Ultrasound guided common extender tendon injections.

Performing an Ultrasound Guided Lateral Epicondyle Injection

Introduction

Lateral epicondylosis is seen in 1 to 3% of the population(1). Patients are typically between the ages of 40 to 60 years old (3). Patients will typically complain of lateral sided elbow pain at the level of the lateral epicondyle. Pain can worsen with lifting heavy objects and will also be exacerbate with forearm twisting. The exact mechanism for developing lateral epicondylosis is unknown. However, microtears in the tendon are thought to play a role (3). Histologic evaluation shows collagen tissue disorganization and angiofibroblastic proliferation (3).

Historically, corticosteroid injections have been performed to help relieve symptoms of lateral epicondylosis. However, there are side effects of corticosteroid injections in this area, which include subcutaneous fat atrophy, skin hypopigmentation, and tendon atrophy and possible rupture (1). Platelet rich plasma is also an option for patients with lateral epicondylosis. Studies have shown improvements in pain after PRP injections for lateral epicondylosis (2).

Procedure

Typical placement of the patient is in a seated or supine position with the elbow in 90 degrees of flexion and a pronated forearm. Typically, a 25g needle can be used for corticosteroids and a 22g needle will be used for injectate of PRP (5). The needle will typically be a 1.5 to 2 inch needle (5). A linear array transducer will typically be used and placed over the lateral epicondyle. The ultrasound view showed includes the lateral epicondyle and the radial head, which should show a long axis view of the common extensor tendon (6). Typical pathology of this area should show tendon thickening, partial thickness tearing, and hyperemia (6).

lateral epicondyle ultrasound

Initial imaging of lateral epicondyle (7)

Prior to needle insertion, the ultrasound probe should be moved proximally until the common extensor tendon is at the bottom of the image to limit the distance the needle has to travel (7).

lateral epicondyle zoomed image

Imaging prior to injection of common extensor origin (7)

The needle will be in plane with the ultrasound transducer and the needle can be directed into the peritendinous region or intratendinous.  If the injection is with corticosteroids, the needle should not fenestrate the tendon and the steroid should only be injected in the peritendinous region (5). For the purposes of this review, we will also discuss the intra-tendinous injection of orthobiologics.

epicondyle injection position

Positioning of lateral epicondyle injection (5)

A study looked at injectate distribution with either 1cc of 3cc of fluid (4). What they found was that either a single location or fenestrated injection with either 1cc of 3cc of fluid will distribute amongst 97% of the common extensor origin (4).

ultrasound guided needle

Ultrasound guided injection of common extensor origin (4)

Conclusion

Lateral epiconylosis is commonly seen and can cause significant lateral sided elbow pain. Treatment can range from physical therapy to injections. Corticosteroids, while historically were done commonly, have been found to cause significant side effects. As a result, PRP is done more commonly at this time with studies showing improvement in pain.

By: Gregory Rubin, DO
Rubinsportsmed.com

– More elbow pain: https://www.sportsmedreview.com/by-joint/elbow/

– More @ Wiki sports medicine: https://wikism.org/Common_Extensor_Tendon_Injection

References

  1. Gautam, V. K., et al. “Platelet-Rich Plasma versus Corticosteroid Injection for Recalcitrant Lateral Epicondylitis: Clinical and Ultrasonographic Evaluation.” Journal of Orthopaedic Surgery (Hong Kong), vol. 23, no. 1, Apr. 2015, pp. 1–5. PubMed, https://doi.org/10.1177/230949901502300101
  2. Silva, Flávio Duarte, et al. “Tendon Injections – Upper Extremity.” Skeletal Radiology, vol. 52, no. 5, May 2023, pp. 979–90. PubMed, https://doi.org/10.1007/s00256-022-04174-7
  3.  Ha, Cheungsoo, et al. “Effect of Repetitive Corticosteroid Injection on Tennis Elbow Surgery.” The American Journal of Sports Medicine, vol. 51, no. 7, June 2023, pp. 1886–94. PubMed, https://doi.org/10.1177/03635465231166397
  4. vans, Jonathan P., et al. “The Spread of Injectate after Ultrasound-Guided Lateral Elbow Injection – a Cadaveric Study.” Journal of Experimental Orthopaedics, vol. 5, no. 1, July 2018, p. 27. PubMed, https://doi.org/10.1186/s40634-018-0142-8
  5. Sussman, Walter I., et al. “Ultrasound-Guided Elbow Procedures.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 573–87. PubMed, https://doi.org/10.1016/j.pmr.2016.04.002\
  6. Peck, Evan, et al. “Advanced Ultrasound-Guided Interventions for Tendinopathy.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 733–48. PubMed, https://doi.org/10.1016/j.pmr.2016.04.008
  7. Waldman, Steven. “Injection Technique for Tennis Elbow.” Atlas of Pain Management Injection Techniques, 5th ed., Elsevier.