The Use of Ultrasound-Guided Injections for Tendinopathies
Purpose of Review
The purpose of the study was to review the efficacy and safety of common ultrasound-guided injections for tendinopathy conditions. Corticosteroid injections have historically been the most common injection used for tendinopathy; however, there are an increasing number of injections including platelet-rich plasma, hyaluronan, polidocanol, botulinum toxin, and high volume saline injections.
There is growing evidence that while corticosteroid injections for tendinopathies usually have short-term efficacy, they may result in medium-term harm, particularly for tennis elbow (lateral epicondylitis). Corticosteroid injections appear to have more clinical utility for tenosynovitis conditions. There is insufficient evidence regarding other injection options to make a broad recommendation in favour, although individual trials for certain tendons illustrate benefits for some of the non-corticosteroid options.
When considering the use of ultrasound-guided corticosteroid injections for tendinopathies, the risk of possible medium-term harm must be weighed up against any short-term efficacy. Other injection-based therapies may be appropriate in certain clinical situations; however, the evidence and clinical circumstances must be considered for the particular tendon and patient. Load-based rehabilitation remains the cornerstone of tendinopathy management.
KeywordsTendinopathy Tenosynovitis Ultrasound-guided Injection Corticosteroid Platelet-rich-plasma
Compliance with Ethical Guidelines
Conflict of interest
John W. Orchard, Richard Saw, and Lorenzo Masci each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
None of the images illustrated in this study were obtained from live patients where consent would have been required (either cadaver models or self-images of the authors were used for all Figures).
Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance
- 2.Liew D. Therapeutic guidelines: rheumatology. Version 3. Aust Prescr. 2017;40(5):202.Google Scholar
- 5.Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461–9. https://doi.org/10.1001/jama.2013.129.CrossRefPubMedGoogle Scholar
- 6.Coombes BK, Connelly L, Bisset L, Vicenzino B. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sports Med. 2016;50(22):1400–5. https://doi.org/10.1136/bjsports-2015-094729.CrossRefPubMedGoogle Scholar
- 7.Olaussen M, Holmedal O, Mdala I, Brage S, Lindbaek M. Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial. BMC Musculoskelet Disord. 2015;16:122. https://doi.org/10.1186/s12891-015-0582-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657–62. https://doi.org/10.1016/s0140-6736(02)07811-x.CrossRefPubMedGoogle Scholar
- 10.Tosun HB, Gumustas S, Agir I, Uludag A, Serbest S, Pepele D, et al. Comparison of the effects of sodium hyaluronate-chondroitin sulphate and corticosteroid in the treatment of lateral epicondylitis: a prospective randomized trial. J Orthop Sci. 2015;20(5):837–43. https://doi.org/10.1007/s00776-015-0747-z.CrossRefPubMedGoogle Scholar
- 13.Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463–71. https://doi.org/10.1177/0363546513494359.CrossRefPubMedGoogle Scholar
- 14.Gosens T, Mishra AK. Editorial in response to the systematic review by de Vos et al: strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):945–6. https://doi.org/10.1136/bjsports-2014-093704.CrossRefPubMedGoogle Scholar
- 16.Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435–46. https://doi.org/10.1177/0363546512458237.CrossRefPubMedGoogle Scholar
- 17.Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39(6):1200–8. https://doi.org/10.1177/0363546510397173.CrossRefPubMedGoogle Scholar
- 18.Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255–62. https://doi.org/10.1177/0363546509355445.CrossRefPubMedGoogle Scholar
- 19.Chiavaras MM, Jacobson JA, Carlos R, Maida E, Bentley T, Simunovic N, et al. IMpact of Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain and quality of life in patients with lateral epicondylitis. Acad Radiol. 2014;21(9):1144–55. https://doi.org/10.1016/j.acra.2014.05.003.CrossRefPubMedGoogle Scholar
- 21.Fogli M, Giordan N, Mazzoni G. Efficacy and safety of hyaluronic acid (500–730 kDa) Ultrasound-guided injections on painful tendinopathies: a prospective, open label, clinical study. Muscles Ligaments Tendons J. 2017;7(2):388–95. https://doi.org/10.11138/mltj/2017.7.2.388.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.• Degen RM, Cancienne JM, Camp CL, Altchek DW, Dines JS, Werner BC. Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients. J Shoulder Elbow Surg. 2017;26(4):704–9. https://doi.org/10.1016/j.jse.2016.10.022. One of a few recent studies showing cortisone injection predicts failure of subsequent surgery (elbow), suspicious but hard to remove confounders.
