Injections for Elbow Pain

Fig. 20.1

Anatomy of the lateral elbow. The blue box is the region of the common extensor tendon and area of interest for ultrasound scanning

../images/457420_1_En_20_Chapter/457420_1_En_20_Figb_HTML.jpg — Fig. 20.2

The ligaments in the lateral elbow. (Reprinted with permission from Philip Peng Educational Series)

../images/457420_1_En_20_Chapter/457420_1_En_20_Figc_HTML.png — Fig. 20.3

Anatomy of the medial elbow. The blue box is the region of the common flexor tendon and area of interest for ultrasound scanning

../images/457420_1_En_20_Chapter/457420_1_En_20_Figd_HTML.jpg — Fig. 20.4

Anatomy of the posterior elbow. The blue boxes are the area of interest for ultrasound scanning

Patient Selection

Common extensor and flexor tendinopathies are diagnosed based on pain and tenderness at the lateral and medial epicondyles and pain on resisted wrist extension or flexion. Relative rest, activity modifications, and physical therapy should be considered before an injection. Injections can be done using local anesthetic (e.g., ropivacaine) with or without steroid, platelet-rich plasma (PRP), or whole blood. The possibility of an underlying radial collateral ligament injury should be considered among patients with chronic lateral epicondylosis who have failed previous treatment, particularly corticosteroid injections. Humero-ulnar and radio-humeral (also known as radio-capitellar) joint arthritis is diagnosed on the basis of focal tenderness, painful movement, ultrasound findings of an effusion, or radiographic abnormalities.

Ultrasound Scan

Position: Seated or supine
Probe: Linear 5–12 MHz

Lateral Elbow

../images/457420_1_En_20_Chapter/457420_1_En_20_Fige_HTML.jpg — Fig. 20.5

Sonoanatomy of the lateral elbow

The key landmark is the lateral epicondyle (LE), the origin of the common extensor tendon (CET). Additional structures include the radio-capitellar joint (J) between head of the radius (R) and capitellum (C) of the humerus, and the radial collateral ligament (RCL) (Fig. 20.5).

Medial Elbow

../images/457420_1_En_20_Chapter/457420_1_En_20_Figf_HTML.jpg — Fig. 20.6

Sonoanatomy of medial elbow with the ultrasound probe in scan position 1

Medial elbow scan 1: The key landmark is the medial epicondyle (ME), from which the common flexor tendon (CFT) originates (Fig. 20.6).

../images/457420_1_En_20_Chapter/457420_1_En_20_Figg_HTML.jpg — Fig. 20.7a

Sonoanatomy of the medial elbow with the ultrasound probe in scan position 2

Medial elbow scan 2: Short-axis views of the ulnar nerve (UN) in its usual retrocondylar position (Fig. 20.7a) and subluxed over the medial epicondyle (ME) of the humerus where it could be injured during an injection (Fig. 20.7b). Additional structures include the olecranon of ulna (U) and the triceps muscle (TM).

../images/457420_1_En_20_Chapter/457420_1_En_20_Figh_HTML.jpg — Fig. 20.7b

Sonograph showed the ulnar nerve (UN) subluxed on the other side of medial epicondyle (ME)

Posterior Elbow

../images/457420_1_En_20_Chapter/457420_1_En_20_Figi_HTML.png — Fig. 20.8

Sonoanatomy of the posterior elbow with the ultrasound probe in the scan position 1

Posterior elbow scan 1. The position is shown in scan position 1. The key landmark is the olecranon (O) of the ulna and the triceps muscle (TM) and triceps tendon (TT). Humero-ulnar joint (HUJ) is seen between the humerus (H) and olecranon (O) (Fig. 20.8).