confident that chronic tendon issues should be treated with corticosteroid injections.
Dr. Klein is an Associate and the Associate Director of Research of the Weil Foot and Ankle Institute. She is a Clinical Instructor at the William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science. Dr. Klein is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Medicine.
Point References
1. Speed CA. Fortnightly review: Corticosteroid injections in tendon lesions. BMJ. 2001;323(7309):382-386.
2. Jelsema TR, Tam AC, Moeller JL. Injectable Ketorolac and corticosteroid use in athletes: a systematic review. Sports Health. 2020;12:521-527.
3. Fredberg U, Bolvig L, Pfeiffer-Jensen M, Clemmensen D, Jakobsen BW, Stengaard-Pedersen K. Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper’s knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study. Scand J Rheumatol. 2004;33(2):94-101.
4. DaCruz DJ, Geeson M, Allen MJ, Phair I. Achilles’ paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22:6465.
5. Nepple JJ, Matava MJ. Soft tissue injections in the athlete. Sports Health. 2009;1:396-404.
6. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15:370-375.
7. Cowan MA, Alexander S. Simultaneous bilateral rupture of Achilles tendons due to triamcinolone. Br Med J. 1961;1(5240):1658.
8. Tsai WC, Tang FT, Wong MK, Pang JH. Inhibition of tendon cell migration by dexamethasone is correlated with reduced alpha smooth muscle actin gene expression: a potential mechanism of delayed tendon healing. J Orthop Res. 2003;21(2):265–271.
9. McWhorter JW, Francis RS, Heckmann RA. Influence of local steroid injections on traumatized tendon properties. A biomechanical and histological study. Am J Sports Med. 1991;19:435-439.
10. Subotnick S, Sisney P. Treatment of achilles tendinopathy in the athlete. J Am Podiatr Med Assoc. 1986;76:552–557.
11. Read M, Motto S. Tendo achilles pain: steroids and outcome. Br J Sports Med. 1992;26:15–21.
12. Read MT. Safe relief of rest pain that eases with activity in achillodynia by intrabursal or peritendinous steroid injection: the rupture rate was not increased by these steroid injections. Br J Sports Med. 1999;33(2):134-135.
13. Kluczynski MA, Kelly WH, Lashomb WM, Bisson LJ. A systematic review of the orthopaedic literature involving National Football League players. Orthop J Sports Med. 2019;7(8):2325967119864356.
14. Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int. 2011;32(4):394-399.
15. Mattila J. Prolonged action and sustained serum levels of methylprednisolone acetate. Clin Trials J. 1983;20:1823.
16. Arslan I, Yücel I, Öztürk TB, Karahan N, Orak MM, Midi A. The effects of corticosteroid injection in the healthy and damaged Achilles tendon model: histopathological and biomechanical experimental study in rats. Turk Patoloji Derg. 2020;36(1):39-47.
17. Wetke E, Johannsen F, Langberg H. Achilles tendinopathy: a prospective study on the effect of active rehabilitation and steroid injections in a clinical setting. Scand J Med Sci Sports. 2015;25(4):e392-399.
18. Blomgran P, Hammerman M, Aspenberg P. Systemic corticosteroids improve tendon healing when given after the early inflammatory phase. Sci Rep. 2017;7(1):12468. doi: 10.1038/s41598-017-12657-0.
Counterpoint References
1. Paavola M, Kannus P, Jarvinen TA, Jarvinen TL, Jozsa L, Jarvinen M. Treatment of tendon disorders. Is there a role for corticosteroid injection? Foot Ankle Clin. 2002;7(3):501-513.
2. Guttu RL, Page DG, Laskin DM. Delayed healing of muscle after injection of bupivicaine and steroid. Ann Dent. 1990;49(1):5 - 8.
3. Muto T, Kokubu T, Mifune Y, et al. Temporary inductions of matrix metalloprotease-3 (MMP-3) expression and cell apoptosis are associated with tendon degeneration or rupture after corticosteroid injection. J Orthop Res. 2014;32(10):1297-1304.
4. Hugate R, Pennypacker J, Saunders M, Juliano P. The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am. 2004;86(4):794 - 801.
5. Nichols A. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sports Med. 2005;15(5):370-375.
6. Mosca M, Fuiano M, Massimi S, et al. Ruptures of the plantar fascia: a systematic review of the literature. Foot Ankle Spec. Online ahead of print. 2020. doi: 10.1177/1938640020974889.
7. Irby A, Gutierrez J, Chamberlin C, Thomas S, Rosen A. Clinical management of tendinopathy: a systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scand J Med Sci Sports. 2020;30(10):1810-1826.
