New Tennis Elbow Treatment – Inject Lubricant (Hyaluronate)

New Study form London, Ontario: Subjects with 3 month + tennis elbow. Injection of 1% Hyaluronate into “into the subcutaneous tissue and muscle 1 cm. from the lateral epicondyle toward the primary point of pain” twice a week apart led to persistent improvement.

Petrella et al.:
Management of Tennis Elbow with sodium hyaluronate periarticular injections.
Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2010 2:4. abstract

  • mentions research “lesion is found primarily in”:
    • the extensor carpi radialis brevis (ECRB) origin,
    • the extensor carpi radialislongus (ECRL) less often
    • anterior portion of the extensor digitorum communis less often

  • Hyaluronate is “major component of synovial fluid cartilage and surrounding structures of arthroidial joints.” – 1.2 ml syringe used vs a saline control
  • 27- gauge, 1-inch needle.
  • “Injections were be administered into the soft tissue 1 cm from the lateral epicondyle at the point of greatest pain in two planes using a fanning technique whereby contents were injected on withdrawl of the needle from the point of maximal tenderness in a single puncture.” – Notice below lateral epicondyle
    The fanning technique involved 3 needle placements:

    • up and down = Anterior=posterior
    • medially
    • laterally

    For the fanning technique the refer to an ankle article so the image might look more like an ankle than an elbow:

Their image of actual injection shows multiple puncture but since they say one, I presume this means these were various localtions they could have been sorest in. looks more on lateral epicondyle to me – only one hole is below radio-humeral joint line.

Injection technique followed a technique I like to use with triggers – after hit trigger inject as you withdraw through muscle and stop when beyond muscle – They state “contents were injected on withdrawl of the needle from the point of maximal tenderness in a single puncture”

Results:

Comments

– I love the fact they don’t think one shot will do it – they gave two, a week apart. It’s hard to find many studies with multiple tennis elbow injections despite fact Cyriax made it clear if it was not all gone in followup, it would just come back. One shot of cortisone will give early though not sustained relief. Some had some multiple injections:
Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial
Nynke Smidt, Daniëlle A W M van der Windt, Willem J J Assendelft, Walter L J M Devillé, Ingeborg B C Korthals-de Bos, Lex M Bouter
Lancet 2002; 359: 657–62

  • Physio was complex and included nine treatments of pulsed ultrasound, deep friction massage, and an exercise programme over 6 weeks. Pulsed ultrasound (20% duty cycle) was given with an intensity of 2 W/cm2 for 7·5 minutes per session.
  • Those who had no treatment did best so obviously these were not recalcitrant cases.
  • They used only 10 mg triamcinolone (I use 40 mg for the first one and will inject the supinator tunnel if sore as well).
  • 27% in got 2 and 15% got 3 injections. This leads me to believe that steroids may have their limitations. There are alternate explanations – one is that those on no treatment have to limit their activities and get better – the ones with cortisone shots feel better almost immediately and carry on without modifying things. I had a tennis player recently that continued to play following a shot and continued to have problems, albeit in this case I found his neck was a player as well.

Conclusions –

Hyaluronate looks very tempting and virtually free of side effects. It is expensive, not covered by drug plans, and I doubt many will be that interested. Steroids are cheap and initially effective – they need to be repeated at intervals and that does not seem to be worked out yet. Steroids could thin skin where injected so should be injected deep and patient informed of this hazard.

Any suggestions or comments? joyeria pandora joyeria pandora

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