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Medial Epicondyle Injection

  • Author: Ritu Khurana, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Oct 05, 2015
 

Overview

Background

Medial epicondylitis of the elbow is a lesion of the common flexor tendon at the medial epicondyle (see the image below).[1, 2]  This condition, also known as golfer's elbow, occurs primarily in golfers with faulty pullthrough, tennis players who have a twist American serve, and throwers.[3]  It is approximately 15 times less common than lateral epicondylitis.[4] For information on injection for lateral epicondylitis, see Lateral Epicondyle Injection.

Medial epicondyle. Medial epicondyle.

The diagnosis of medial epicondylitis is based on a history of pain over the medial epicondyle and the following findings on physical examination[5] :

  • Local tenderness directly over the medial epicondyle
  • Pain aggravated by resisted wrist flexion and radial deviation
  • Pain aggravated by strong gripping or decreased grip strength
  • Normal elbow range of motion

The histopathology of the affected musculature reveals edema and fibroblast proliferation in the subtendinous space, tendinopathy with hypervascularity (particularly involving the flexor tendon), and spur formation with a sharp longitudinal ridge on the epicondyle.[4, 6]

Patients report local tenderness and aching pain around the medial epicondyle while performing certain movements. Pain on resisted wrist flexion with the elbow in extension is the most reliable sign. Rarely, flexion of the fingers rather than of the wrist best elicits symptoms.

Corticosteroids often are injected in and around soft-tissue periarticular lesions to treat regional pain syndromes.[7]  Epicondylitis can be treated successfully in 90% of cases by local corticosteroid injection into the tender tendon origin at the humeral epicondyle.[3]  No more than two repeat injections should be given, and the arm should not be strained for at least 3 months afterwards.

Pulsed therapeutic ultrasonography, when used optimally, can be an effective alternative to injection. It is nonpainful but is less frequently successful.[4, 8, 9]

Indications

Indications for medial epicondyle injection include the following:

  • Failure of conservative treatment
  • To shorten the symptomatic period [10] (long-term outcome in patients who receive injection is similar to that in patients who do not)
  • To speed up recovery in high-performance athletes, though this is a controversial practice

Contraindications

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.[3, 4, 11]  The presence of a significant bleeding disorder or diathesis or severe thrombocytopenia may also preclude joint aspiration.[3, 4, 11]  Lack of response to previous injections may be a relative contraindication.

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.[3, 4]  If infection is suspected as the underlying cause of the musculoskeletal problem, injection of corticosteroid must be avoided for fear of exacerbating the infection.

Warfarin anticoagulation with international normalization ratio (INR) values in the therapeutic range is not a contraindication to joint or soft-tissue aspiration or injection.

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Periprocedural Care

Equipment

Aspiration or injection of soft tissues may be performed as an outpatient procedure and does not require specialized equipment.[12]  The following items are used:

  • Needle, 25 or 27 gauge
  • Readily available syringes for injection (3-5 mL)
  • Methylprednisolone acetate 30-40 mg
  • Lidocaine 1% (0.5-1 mL) without epinephrine

Patient preparation

Anesthesia

Experienced physicians often prefer to use topical ethyl chloride or no anesthetic at all. The latter is often appropriate for joint aspiration; the capsule is difficult to anesthetize, and a single quick needle thrust may be much less painful than the administration of local anesthesia.

Positioning

Place the patient in a comfortable supine position; this facilitates relaxation and guards against possible fainting.[3]  Have the patient flex the affected elbow to 90º with 90º of shoulder rotation. Mark the medial epicondyle and the olecranon process.[3, 4]  (See the image below.)

Injection site. Injection site.
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Technique

Procedure

Corticosteroid injections and infiltrations are basic treatment tools in rheumatology. Corticosteroid injections and infiltrations carry minimal risk to the patient when properly indicated and performed. Technical difficulties vary; some injection and infiltration procedures require specialized knowledge for optimal results.

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 perpendicular to the skin, 0.5 in. distal to the center of the epicondyle (if the patient has sufficient subcutaneous fat), or at a 45º, to a depth of 3/8 to 5/8 in. (See the image and video below.)

