Steroid injection for tennis elbow at the lateral epicondyle.

History
Causes lateral elbow pain that is activity related, and due to the mechanical overload of part of the common extensor tendon origin (the ECRB or extensor carpi radialis brevis, which is a wrist extensor muscle).
Pain may radiate to the wrist.
Most common diagnosis in a patient with elbow pain.
4:1 men, aged 30-50.

Examination
Tenderness over anterior/inferior lateral epicondyle.
Provocative test= pain on resisted wrist extension (with elbow extended). Almost always present in this condition. If not, then think of another diagnosis.

Differential Diagnosis

• Radial Tunnel syndrome. Pain slightly more distally away from lateral epicondyle.
• Biceps tendinitis. Pain on elbow flexion and supination.
• Elbow arthritis. Often crepitus noted in elbow on movement.
• Rule out more proximal pathology from neck and shoulder.

Investigations
Usually a clinical diagnosis.
MRI scan if symptoms and signs are not fully clear to make a diagnosis.
X-Ray of elbow to rule out arthritis.

Treatment
50-70 % get better over a period of 6-18 months with conservative treatment, which includes;-

• Activity modification. Stop doing activities which cause it.
• Medication. NSAID’s
• Steroid Injection. See below for further information.
• Splints. Wrist extension splint – protects the ECRB – Counterforce brace (tennis elbow clasp) – spreads load at the elbow.
• Physio. Can be very helpful. Includes ultrasound, strengthening programmes, acupuncture.
• Surgery. Only consider after at least 9/12 of the above. – Success rate of around 80%. – Can take up-to 6-9/12 to gain full affect. Warn patient.
• Stem Cell Injection. A newish technique, which has good preliminary results with low complication rate and quicker rehab than open surgery. 60-70% successful.
• Shockwave therapy. A technique where sound waves are passed through the area, leading to an inflammatory response, and resolution of symptoms over a 2-4 month period. 60 -70% successful.

When to Refer

• If diagnosis is not fully clear.
• If conservative treatments have failed after a period of 6-9/12.

Injections
Please refer to section on steroid injections.

What’s the Evidence?
BMJ 1999 319. 964
164 pts into 3 groups (steroid injection, NSAID, Placebo)
Steroid better at 1 month.
NSAID, Placebo slightly better at 6 months
No difference at 1 year

Cochrane Review of 13 studies
As above, good for short term improvement, no difference in longterm.

It’s my opinion that a maximum of 2 injections in a treatment cycle (i.e 1 year) is indicated. Too many lead to skin and fat atrophy which makes surgery more risky.

How to Inject

• Blue Needle
• 2mls Lignocaine, 20mgs Kenalog
• Aim for anterior facet of lateral epicondyle
• Pepper pot technique (i.e multiple movement around the epicondyle during injection). This spreads the injection, but also causes bleeding which is good (as leads to scar tissue)
• Rest for a week post injection.