Lateral Epicondyle Injection
- Author: Ritu Khurana, MD; Chief Editor: Erik D Schraga, MD more...
Though commonly known as tennis elbow, lateral epicondylitis may be caused by various sports and occupational activities.
The diagnosis of lateral epicondylitis is based upon a history of pain over the lateral epicondyle and the following findings on physical examination:
Local tenderness directly over the lateral epicondyle 
Pain aggravated by resisted wrist extension and radial deviation
Decreased grip strength or pain aggravated by strong gripping
Normal elbow range of motion
Strain or tear of various portions of the extensor digitorum and extensor carpi radialis brevis muscles due to repetitive use results in chronic inflammation.
The histopathology of the affected musculature reveals edema and fibroblast proliferation in the subtendinous space, tendinopathy with hypervascularity (particularly involving the extensor carpi radialis brevis tendon), and spur formation with a sharp longitudinal ridge on the lateral epicondyle.
Corticosteroids and other drugs often are injected in and around soft-tissue periarticular lesions to treat regional pain syndromes. In a randomized controlled trial, Dojode concluded that autologous blood injection is efficient compared with corticosteroid injection and offers fewer side effects and a minimum recurrence rate. Several studies have suggested that injection of platelet-rich plasma is effective in cases of recalcitrant lateral epicondylitis.[8, 9]
The principles and practice of inserting a needle into a joint cavity are very similar to the principles and practice of inserting a needle into a periarticular lesion.
Indications for lateral epicondyle injection include the following:
Failure of conservative treatment
To shorten symptomatic period (long-term outcome is similar in patients who do or do not receive injection) [10, 11]
To speed up recovery in high-performance athletes, although this is a controversial practice
Joint or soft-tissue aspirations and injections have few absolute contraindications. The procedure should probably be avoided if the overlying skin or subcutaneous tissue is infected or if bacteremia is suspected. The presence of a significant bleeding disorder or diathesis or severe thrombocytopenia may also preclude joint aspiration. Aspiration of a joint with a prosthesis in it carries a particularly high risk of infection and is often best left to a surgeon using full aseptic techniques. Lack of response to previous injections may be a relative contraindication.
If infection is suspected as the underlying cause of the musculoskeletal problem, injection of corticosteroids must be avoided for fear of exacerbating the infection. Corticosteroids are contraindicated in patients with septic arthritis.
Warfarin anticoagulation with international normalized ratio (INR) values in the therapeutic range is not a contraindication to joint or soft-tissue aspiration or injection.
Aspiration or injection of soft tissues may be performed as an outpatient procedure and does not require specialized equipment.
Needle, 25 or 27 gauge
Readily available syringes for injection (3-5 mL)
Methylprednisolone acetate 20-40 mg
Lidocaine 1% (0.5-1 mL) without epinephrine
With regard to anesthesia, experienced clinicians often prefer to use topical ethyl chloride or no anesthetic at all. This is often appropriate for joint aspiration, as the capsule is difficult to anesthetize, and a single quick needle thrust may be much less painful than the administration of local anesthesia.
Place the patient in a comfortable, supine position. This aids relaxation and guards against possible fainting. Have the patient flex the affected elbow to 90° with the hand tucked under the buttock. Mark the lateral epicondyle and radial head.[1, 2]
Corticosteroid injections and infiltrations are basic treatment tools in rheumatology, orthopedics, physiatry, and general medicine. They carry minimal risk to the patient when properly indicated and performed. Technical difficulties vary; some of these procedures require specialized knowledge for optimal results. It is particularly important not to inject too superficially.
Lack of improvement with lidocaine infiltration suggests an alternative diagnosis, such as compressive neuropathy of the deep branch of the radial nerve or cervical radiculopathy.
Reinjection may be necessary in 4-6 weeks if symptoms have not been reduced by at least 50%. Surgical consultation can be considered if 2 injections combined with wrist immobilization fail to resolve the condition. For chronic cases, no more than 4 injections should be performed in the same arm.
