Education plus exercise better than corticosteroid injection for gluteal tendinopathy
In gluteal tendinopathy, corticosteroid injection (CSI) use and education plus exercise (EDX) both lead to higher rates of patient-reported global improvement and lower pain intensity in the short term compared with a wait-and-see (WS) approach, according to a recent study, adding that EDX is better than CSI use.
“At 52-week follow-up, EDX led to better global improvement than CSI use, but no difference in pain intensity,” researchers said. “These results support EDX as an effective management approach for gluteal tendinopathy.”
A total of 204 participants (mean age 54.8 years; 167 women) were randomized to a physiotherapy-led EDX programme of 14 sessions over 8 weeks (n=69), one CSI (n=66) or a WS approach (n=69). Of these, 189 (92.6 percent) completed the 52-week follow-up. [BMJ 2018;361:k1662]
At 8 weeks, 51 participants in the EDX arm, 38 in the CSI arm and 20 in the WS arm reported success on the global rating of change. EDX and CSI resulted in better global improvement scores than WS (EDX: risk difference, 49.1 percent; 95 percent CI, 34.6–63.5 percent; number needed to treat, 2.0; 1.6–2.9; CSI: risk difference, 29.2 percent; 13.2–45.2 percent; number needed to treat, 3.4; 2.2–7.6). Global improvement scores were higher in EDX than in CSI.
The reported pain mean score on the numerical rating scale at 8 weeks was 1.5, 2.7 and 3.8 for EDX, CSI and WS, respectively. Participants in the EDX (mean difference, –2.2; –2.89 to –1.54) and CSI (mean difference, –1.2; –1.85 to –0.50) groups reported less pain than those in the WS group, and EDX participants reported less pain than those who received CSI (mean difference, –1.04; –1.72 to –0.37).
At 52 weeks, 51 participants in the EDX arm, 36 in the CSI arm and 31 in the WS arm reported success on the global rating of change. EDX performed better than CSI (risk difference, 20.4 percent; 4.9–35.9 percent; number needed to treat, 4.9; 2.8–20.6) and WS (risk difference, 26.8 percent; 11.3–42.3 percent; number needed to treat, 3.7; 2.4–8.8).
Reported pain at 52 weeks was 2.1, 2.3 and 3.2 for EDX, CSI and WS, respectively. Both EDX (mean difference, 1.13; –1.93 to –0.33) and CSI (mean difference, 0.87; –1.68 to –0.07) did better than WS, and EDX did not differ from CSI (mean difference, –0.26; –1.06 to 0.55).
“Our study results regarding the CSI concur with the only other comparable randomized trial in gluteal tendinopathy, where injections provided benefits in the short term (at 12 weeks) but not in the longer term (at 52 weeks), compared with usual care,” researchers said. [Ann Fam Med 2011;9:226-234]
“These outcomes are also broadly consistent with trials involving tendinopathies at other sites,” they added. [Arthritis Rheum 1987;30:1040-1045; Lancet 2002;359:657-662]
In addition, the novel finding of the greater benefit of EDX over CSI on all primary outcomes at 8 weeks contrasts those from a previous clinical trial involving home-based exercise for gluteal tendinopathy, which found a significantly lower success rate of only 7 percent for exercise vs 75 percent for CSI use at 1-month follow-up. [Am J Sports Med 2009;37:1981-1990]
“Considering the favourable outcomes of an EDX programme in both the short and long term, further research might be well directed towards establishing the degree of contribution of specific education alone about the condition itself, tendon loading principles and appropriate strategies for self-management,” researchers said.
“Future work should also look at whether this approach could be a viable, cost effective approach to early management and prevention of progression and recurrences,” they added.