Medial epicondyle injection. Medial epicondyle injection.
A 55-year-old woman with a long history of medial epicondylitis in whom several previous cortisone injections have failed. A multipuncture technique with attempted percutaneous tenotomy is performed to hopefully stimulate a healing inflammatory response. Video courtesy of James R Verheyden, MD.

Inject 0.5 mL of lidocaine subcutaneously and 0.5 mL at the tendon/fat. Inject at the most tender point. Avoid injecting too superficially. Infiltrate the corticosteroid deeply at the tenoperiosteal junction. Always inject the corticosteroid at the tissue plane between the subcutaneous fat and the tendon. At the end of the injection, withdraw the needle swiftly, and apply light pressure over the needle site.

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 this occurs, 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.

Lack of improvement with lidocaine infiltration suggests an alternative diagnosis, such as compressive neuropathy of the median 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 two injections combined with wrist immobilization fail to resolve the condition. For the chronic case, no more than four injections should be performed in the same arm. Débridement with restoration of the flexor-pronator origin may be efficacious for restoring function and relieving pain in recalcitrant cases of medial epicondylitis.[13]

Complications

Surprisingly few complications arise as results of these procedures.[3, 4]  The most significant issue is the risk of infection. Care must always be taken to use sterile no-touch 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 of complications.

The best-described complication is tendon rupture following corticosteroid injections for tendinitis. 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). Other complications can arise from misplaced injections.

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 may last as long as several days. Serial infiltrations may cause adrenal suppression and result in acute adrenal crisis.

Patients who have undergone serial injections are at greater risk for localized osteoporosis.

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Contributor Information and Disclosures
Author

Ritu Khurana, MD Chief of Rheumatology, Crozer Chester Medical Center, Upland, PA

Ritu Khurana, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Medscape Reference also thanks James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades, for assistance with the video contribution to this article.

References
  1. Inagaki K. Current concepts of elbow-joint disorders and their treatment. J Orthop Sci. 2013 Jan. 18(1):1-7. [Medline]. [Full Text].

  2. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun. 23 (6):348-55. [Medline].

  3. Wise C. Arthrocentesis and injection of joints and soft tissues. Harris ED, Budd RC, Genovese MC, Firestein GS, Sargent JS, Sledge CB. Kelley's Textbook of Rheumatology. 7th ed. New York: Saunders; 2004. Vol 1: Chap 47.

  4. 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.

  5. Wang Q. Baseball and softball injuries. Curr Sports Med Rep. 2006 May. 5(3):115-9. [Medline].

  6. Zeisig E, Ljung BO, Alfredson H, Danielson P. Immunohistochemical evidence of a local production of catecholamines in cells of the muscle origins at the lateral and medial humeral epicondyles: of importance for the development of tennis and golfer's elbow?. Br J Sports Med. 2009 Jan 20. [Medline].

  7. Stephens MB, Beutler AI, O'Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. 2008 Oct 15. 78(8):971-6. [Medline].

  8. Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol. 2008 Oct. 35(10):2038-46. [Medline].

  9. Lee SS, Kang S, Park NK, Lee CW, Song HS, Sohn MK, et al. Effectiveness of initial extracorporeal shock wave therapy on the newly diagnosed lateral or medial epicondylitis. Ann Rehabil Med. 2012 Oct. 36(5):681-7. [Medline]. [Full Text].

  10. Hume PA, Reid D, Edwards T. Epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management and prevention. Sports Med. 2006. 36(2):151-70. [Medline].

  11. Dooley P, Martin R. Corticosteroid injections and arthrocentesis. Can Fam Physician. 2002 Feb. 48:285-92. [Medline]. [Full Text].

  12. Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002 Dec 1. 66(11):2097-100. [Medline]. [Full Text].

  13. Vinod AV, Ross G. An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg. 2015 Aug. 24 (8):1172-7. [Medline].

 
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Medial epicondyle.
Injection site.
Medial epicondyle injection.
A 55-year-old woman with a long history of medial epicondylitis in whom several previous cortisone injections have failed. A multipuncture technique with attempted percutaneous tenotomy is performed to hopefully stimulate a healing inflammatory response. Video courtesy of James R Verheyden, MD.
 
 
 
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