This condition mirrors the lesion of tennis elbow, occurring in the origin of the forearm flexor muscles at the medial epicondyle of the humerus. Also known as medial epicondylitis, it may be due to a golf player's faulty backswing or other repetitive movements affecting the flexor muscle group.
Presentation and diagnosis
The patient complains of acute tenderness on a spot over the medial epicondyle, which is easily reproduced by asking the patient to flex the hand at the wrist against resistance.
The common tendon insertion of the muscles of the flexor group at the medial epicondyle is affected. They are the flexor carpi radialis, digitorum superficialis, flexor carpi ulnaris and palmaris longus. As in tennis elbow, the lesion is localised to the tenoperiosteal junction. It is important to remember that the ulnar nerve is in close proximity in the canal posterior to the medial epicondyle and may be punctured easily by the injecting needle. Prior to the injection, when the needle is in situ the doctor should confirm that no paraesthesiae are felt in the ulnar distribution – in other words, in the little finger and the ulnar side of the ring finger.
The patient sits with his back to the operator or lies on a couch with the forearm of the affected side behind the back and the dorsum of the hand resting on the buttock. The tender spot in the medial epicondyle is identified by asking the patient to flex the hand against resistance. Mark the spot with a thumbnail indentation as the site of needle entry.
Use 1ml steroid in a 2ml syringe with a 1.6cm needle and proceed to infiltrate all the tender spots of the lesion precisely as described above for treating tennis elbow.
This is essential, as for tennis elbow. Advise the patient to avoid the painful movements for a few days after the injection. Remember that there may be ‘after pain' for up to 48 hours, after which the condition is expected to improve. Simple analgesic tablets may be all that is required for a day or so. Repeat injections may be given at three- or four-weekly intervals, up to a total of three injections in 12 months if necessary.
Remember that both tennis and golfer's elbow are superficial lesions and the injection must be made deep into the fibrous substance of the tenoperiosteal junction. This effectively means that the needle point may well touch the periosteum. If this is not ensured, it is all too easy to inject steroid into the subcutaneous fat, in which case dimpling of the skin due to fat dissolution may occur. It is always wise when injecting these lesions to warn the patient beforehand of this possibility in order to minimise any future complaint of negligence. The more potent intra-articular steroids have the reputation of causing lipodystrophy, but any steroid preparation injected into the subcutaneous fat layer may produce it.
This extract is taken from Joint and Soft Tissue Injection 5th Edition, by Dr Trevor Silver which is now available to purchase from Radcliffe Publishing with an exclusive 20% discount available until 30th September – simply quote PULSETS12.
- Confidently diagnose conditions of the joints and soft tissue.
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