- 29.Titchener AG, Booker SJ, Bhamber NS, Tambe AA, Clark DI. Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current U.K. specialist practice and a call for clinical guidelines. Br J Sports Med. 2015;49(21):1410–3. https://doi.org/10.1136/bjsports-2013-092674.CrossRefPubMedGoogle Scholar
- 31.• Vicenzino B, Britt H, Pollack AJ, Hall M, Bennell KL, Hunter DJ. No abatement of steroid injections for tennis elbow in Australian General Practice: a 15-year observational study with random general practitioner sampling. PLoS ONE. 2017;12(7):e0181631. https://doi.org/10.1371/journal.pone.0181631. Despite high quality evidence showing harm of cortisone injections these persist as common practice for tennis elbow treatment.
- 32.•• Mohamadi A, Chan JJ, Claessen FM, Ring D, Chen NC. Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: a meta-analysis. Clin Orthop Relat Res. 2017;475(1):232–43. https://doi.org/10.1007/s11999-016-5002-1. A balanced review revealing benefits of corticosteroid for rotator cuff pain but with authors also cautioning that these may be overstated in clinical practice.
- 33.• Cook T, Minns Lowe C, Maybury M, Lewis JS. Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review. Br J Sports Med. 2018;52(8):497–504. https://doi.org/10.1136/bjsports-2016-097444. Review of high quality cortisone vs local only injections showing definite benefit of cortisone at under 8 weeks but also evidence of no medium term benefit.
- 38.Flores C, Balius R, Alvarez G, Buil MA, Varela L, Cano C, et al. Efficacy and tolerability of peritendinous hyaluronic acid in patients with supraspinatus tendinopathy: a multicenter, randomized, controlled trial. Sports Med. 2017;3(1):22. https://doi.org/10.1186/s40798-017-0089-9.CrossRefGoogle Scholar
- 40.Morrisroe K, Nakayama A, Soon J, Arnold M, Barnsley L, Barrett C, et al. EVOLVE: the Australian Rheumatology Association’s ‘top five’ list of investigations and interventions doctors and patients should question. Intern Med J. 2018;48(2):135–43. https://doi.org/10.1111/imj.13654.CrossRefPubMedGoogle Scholar
- 41.• Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W et al. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. Br J Sports Med. 2015;49(3):145–50. https://doi.org/10.1136/bjsports-2014-094219. Recent narrative view of ultrasound-guided injections in general, not just tendinopathies.
- 44.•• Fawcett R, Grainger A, Robinson P, Jafari M, Rowbotham E. Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes. Clin Radiol. 2018. https://doi.org/10.1016/j.crad.2018.03.016. Study showing that rotator cuff tendon quality may be an important determining factor regarding the success or failure of subacromial cortisone injections.
- 46.• Traven S, Brinton D, Simpson K, Adkins Z, Althoff A, Palsis J et al. Shoulder injection prior to rotator cuff repair is associated with increased risk of subsequent surgery. AOSSM Spec Day; https://www.sportsmed.org/aossmimis/Members/Downloads/MeetingResources/SD2018/Abstract3.pdf2018. One of a few recent studies showing cortisone injection predicts failure of subsequent surgery (shoulder), abstract form publication only to date.
- 49.Rowland P, Phelan N, Gardiner S, Linton KN, Galvin R. The effectiveness of corticosteroid injection for De Quervain’s stenosing tenosynovitis (DQST): a systematic review and meta-analysis. Open Orthop J. 2015;9:437–44. https://doi.org/10.2174/1874325001509010437.CrossRefPubMedPubMedCentralGoogle Scholar
- 51.• Cavaleri R, Schabrun SM, Te M, Chipchase LS. Hand therapy versus corticosteroid injections in the treatment of De Quervain’s disease: a systematic review and meta-analysis. J Hand Ther. 2016;29(1):3–11. https://doi.org/10.1016/j.jht.2015.10.004. Meta-analysis showing hand orthoses prescribed by therapist and cortisone injections for de Quervain’s tenosynovitis superior to either treatment option alone.
- 52.• Danda RS, Kamath J, Jayasheelan N, Kumar P. Role of guided ultrasound in the treatment of De Quervain Tenosynovitis by local steroid infiltration. J Hand Microsurg. 2016;8(1):34–7. https://doi.org/10.1055/s-0036-1581123. Moderate level study suggesting that multiple injections of cortisone into different compartments may be more successful than single cortisone injection for De Quervain Tenosynovitis.
- 55.Waryasz GR, Tambone R, Borenstein TR, Gil JA, DaSilva M. A Review of anatomical placement of corticosteroid injections for uncommon hand, wrist, and elbow pathologies. Rhode Island Med J. 2017;100(2):31–4.Google Scholar
- 57.•• Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662. https://doi.org/10.1136/bmj.k1662. Corticosteroid did beat ‘wait and see’ in this study but both arms inferior to an education and exercise based arm in this high quality RCT.
