Injections for Tennis or Golfer's Elbow and Biceps Tendonitis

Injections are a well established technique to treat these lesions but it is imperative to remind the patient that they are overuse injuries to prevent rapid recurrence. This article will examine not just the techniques but the evidence base for their efficacy. There is cause for concern.

History and examination for tennis elbow or golfer's elbow or of the shoulder should reveal the diagnosis and the tender spot should be identified.

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 lignocaine 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 1ml 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 and either further massage to move the liquid to the spot is 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 object 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 Increased resistance to the injection suggests that the needle is in the tendon and it should be withdrawn a little.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.
• Weightlifters 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 shock wave 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 it 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 well enshrined in practice but review of the evidence, such that it is, may cast doubt upon the procedure. The level of evidence is generally poor. It relates to tennis rather than golfer's elbow but as they have a common aetiology but the latter is less common, it would appear reasonable to extrapolate from one to the other.
With the present level of knowledge, enthusiam for the procedure should be tempered. Large RCTs, based in General Practice, with follow up for at least a year, may be suitable projects for local research networks. There seems to be a growing body of 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
• On the basis of primum non nocere, both medium term outcome and the risk of adverse effects from injections would make injection an undesirable intervention.

If the evidence becomes more adverse then serious consideration should be given to removal of these techniques from the list of those that attract payment as an enhanced service.