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. Various ultrasound-based techniques for guiding the injection have been described. [17]
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. [18] A double-blind randomized controlled study published in 2017 did not find significant differences between corticosteroid and botulinum toxin injections. [19] A 2020 systematic review by Song et al suggested that the location of the botulinum toxin injection may influence efficacy. [20]
Hyaluronic acid, platelet-rich plasma (PRP), autologous blood, and hypertonic dextrose have also been used. [10, 13, 21, 22, 23] Biologic enhancement products (eg, bone marrow aspirate concentrate and autologous tenocyte injectates) are being studied.
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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.
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.
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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. [24] 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. [25]
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.
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Author
Ritu Khurana, MD, MLS, FACR Faculty, Department of Rheumatology, Geisinger Healthcare System
Ritu Khurana, MD, MLS, FACR is a member of the following medical societies: American College of Physicians, American College of Rheumatology, International Society for Clinical Densitometry
Disclosure: Nothing to disclose.
Chief Editor
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
Medscape Reference also thanks James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades, for assistance with the video contribution to this article.