- 58.• Fitzpatrick J, Bulsara MK, O’Donnell J, McCrory PR, Zheng MH. The effectiveness of platelet-rich plasma injections in gluteal tendinopathy: a randomized, double-blind controlled trial comparing a single platelet-rich plasma injection with a single corticosteroid injection. Am J Sports Med. 2018;46(4):933–9. https://doi.org/10.1177/0363546517745525. PRP injection superior to cortisone in this study but no inactive (placebo) injection option and therefore hard to differentiate between assistance of PRP versus possible harm of cortisone.
- 60.Nicholson LT, DiSegna S, Newman JS, Miller SL. Fluoroscopically guided peritendinous corticosteroid injection for proximal hamstring tendinopathy: a retrospective review. Orthop J Sports Med. 2014;2(3):2325967114526135. https://doi.org/10.1177/2325967114526135.CrossRefPubMedPubMedCentralGoogle Scholar
- 64.•• David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;6:Cd009348. https://doi.org/10.1002/14651858.cd009348.pub2. High quality systematic review but revealing low quality evidence in primary trials, generally showing some benefit of cortisone injection for up to 4 weeks in plantar fasciitis but not beyond.
- 66.• Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT et al. Platelet-rich plasma as a treatment for plantar fasciitis: a meta-analysis of randomized controlled trials. Medicine. 2017;96(44):e8475. https://doi.org/10.1097/md.0000000000008475. No differences seen between PRP and cortisone for plantar fasciitis at 12 weeks or less, but some evidence of benefit favouring PRP at 24 weeks or more.
- 67.• Kearney RS, Parsons N, Metcalfe D, Costa ML. Injection therapies for Achilles tendinopathy. Cochrane Database Syst Rev. 2015(5):Cd010960. https://doi.org/10.1002/14651858.cd010960.pub2. Important publication but concluding quality of evidence for almost all Achilles injection options is poor and very few conclusions can be made.
- 74.Turmo-Garuz A, Rodas G, Balius R, Til L, Miguel-Perez M, Pedret C, et al. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle? Musculoskelet Surg. 2014;98(2):121–6. https://doi.org/10.1007/s12306-013-0305-9.CrossRefPubMedGoogle Scholar
- 76.• Stenson JF, Reb CW, Daniel JN, Saini SS, Albana MF. Predicting failure of nonoperative treatment for insertional Achilles tendinosis. Foot Ankle Spec. 2018;11(3):252–5. https://doi.org/10.1177/1938640017729497. One of a few recent studies showing cortisone injection predicts failure of subsequent surgery (Achilles), suspicious but hard to remove confounders.
- 77.Srivastava P, Aggarwal A. Ultrasound-guided retro-calcaneal bursa corticosteroid injection for refractory Achilles tendinitis in patients with seronegative spondyloarthropathy: efficacy and follow-up study. Rheumatol Int. 2016;36(6):875–80. https://doi.org/10.1007/s00296-016-3440-4.CrossRefPubMedGoogle Scholar
- 78.Danielson P, Andersson G, Alfredson H, Forsgrenn S. Marked sympathetic component in the perivascular innervation of the dorsal paratendinous tissue of the patellar tendon in arthroscopically treated tendinosis patients. Knee Surg Sports Traumatol Arthrosc. 2008;16(6):621–6.CrossRefPubMedGoogle Scholar
- 80.Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol. Knee Surg Sports Traumatol Arthrosc. 2008;16(9):859–64. https://doi.org/10.1007/s00167-008-0579-x.CrossRefPubMedGoogle Scholar
- 83.Kumai T, Muneta T, Tsuchiya A, Shiraishi M, Ishizaki Y, Sugimoto K, et al. The short-term effect after a single injection of high-molecular-weight hyaluronic acid in patients with enthesopathies (lateral epicondylitis, patellar tendinopathy, insertional Achilles tendinopathy, and plantar fasciitis): a preliminary study. J Orthop Sci. 2014;19(4):603–11. https://doi.org/10.1007/s00776-014-0579-2.CrossRefPubMedGoogle Scholar
- 85.Gorelick L, Saab A. Single hyaluronate injection in the management of insertional achilles tendinopathy in comparison to corticosteroid injections and non-invasive conservative treatments. Scholars Bull. 2015;1(1):16–20.Google Scholar
- 86.• Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study. Am J Sports Med. 2017;45(9):2034–43. https://doi.org/10.1177/0363546517702862. High volume injection including cortisone (particularly in the short-term) and PRP (over medium-term time-frame) superior to placebo injection for Achilles tendinopathy, but study likely to be at risk of bias due to clearly different injection regimes.
- 90.Wheeler PC, Mahadevan D, Bhatt R, Bhatia M. A comparison of two different high-volume image-guided injection procedures for patients with chronic noninsertional Achilles tendinopathy: a pragmatic retrospective cohort study. J Foot Ankle Surg. 2016;55(5):976–9. https://doi.org/10.1053/j.jfas.2016.04.017.CrossRefPubMedGoogle Scholar