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[CLINICAL TECHNIQUES]

Lateral Epicondylitis Injection

William O. Roberts, MD
Department Editor

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 7 - JULY 2000


Lateral epicondylitis, also known as tennis elbow, is a restricting injury for active people that sometimes requires an injection of corticosteroid and local anesthetic for pain relief. The chief symptom is that activities that supinate or dorsiflex the wrist usually cause pain at the origin of the extensor muscle group (figure 1: not shown). This muscle group acts in extension of the wrist, hand, and digits, and in supination of the wrist. Medial to the lateral epicondyle are the radial nerve and the radial recurrent artery.

The pain is usually at its worst when grasping an object with the elbow in extension. The loss of grip strength and accompanying pain is difficult to tolerate for an active patient, and equally difficult to "cure."

The discomfort can often be controlled and the tissue allowed to heal with short-term restriction of exacerbating activities, tennis elbow straps, wrist splinting, ice massage, and stretching and strengthening of the extensor muscles. Using a wrist splint can decrease the stress on the muscle origin on the lateral epicondyle, and it often provides relief.

In cases that do not respond readily to conservative care, an injection into the origin of the common extensor muscle group on the lateral epicondyle can relieve pain and may promote more rapid healing of the injury. Corticosteroid injection may be indicated earlier in the treatment regimen than has been common in office practice. A fairly recent study (1). has shown corticosteroid injection to be superior at 6 weeks to physical therapy treatments. At 1-year reevaluation, however, there was no difference in the groups' success rates, and nearly equal numbers of patients went on to surgical intervention.

Injection Procedure

The painful area can be localized with direct palpation over the lateral epicondyle. The injection area can usually be covered by a dime (figure 2: not shown). The injection is done using small aliquots of solution in a systematic "hunt-and-peck" pattern in the painful area. This is done without removing the needle from the original entry site and using the smallest volume of solution to make the area pain free.

The hunt-and-peck infiltration technique involves moving the needle tip around the injection area by bracketing the epicondyle skin with the thumb and index finger of the free hand prior to the initial skin penetration (figure 3: not shown) and partially withdrawing, redirecting the tip 1 to 2 mm, and reinserting the needle to inject another small aliquot of solution. The skin can be moved or shifted to deliver the medication to the entire origin of the muscle group.

The total 1.5 mL of injection solution combines 10 mg (20 mg/dL) of triamcinolone hexacetonide with 0.5 mL of 1% lidocaine hydrochloride and 0.5 mL of 0.5% marcaine. A 1/2-in., 30-gauge needle is small enough to enter the area without local anesthetic in the skin and rigid enough to allow a hunt-and-peck movement of the tip of the needle around the entire origin of the extensor muscle group. After the injection site is located and the sterile prep is completed, the skin is pierced quickly and the tip of the needle is inserted into the extensor origin until it touches the bone or enters a painful area.

When a painful area is located, the needle tip can be systematically marched along the lateral epicondyle in a grid pattern, infiltrating each painful spot with a minimal (0.1 to 0.2 mL) amount of injection solution. With several passes of the needle tip, the lateral epicondyle is blanketed by injecting small aliquots of anesthetic and corticosteroid solution until pain is relieved. In my experience, 20 to 30 points on the "grid," for a total of 1.0 to 1.5 mL of solution, is typical.

Injection Risks

The risks of an injection procedure must be thoroughly understood by both the physician and the patient. The major risk of injecting the origin of the extensor group on the lateral epicondyle is rupture of the tissue. This is most common in athletes who have multiple injections and do not restrict impact-loading activities for 7 to 14 days after the injection. Patients who follow recommendations to avoid impact-loading activities and use a gentle stretching and strengthening program rarely experience postinjection ruptures.

The injection could affect surrounding tissues. Proper needle placement and minimal injection volume should help avoid these potential complications. The risk of skin depigmentation is particularly high because the injection site is so close to the pigmented layer of the skin. The small-volume, multiple-point injection should decrease this risk.

Potential complications listed in various textbooks of a joint or soft-tissue injection containing local anesthetic and corticosteroid include allergic and toxic reactions; infection, sterile abscess; postinjection steroid flare; skin hypopigmentation; fat, cartilage, tendon, nerve, or bone necrosis; pericapsular calcification; uterine bleeding; and posterior subcapsular cataracts.

Billing

The injection should be billed with a 20550 (injection of a tendon) procedure code, in addition to billing for the evaluation or consultation if the injection is done as a part of the initial evaluation or consultation. The corticosteroid medication used in the injection is charged separately.

Reference

  1. Verhaar JA, Walenkamp GH, van Mameren H, et al: Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg (Br) 1996;78(1):128-132

Dr Roberts is a family physician at MinnHealth Family Physicians in White Bear Lake, Minnesota.


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