Lateral condyle injection
Follow sterile precautions throughout the procedure. Clean the skin carefully with antiseptic agents. Ethyl chloride may be applied to the skin for anesthesia.
Insert a 5/8-in. 25-gauge needle directly over the center of the epicondyle, either perpendicular to the skin (if the patient has sufficient subcutaneous fat) or at a 45º angle, to a depth of 1/4 to 5/8 in. (see the image below).
Inject the corticosteroid and local anesthetic into the common extensor tendon origin at the lateral humeral epicondyle. Infiltrate the corticosteroid deeply at the tenoperiosteal junction.
A painful reaction to injection or firm resistance during injection suggests that the needle is too deep and is within the body of the tendon; if either is noted, withdraw the needle 1/8 in. The needle should move freely with skin traction if the tip is above the tendon; conversely, the needle sticks in place if the tip is within the body of the tendon.
Inject the corticosteroid at the tissue plane between the subcutaneous fat and the tendon. At the end of injection, withdraw the needle swiftly, and apply light pressure to the needle site. (See the video below.)
Surprisingly few complications arise as results of these procedures.[1, 2] The most significant issue is the risk of infection. Care must always be taken to use sterile techniques. Corticosteroids are contraindicated in patients with septic arthritis. The estimated risk of septic arthritis following a corticosteroid injection is on the order of 1 per 15,000 procedures. Patients with severe immunodeficiency or implants may be at greater risk for complications.
Other complications can arise from misplaced injections. The best-described complication is tendon rupture following corticosteroid injections for tendonitis. The risk of this complication can be minimized by avoiding injection into the tendon itself. No therapeutic agent should be injected against any unexpected resistance.
Occasionally, nerve damage can also result from a misplaced injection (eg, median nerve atrophy following attempted injections for carpal tunnel syndrome). Lee et al reported a case of lateral antebrachial cutaneous neuropathy occurring after steroid injection at the lateral epicondyle, though it is possible that the injury was attributable to a variant location of the lateral antebrachial cutaneous nerve rather than to a misplaced injection.
A transient increase in pain is seen in 20-40% of patients. Repeated corticosteroid infiltrations may result in chronic pain.
Superficial corticosteroid infiltrations often cause a hypopigmented patch, which may be quite disfiguring in people with dark skin. The condition resolves in a few months to 2 years. Skin atrophy is a frequent complication of superficial infiltrations.
Rarely, corticosteroid injections can cause transient pituitary inhibition that lasts up to several days. Serial infiltrations may cause adrenal suppression and result in acute adrenal crisis.
Patients who have been injected serially are at greater risk for localized osteoporosis.
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Canoso, JJ. Evaluation, signs and symptoms. Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH. Rheumatology. 3rd ed. St. Louis, Mo: Mosby; 2003. Vol 1: Chap 23.
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Weerakul S, Galassi M. Randomized controlled trial local injection for treatment of lateral epicondylitis, 5 and 10 mg triamcinolone compared. J Med Assoc Thai. 2012 Oct. 95 Suppl 10:S184-8. [Medline].
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Dojode CM. A randomised control trial to evaluate the efficacy of autologous blood injection versus local corticosteroid injection for treatment of lateral epicondylitis. Bone Joint Res. 2012 Aug. 1(8):192-7. [Medline]. [Full Text].
Gautam VK, Verma S, Batra S, Bhatnagar N, Arora S. Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation. J Orthop Surg (Hong Kong). 2015 Apr. 23 (1):1-5. [Medline].
Ford RD, Schmitt WP, Lineberry K, Luce P. A retrospective comparison of the management of recalcitrant lateral elbow tendinosis: platelet-rich plasma injections versus surgery. Hand (N Y). 2015 Jun. 10 (2):285-91. [Medline].
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Lee JH, Lee SH. Lateral antebrachial cutaneous neuropathy after steroid injection at lateral epicondyle. J Back Musculoskelet Rehabil. 2015. 28 (2):419-22. [Medline].