Injections for Tennis or Golfer's Elbow and Biceps Tendonitis

See related record Tennis and Golfer's Elbow.

Injections are a well-established technique for the treatment of tendonitis. However there is some controversy about the value of steroid injections and a discrepancy between clinical practice and research evidence. Some practitioners and their patients may choose to follow a 'wait and see policy' citing research which shows better long-term results by so doing. Some may prefer the better short-term benefits from steroid injection.

Whichever approach to management is adopted and whatever interpretation is put on research results, it is appropriate to assess patients thoroughly and diagnose accurately. Clinical experience suggests that a holistic approach, patient choice and a combined use of different treatment approaches may be useful. Care is required in the interpretation of research results, as there are many confounding factors and variables which may explain the discrepancies between clinical experience and research evidence.

It is important to consider the mechanism of injury and to examine thoroughly before embarking on treatment. Often these are overuse injuries and recurrence is likely. This article will consider the method but wider issues to help achieve greater success when employing the techniques may be important in overall management. It is unlikely that injection of a tendon alone will resolve the problem. Resolution is most likely when combined with other treatments, education and self-management strategies for the patient. Early treatment is recommended to prevent development of a chronic problem.

History and examination should confirm the diagnosis in each condition before injection.

Tennis elbow

• It is characterised by pain in the region of the lateral epicondyle.
• It occurs most commonly in the tendon of the extensor carpi radialis brevis muscle at approximately 2 cm below the outer edge of the lateral epicondyle of the humerus bone.
• Typical symptoms include:
  • Weakness in the wrist (difficulty opening door handles or shaking hands).
  • Pain on the outside of the elbow when the hand is extended (bent back) against resistance.
  • Pain on the outside of the elbow when trying to straighten the fingers against resistance.
• Ask about paraesthesia, numbness or weakness which may suggest neurological disease or a neural component to the pain.
• Examine briefly neck and shoulder, assessing range and extent of movements. Look for restriction of movement or muscle tension.
• The dominant arm is affected in most people.
• Pain is exacerbated by active and resisted movements of the extensor muscles of the forearm. For example, pain on resisted extension of the middle finger is typical in tennis elbow.
• Mills' test can be used. This is resisted wrist extension with the palm pronated whilst moving the hand sideways in the direction of the thumb. If this is painful the test is positive.
• A tender spot can usually be identified just below the lateral epicondyle on the outside of the elbow.

Golfer's elbow

• Symptoms are similar to tennis elbow but pain is felt at the inner aspect of the elbow.
• Assess as above with neck and shoulder examination.
• Golfer's elbow test: pronate and flex the wrist and forearm at the same time (turns from palm up to palm down and bends the wrist back towards them). A positive result is when pain is located over the attachment of the wrist flexor muscles on medial aspect of the elbow.

Biceps tendonitis

This can be more difficult to assess and should be considered in the context of a thorough shoulder examination. Assessment should locate the site of tenderness and demonstrate which movements aggravate the pain. The following pointers may help:

• The long tendon of the biceps tendon muscle on the anterior aspect of the humerus between attachments of the supraspinatus (greater tuberosity) and subscapularis (lesser tuberosity).
• Between the lesser and greater tuberosities is a ligament which retains the long biceps tendon which runs in a groove.
• The tendon may dislocate from this groove or become inflamed.
• Bending the elbow and abduction of the shoulder may cause pain up to the shoulder.
• The biceps tendon is vulnerable to inflammatory change but particularly to rupture.

All three conditions are essentially clinical diagnoses and investigation is not routinely required or helpful. However investigations may occasionally be useful, for example when pain is severe, the diagnosis is in doubt or functional limitation is marked.

• Ultrasound: soft tissue ultrasound is not easily available in primary care but can help in the diagnosis and exclude degenerative disease of the tendon prior to injection.
• Plain X-ray
• MRI

Many people use methylprednisolone or triamcinolone that are available already mixed with local anaesthetic. Although this is convenient, these strong steroids can cause fat atrophy and depigmentation in the skin over the injection site and so it is often argued that hydrocortisone with lidocaine should be used in preference and the stronger steroids saved for deeper injections. Bandolier noted that whilst skin atrophy occurred in 27% of patients injected with steroid with local anaesthetic, it occurred in 17% injected with local anaesthetic alone.¹

Tennis and golfer's elbow

About 1 ml of the steroid and local anaesthetic mixture is drawn into a small syringe and a small needle (orange hub) is applied. Confirm again the point of maximum tenderness and inject there, going right down to feel the periosteum. Spread out the injection to cover the area, although this will be quite small. Withdraw the needle and take a piece of cotton wool and rub the site quite briskly to spread the injection around.
One advantage of using local anaesthetic is that almost immediately after the injection it is possible to repeat the techniques to elicit the physical signs and they should be gone. If they are not, the injection may not be in quite the right place. In this case either massage the liquid to the spot required, or repeat the injection.

