Tennis elbow is common in young to middle-aged patients because of strain of the extensor tendons of the forearm. It occurs at the tenoperiosteal insertion into the extensor epicondyle of the humerus and is also known as lateral epicondylitis. Tennis elbow is often caused by repetitive movements at work, such as using a screwdriveror polishing. A defective backhand or forehand drive at tennis, squash or badminton is also often a causative factor.
Very rarely, a bony secondary deposit may cause pain and tenderness on palpation, which is not reproduced by resisted extension of the wrist. If in doubt, X-ray the elbow joint before injecting steroids.
Presentation and diagnosis
On palpation, there is exquisite pain and localised tenderness over the lateral epicondyle of the humerus. This pain may be reproduced by asking the patient to extend the hand at the wrist (dorsiflexion) against resistance. All other movements at the elbow are normal.
The common insertion of the extensor muscles of the forearm and the hand is the lateral epicondyle of the humerus. Strain of any of these muscles at their insertion will cause a tendinitis at this site, which will produce an easily localised point of acute tenderness. Asking the patient to extend the wrist against resistance enables you to pinpoint the lesion accurately.
Use 1ml steroid in a 2ml syringe with a 1.6cm needle. It is personal choice whether to mix the steroid with local anaesthetic. Remember that local anaesthetic, such as lidocaine, will prevent the discovery of all the tender points of the lesion as it is so effective. Using steroid alone is more painful for the patient, but the overall success of the injection is higher because you will be able to detect all the tender parts of the lesion.
Success depends on identifying and infiltrating all the points of tenderness in the tenoperiosteal junction at one injection. First locate the point of maximal tenderness with the patient, extending the hand against your resistance, then make a thumbnail indentation at the needle entry point. After inserting the needle in a proximal direction, ask the patient each time whether the needle is in a tender spot, moving the needle around the lesion in a clockwise direction and in a fan shape subcutaneously after the initial skin puncture and ensuring that all tender points are injected accurately with about 0.1-0.2ml steroid each time, delivering in all up to 1ml steroid.
Using this technique, you can be more assured of complete success in treating tennis elbow and also lessening reported recurrences.
The patient may sit or lie down during this procedure and should be warned the pain of the injection may persist for up to 48 hours, but should then subside. Simple analgesia may be advised. The arm should be rested for a day or two after the injection. Patients should be advised not to carry bags with the affected arm for a week or so after the injection.
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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