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Glucocorticoids are generally used to relieve pain and/or inflammation in a wide variety of musculoskeletal disorders including osteoarthritis, inflammatory arthritis, tendinopathy and degenerative spine disease. Glucocorticoids reduce tendon derived cell proliferation in vitro and reduce extracellular matrix synthesis both in vitro and in vivo, in particular type I collagen synthesis. Glucocorticoids also appear to result in acute deleterious changes in healthy in vivo tendon including collagen necrosis, collagen disorganisation and inflammatory cell infiltration; while the overall effect of glucocorticoid administration on the mechanical properties of healthy in vivo tendon are generally negative. Overall the existing in vitro and in vivo evidence suggests that glucocorticoids should be used with caution in treating painful tendinopathy. Certainly a real need exists to follow up the long term clinical effects of glucocorticoid in treating tendinopathy, as there is currently a paucity of evidence in this area. However in this context while the short term benefits are clear, glucocorticoids remain a useful treatment option provided they are used in the right patients in sensible moderation.

Background: Glucocorticoid injection (GCI) and surgical rotator cuff repair are two widely used treatments for rotator cuff tendinopathy. Little is known about the way in which medical and surgical treatments affect the human rotator cuff tendon in vivo. We assessed the histological and immunohistochemical effects of these common treatments on the rotator cuff tendon., Study Design: Controlled laboratory study., Methods: Supraspinatus tendon biopsies were taken before and after treatment from 12 patients undergoing GCI and 8 patients undergoing surgical rotator cuff repair. All patients were symptomatic and none of the patients undergoing local GCI had full thickness tears of the rotator cuff. The tendon tissue was then analysed using histological techniques and immunohistochemistry., Results: There was a significant increase in nuclei count and vascularity after rotator cuff repair and not after GCI (both p=0.008). Hypoxia inducible factor 1α (HIF-1α) and cell proliferation were only increased after rotator cuff repair (both p=0.03) and not GCI. The ionotropic N-methyl-d-aspartate receptor 1 (NMDAR1) glutamate receptor was only increased after GCI and not rotator cuff repair (p=0.016). An increase in glutamate was seen in both groups following treatment (both p=0.04), while an increase in the receptor metabotropic glutamate receptor 7 (mGluR7) was only seen after rotator cuff repair (p=0.016)., Conclusions: The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after GCI. The increase in the glutamate receptor NMDAR1 after GCI raises concerns about the potential excitotoxic tendon damage that may result from this common treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Our primary objective was to summarise the known effects of locally administered glucocorticoid on tendon tissue and tendon cells., Methods: We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines of the Medline database using specific search criteria. The search yielded 50 articles, which consisted of 13 human studies, 36 animal studies and one combined human/animal study., Results: Histologically, there was a loss of collagen organisation (6 studies) and an increase in collagen necrosis (3 studies). The proliferation (8 studies) and viability (9 studies) of fibroblasts was reduced. Collagen synthesis was decreased in 17 studies. An increased inflammatory cell infiltrate was shown in 4 studies. Increased cellular toxicity was demonstrated by 3 studies. The mechanical properties of tendon were investigated by 18 studies. Descriptively, 6 of these studies showed a decrease in mechanical properties, 3 showed an increase, while the remaining 9 showed no significant change. A meta-analysis of the mechanical data revealed a significant deterioration in mechanical properties, with an overall effect size of -0.67 (95% CI = 0.01 to -1.33) (data from 9 studies)., Conclusions: Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections., (© 2013 Elsevier Inc. All rights reserved.)