Biceps tendonitis

The technique for biceps tendonitis is slightly different. With the patient sitting or lying, the biceps tendon is identified in the groove, and the point of insertion noted. To inject into the area of the long head of the biceps tendon, the needle is inserted directly into the most tender area over the bicipital groove. The needle should enter the skin at 30° and be directed parallel to the groove. The objective is to infiltrate the area in and around the groove and not into the tendon, as this may result in rupture. Increased resistance to the injection suggests that the needle is in the tendon and it should be withdrawn a little.
As with the other injections, shortly after performing it, repeat physical examination, and pain and restriction of movement should have disappeared.

Advice after injection

The patient may be impressed by the instant cure but warn:

• The initial benefit is from the local anaesthetic and its presence assures that the injection was put in the right place. However, it will wear off over the next 2 or 3 hours.
• The benefit of the injection takes 2 or 3 days.
• Sometimes the pain becomes worse than it was before it gets better.
• Rarely, crystals of steroid precipitate and cause extreme pain. This may still precede cure.
• Do not forget what caused the lesion initially and return slowly to full activity.

In the experience of most GPs, these injuries are not caused by spending too long on the tennis courts or golf course but from heavy and prolonged manual work using spanners, wrenches, screwdrivers, hammers, repetitive lifting or doing housework, especially wringing out.

• Biceps tendonitis tends to occur in weight lifters and with repetitive overhead activity.
• Where sport is the cause, the problem is less often overtraining than poor technique. Good players are less likely to get tennis elbow than poor ones as they tend to hit the ball with the "sweet" (centre) part of the racquet. A wider racquet handle may also help.
• Golfers should ask the club professional to look at their technique.
• Weight lifters should use smaller weights with more repetitions as this is less likely to cause injury.
• Where manual labour is to blame, attention to technique is also required. A more advantageous position or a better tool may be required. Where appropriate they should discuss the problem with the foreman, manager or occupational health.

If the condition recurs, the site can be injected again but it is wise to limit the number of injections given. No more than 3 injections in a year may be suitable advice but, if there is rapid recurrence, look to the cause and to other forms of treatment.

• Physiotherapy can be useful with deep friction.²
• Acupuncture has been used but the evidence is limited³ and a Cochrane review was unable to form a firm conclusion.⁴
• Surgery may be required but there is a marked shortage of RCTs to assess its effectiveness.⁵ A Cochrane review found no adequate RCTs.⁶
• A Cochrane review of shockwave therapy for lateral elbow pain concluded most firmly that it is ineffective.⁷ NICE is also unconvinced.

• Pain after the injection has already been mentioned
• So too has fat atrophy and depigmentation of skin over the site of injection of strong steroids
• Particularly with biceps tendonitis, if injection is made into the tendon, this can be weakened and is more likely to rupture. Steroid injections should be used with great care in athletes.⁸

Tennis elbow is a common condition with an incidence of 4 to 7 cases per 1,000 per year. The peak age of occurrence is 35 to 54. Regardless of treatment, 89% of cases are better within a year and most, or all, by 2 years. Long duration of elbow complaints, concomitant neck pain, and severe pain at presentation are associated with poor outcome at 12 months.⁹ There is a tendency for injections for tennis elbow to have a good initial result followed by deterioration over the next 3 months.^{1 10}Bandolier is unconvinced that injections for biceps tendonitis work at all.¹ The RCTs that Bandolier use are based on hospital rather than GP patients and so the prognosis may be unduly pessimistic.
Rather than return to full activity immediately, an exercise programme should be planned.¹¹

The use of steroid injections for tennis and golfer's elbow is enshrined in practice but critical evidence that they are effective is limited. A systematic review in the British Journal of General Practice in 1996 concluded much that would not be disputed today.¹² The conclusion is worthy of quotation:

Conclusion

The use of corticosteroid injections for tennis and golfer's elbow is still commonly used. Some evidence casts doubt on the effectiveness and efficacy of the procedure. However the level of evidence is generally poor.
There is evidence that:

• No action will result in a satisfactory long-term outcome.
• Steroid injection is a "quick fix" with good results at 6 weeks but a high rate of relapse and poorer outcome after 6 weeks.
• Physiotherapy gives better medium-term results.

Although there is a paucity of RCTs and evidence, there is a great deal of experience and anecdotal evidence of benefit from sports medicine and rheumatology. Practitioners achieving success with treatment may not be drawn to research which is often difficult, expensive and time-consuming. This discrepancy between evidence of benefit and clinical experience demands more research to help define optimal treatment strategies for these conditions.