Tennis Elbow Injection

Common extensor tendinitis or Tennis Elbow injection with cortisone is commonly used as a second line of treatment or with combination with oral NSAIDs.

One study concluded that the use of cortisone shot for Tennis Elbow in combination with topical and oral NSAIDs is superior to the use of combination of topical and oral NSAIDs.

Common extensor tendinitis or Tennis Elbow is characterized by pain at lateral aspect of elbow aggravated by gripping and twisting; painful resisted wrist extension with elbow extended, passive wrist flexion with ulnar deviation.

See Also: 

• Lateral Epicondylitis (Tennis Elbow)
• Cozen’s test
• Mills test
• Maudsley Test

Equipment

These equipments are needed in Tennis Elbow Injection, in addition to sterilization of the injection area:

• Syringe: 1 ml
• Needle: Orange, 25 gauge. 0.5 inch (16 mm)
• Kenalog 40: 10 mg
• Lidocaine: 0.75 ml, 2%
• Total volume: 1 ml

Anatomy

Tennis elbow invariably occurs at the teno-osseous origin, or enthesis, of the common extensor tendon at the elbow. The tendon arises from the anterior flat facet of the lateral epicondyle, which is approximately the size of the little fingernail.

Tennis Elbow Injection Technique

• Patient sits with supported elbow at a right angle and forearm supinated
• Identify lateral point of epicondyle, and then move anteriorly onto facet
• Insert needle in line with cubital crease, perpendicular to facet, to touch bone
• Pepper solution into tendon enthesis. Expect resistance to injecting fluid.

See Also: Elbow Injection

After Care

Rest the elbow for at least 10 days. Any lifting must be done only with the palm facing upwards so that the flexors rather than the extensors are used; the causal activity must be avoided. When resisted extension is pain free, two or three sessions of deep friction massage with a strong extension manipulation (Mill’s manipulation) may be given to prevent recurrence.

Self-stretching of the extensors and a strengthening program is then gradually introduced. If the cause was a racket sport, the weight, handle size and stringing of the racket should be checked, as should the technique and advice from a professional coach may be appropriate. Continuous static positions at work should be avoided.

Notes

This is a very common injectable lesion, with a propensity for recurrence. Very often the reason for this is not that the Tennis Elbow injection has failed, but that, on relief of symptoms, the patient has returned too rapidly to their sport.

Although the teno-osseous junction is the most usual site, the lesion can occur in other parts of the extensor complex. Ignore tender trigger points in the body of the tendon, present in everyone, and place the needle exactly at the very small site of the lesion. Repetitive strain injury can include true tennis elbow but neural stretching, relaxation techniques, cervical mobilization and postural advice might be effective if the tendon is clear.

One cortisone shot for Tennis elbow usually suffices but, if symptoms recur, a second injection can be given followed by the above routine 10 days later.

Ensure needle is very tightly attached to syringe to avoid spraying solution over both patient and clinician.

Sclerosant injection can be used, or tenotomy may be performed on recurrent tendinitis. Depigmentation and/or subcutaneous atrophy can occur in thin patients, especially those with dark skins, and they should be informed of this before giving consent. Hydrocortisone should be used if the patient is concerned about these possible side effects.

Golfer Elbow Injection

Golfer’s Elbow is characterized by pain at medial aspect of elbow aggravated by gripping and lifting; painful resisted flexion of wrist, occasionally resisted pronation of forearm.

The common flexor tendon at the elbow arises from the anterior facet on the medial epicondyle. It is approximately the size of the little fingernail at its teno-osseous origin.

See Also: Medial Epicondylitis

See Also: Golfer’s Elbow Test

Golfer Elbow Injection Technique

• Patient sits with supported arm extended
• Identify facet lying anteriorly on medial epicondyle
• Insert needle perpendicular to facet and touch bone
• Pepper solution into tendon. There will be some resistance

Advise relative rest for about 10 days, and then stretching and flexor and extensor strengthening exercises can be started. Deep transverse fiction massage may also be given.

Occasionally, the lesion occurs at the musculotendinous junction, which is invariably a very tender point. Infiltration at this point might not be as effective but deep friction massage can be successful if the patient can tolerate it.

This lesion is not nearly as common as tennis elbow and is less prone to recurrence, so follow-up treatment of deep friction massage and manipulation do not seem to be necessary.

References

1. Ahmed GS, Ali M, Trago IA. Tennis elbow: role of local steroid injection. J Ayub Med Coll Abbottabad. 2012 Apr-Jun;24(2):84-6. PMID: 24397061.
2. Zahn KV, Byerly DW. Medial Epicondyle Injection. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551506/