Achilles tendonitis: are corticosteroid injections useful or harmful?
OBJECTIVE
The use of local corticosteroid injections for the treatment of Achilles tendonitis is controversial. Some authors advocate their use based on efficacy in accelerating the healing process of Achilles tendonitis; others feel the associated side effects should preclude their use altogether. The purpose of this study was to comprehensively review and critically appraise the available literature in order to examine the evidence concerning this clinical dilemma.


METHODS
MEDLINE was searched using MeSH and textwords for English- and French-language articles related to Achilles tendonitis and corticosteroids published since 1966. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 145.


METHODS
All clinical study designs were included as well as related animal studies using experimental and quasi-experimental designs.


METHODS
In reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, the factors associated with effectiveness and safety of injected corticosteroids were examined.


RESULTS
The only rigorous studies (one randomized controlled trial, one cohort study) showed no benefit of corticosteroids over placebo. In animal studies, corticosteroid injections decrease adhesion formation, temporarily weaken the tendon if given intratendinously, but have no effect on tendon strength if injected into the paratenon. The overall incidence of side effects with locally injected corticosteroids is approximately 1%. Most side effects are temporary, but skin atrophy and depigmentation can be permanent. Although there are many case reports of Achilles tendon rupture following local corticosteroid injection, there are no published rigorous studies that evaluate the risk of rupture with or without corticosteroid injection.


CONCLUSIONS
There are insufficient published data to determine the comparative risks and benefits of corticosteroid injections in Achilles tendonitis. The decreased tendon strength with intratendinous injections in animal studies suggests that rupture may be a potential complication for several weeks following injection.
Herzl Family Practice Centre, Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
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I
Shrier
G O
GO
Matheson
H W
HW
Kohl
D000125:Achilles Tendon / Q000187:drug effects / Q000503:physiopathology; D000818:Animals; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001284:Atrophy; D015331:Cohort Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D015994:Incidence; D007267:Injections; D015552:Injections, Intralesional; D010859:Pigmentation Disorders / Q000139:chemically induced; D010919:Placebos; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D012306:Risk; D018570:Risk Assessment; D012422:Rupture, Spontaneous; D012449:Safety; D012867:Skin / Q000187:drug effects / Q000473:pathology; D013256:Steroids; D052256:Tendinopathy / Q000188:drug therapy*; D000267:Tissue Adhesions / Q000517:prevention & control; D014945:Wound Healing
D000893:Anti-Inflammatory Agents; D005938:Glucocorticoids; D010919:Placebos; D013256:Steroids