Anti-inflammatory therapy in tendinopathy: The role of nonsteroidal drugs and corticosteroid injections

Abstract

Strong statements regarding the efficacy of antiinflammatory medication are based primarily on experience with rheumatic disease. Such experience, over 32 years, involving more than 400 000 injections in more than 12000 patients, has led Hollander and associates [118] to conclude that "No other form of treatment for arthritis has given such consistent local symptomatic relief in so many for so long with so few harmful effects." Such endorsement has not been clearly transferable to tendon injury. Anti-inflammatory medications can unquestionably affect excessive inflammation.Whether this tissue effect is significant with regard to enhancing performance has been difficult to prove. To quote former Baltimore Orioles baseball pitcher Jim Palmer [119]: "Cortisone is a miracle drug.. for a week!" This is because, in rheumatologic disease, inflammation is the problem, whereas intratendinous injury represents a degenerative process; as such, recovery depends on restoration of both the injured tissue and its kinetic environment [17]. The tendency to place an inflammatory label (i.e. "itis") on tendon pain has promoted the value of anti-inflammatory treatment while risking a de-emphasis of the role of physical rehabilitation and even well-timed surgical repair. If pain and signs of inflammation are persistent, repeated efforts to turn off the body's alarm are not a substitute for finding the cause of the fire. Indeed, to disable the "fire alarm" of pain from the site of an injury can clearly place the patient in greater jeopardy with respect to tissue overload and failure. Perhaps the greatest criticism that can be raised regarding anti-inflammatory treatment as a sole solution in tendon injury is that it tends, in its worst application, to be too passive and dependent a modality and does not challenge the patient's sense of responsibility to properly recondition, and to avoid abuse.Thus anti-inflammatory therapy may succeed only if the patient has been instilled with the proper expectations and responsibilities. Increasing knowledge of the pathobiology of chronic tendinopathy and the various treatments required for complete recovery has led the experienced clinician to rely far less upon anti-inflammatory medication as a long-term solution. Until more biologically active drugs become available, the judicious application of antiinflammatory therapy remains a sometimes useful but unpredictable adjunctive therapy for both acute and chronic tendinopathy. The successful clinical rationale is best arrived at not by random selection but by cautious individualized prescription.