Lateral Epicondyle Injection 

Updated: Apr 08, 2021
Author: Ritu Khurana, MD; Chief Editor: Erik D Schraga, MD 

Overview

Background

Lateral epicondylitis of the elbow involves pathologic alteration in the musculotendinous origins of the extensor carpi radialis brevis (ECRB) and longus (ECRL) tendons (see the image below).[1, 2, 3, 4]  Although this condition is commonly known as tennis elbow, it may be caused by a variety of sports and occupational activities.

Lateral epicondyle. Lateral epicondyle.

The diagnosis of lateral epicondylitis is based upon a history of pain over the lateral epicondyle and the following findings on physical examination:

  • Local tenderness directly over the lateral epicondyle [5]
  • Pain aggravated by resisted wrist extension and radial deviation
  • Decreased grip strength or pain aggravated by strong gripping
  • Normal elbow range of motion

Strain or tear of various portions of the extensor digitorum and ECRB muscles due to repetitive use results in chronic inflammation.[6]

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

Corticosteroids and other drugs often are injected in and around soft-tissue periarticular lesions to treat regional pain syndromes. In a randomized controlled trial, Dojode concluded that autologous blood injection is efficient as compared with corticosteroid injection and offers fewer side effects and a minimal recurrence rate.[7]  Several studies suggested that injection of platelet-rich plasma (PRP) is effective in cases of recalcitrant lateral epicondylitis.[8, 9, 10, 11]  However, others have not found clear evidence of benefit for some of these agents.[12]

The principles and practice of inserting a needle into a joint cavity are very similar to those of inserting a needle into a periarticular lesion.

Indications

Indications for lateral epicondyle injection include the following:

  • Failure of conservative treatment
  • Shortening the symptomatic period (long-term outcome is similar whether patients receive injection or not) [13, 14]
  • Speeding 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. The presence of a significant bleeding disorder or diathesis or severe thrombocytopenia may also preclude joint aspiration. 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. Lack of response to previous injections may be a relative contraindication.

If infection is suspected as the underlying cause of the musculoskeletal problem, injection of corticosteroids must be avoided for fear of exacerbating the infection. Corticosteroids are contraindicated in patients with septic arthritis.

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

 

Periprocedural Care

Equipment

Aspiration or injection of soft tissues may be performed as an outpatient procedure and does not require specialized equipment.[15]  The following equipment and agents should be available:

  • Needle, 25 or 27 gauge
  • Readily available syringes for injection (3-5 mL)
  • Methylprednisolone acetate 20-40 mg
  • Lidocaine 1% (0.5-1 mL) without epinephrine

Patient Preparation

Anesthesia

With regard to anesthesia, experienced clinicians often prefer to use topical ethyl chloride or no anesthetic at all. This is often appropriate for joint aspiration, in that 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 aids relaxation and guards against possible fainting.[1]  Have the patient flex the affected elbow to 90° with the hand tucked under the buttock. Mark the lateral epicondyle and radial head.[1, 2]

 

Technique

Approach Considerations

Corticosteroid injections and infiltrations are basic treatment tools in rheumatology, orthopedics, physiatry, and general medicine. They carry minimal risk to the patient when properly indicated and performed. Technical difficulties vary; some of these procedures require specialized knowledge for optimal results. It is particularly important not to inject too superficially.

Lack of improvement with lidocaine infiltration suggests an alternative diagnosis, such as compressive neuropathy of the deep branch of the radial 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 chronic cases, no more than four injections should be performed in the same arm.

Injection of botulinum toxin A has also been performed to relieve lateral epicondylitis. A 2014 systematic review of randomized controlled trials did not find it to be superior to corticosteroid injection in this setting.[16]  A double-blind randomized controlled study published in 2017 did not find significant differences between corticosteroid and botulinum toxin injections.[17]  A 2020 systematic review by Song et al suggested that the location of the botulinum toxin injection may influence efficacy.[18]

Hyaluronic acid, platelet-rich plasma (PRP), autologous blood, and hypertonic dextrose have also been used.[10, 19, 20]  Biologic enhancement products (eg, bone marrow aspirate concentrate and autologous tenocyte injectates) are being studied. 

Injection Into Lateral Epicondyle

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. (~1.6 cm) 25-gauge needle directly over the center of the epicondyle, either perpendicular to the skin (if the patient has sufficient subcutaneous fat) or at a 45º angle, to a depth of 1/4 to 5/8 in. (~0.6-1.6 cm). (See the image below.)

Injection of lateral epicondyle. Injection of lateral epicondyle.

Inject the corticosteroid and local anesthetic into the common extensor tendon origin at the lateral humeral epicondyle. Infiltrate the corticosteroid deeply at the tenoperiosteal junction.

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 either is noted, 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.

Inject the corticosteroid at the tissue plane between the subcutaneous fat and the tendon. At the end of injection, withdraw the needle swiftly, and apply light pressure to the needle site. (See the video below.)

Patient with chronic lateral epicondylitis in whom several previous cortisone injections by different providers failed. Multipuncture lateral epicondyle injection is performed in effort to stimulate healing inflammatory response and completely detach partially torn extensor carpi radialis brevis tendon. Video courtesy of James R Verheyden, MD.

Complications

Surprisingly few complications arise as results of these procedures.[1, 2]  The most significant issue is the risk of infection. Care must always be taken to use sterile 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.[21]  Patients with severe immunodeficiency or implants may be at greater risk for complications.

Other complications can arise from misplaced injections. 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). Lee et al reported a case of lateral antebrachial cutaneous neuropathy occurring after steroid injection at the lateral epicondyle, though it is possible that the injury was attributable to a variant location of the lateral antebrachial cutaneous nerve rather than to a misplaced injection.[22]

A 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 lasts up to several days. Serial infiltrations may cause adrenal suppression and result in acute adrenal crisis.

Patients who have been injected serially are at greater risk for localized osteoporosis.