Medial Epicondyle Injection Technique

Updated: Oct 16, 2017
  • Author: Ritu Khurana, MD; Chief Editor: Erik D Schraga, MD  more...
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Technique

Injection At Medial Epicondyle

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, 1/2 in. (1.25 cm) distal to the center of the epicondyle (if the patient has sufficient subcutaneous fat), or at 45º, to a depth of 3/8-5/8 in. (1.0-1.6 cm). (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 (3 mm). 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. Patient-related risk factors for injection failure necessitating surgical treatment include age less than 65 years and obesity (body mass index [BMI] >30). [15]

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. [16]

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Complications

Surprisingly few complications arise as results of these procedures. [3]  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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