Golfer’s Elbow Injection

The primary etiology is a repetitive stress or overuse of the flexor-pronator musculature. Degenerative changes in the musculotendonous region of the medial epicondyle are the result of chronic repetitive concentric and eccentric contractile loading of the flexor-pronator group. Most often such changes are seen in the pronator teres and the flexor carpi radialis muscles, although larger diffuse tears can occur in the palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. Although repetitive overuse has been identified as the primary etiology, a single traumatic event, such as a direct blow or a sudden, extreme eccentric contraction, may result in the development of epicondylitis. Medial epicondylitis has been associated with activities involving repetitive forearm pronation and wrist flexion. Although it occurs frequently in baseball pitchers, resulting from intense valgus forces on the medial elbow during the late cocking and acceleration phases of throwing, medial epicondylitis has also been related to golf, tennis, bowling, racquetball, football , archery, weightlifting and javelin throwing. This disorder, however, is not solely athletic in origin, because it is also associated with occupations such as carpentry, plumbing, and meat cutting, all of which require repetitive forearm, wrist and hand motions.

Since Morris’ first description of epicondylitis in 1882, a vast amount of literature has been dedicated to the pathophysiology of this disorder. Early descriptions postulated an inflammatory process involving the radial humeral bursa, periosteum, synovium, and annular ligament. These theories, however, have recently been discounted by the histologic analysis of Nirschl and Pettrone, and Regan et al. In its earliest stages, epicondylitis may display inflammatory or synovitic characteristics; its later stages demonstrate evidence of microtearing, characterized by tendon degeneration, with or without calcification, and an aborted, incomplete neurovascular response.

Medial epicondylitis is characterized by pain of insidious onset along the medial elbow, which is worsened by resistance to forearm pronation and wrist flexion. Tenderness to palpation usually occurs over the pronator teres and the flexor carpi radialis, and maximally at 5 mm to 10 mm distal and anterior to the midpoint of the medial epicondyle. The severity of pain may vary, but is most often present and acute during the offending activity. Local swelling and warmth may also exist. Initially the range of motion of the afflicted extremity can be full, but over time it may become limited and lead to a flexion contracture, which is commonly noted in the throwing athlete.

The radiographs of affected elbows are generally normal, although 20% to 25% of patients can have soft-tissue calcification in proximity to the epicondyle. Throwing athletes may have medial ulnar traction spurs and medial collateral ligament calcification. Electromyography (EMG) is indicated in patients with neurologic alterations. Laboratory studies can be helpful in patients with suspected rheumatoid disorders.

Local anaesthetic and steroid injection

Patients who do not respond to simple measures may be treated with local corticosteroid injection around the affected tendon insertion. The exact mechanism of action in a tendinopathic condition such as medial epicondylitis is poorly understood, as the effects of corticosteroid are predominantly anti-inflammatory. However the short-term efficacy of such corticosteroid injections has been documented in several prospective, randomized studies.

The corticosteroid aids in relieving the accompanying synovitis. The appropriate injection technique for administering the corticosteroid requires instilling the agent into the fatty subaponeurotic recess deep to the flexor pronator mass. The short-term efficacy of such corticosteroid injections has been documented in several prospective, randomized studies.

Platelet-rich plasma therapy

Platelet-rich plasma (PRP) is a concentrate of platelets derived from the patient’s own blood and is known to contain a high content of growth factors that have the potential to enhance the healing process of the tendon. A blood sample is taken and centrifuged to extract the plasma content, and the blood is then re-injected around the medial epicondyle. A number of RCTs have shown that PRP is superior to autologous blood and bupivacaine injections. However there is a great variation in the way that different commercial systems prepare and activate the PRP, and hence it is difficult to draw clear conclusions on the efficacy of PRP.

Injections are generally avoided in patients with systemic infection or skin infection over puncture site, bleeding disorders or coagulopathy, allergy to local anaesthetics or any of the medications to be administered.

The procedure is usually done on an outpatient basis. The procedure is performed under ultrasound guidance to ensure accuracy of needle placement. Patients need to be aware that the outcome of the procedure is variable and they may not receive the desired benefits. Similarly, they must be aware of the transient nature of the therapeutic benefits and that there may need repeated injections.

Generally a mixture of local anaesthetic and steroid is injected. The local anaesthetic agent within the injectate may act on the nociceptive fibres , whereas corticosteroids may reduce inflammation. The anaesthetic is probably responsible for immediate pain relief, whereas steroids are believed to be responsible for pain relief 2–6 days after their administration.

Complications are rare, particularly if the injections are performed using a precise needle-positioning technique. Possible complications include bruising, infection, hematoma, nerve injury and reaction to the injectates. Infection can be avoided with appropriate aseptic precautions. Severe allergic reactions to local anaesthetics are uncommon. Steroid injections may produce local reactions, occurring most often immediately after injection. These local reactions last for 24 to 48 hours, and are relieved by application of ice packs. Post-procedural pain flare-up may occasionally occur, and may be treated with pain killers. Neurological complications including paraesthesias and numbness have been described but are rare. In addition corticosteroids have been associated with local skin atrophy, depigmentation and muscle wasting, resulting in an increase in the bony prominence of the medial epicondyle.