What are the recommended landmarks for lateral epicondylitis (Tennis Elbow) injections?

Landmarks for Lateral Epicondylitis Injection

The most accurate landmark for lateral epicondylitis injection is the point of maximum tenderness over the lateral epicondyle, specifically at the origin of the extensor carpi radialis brevis tendon.

Anatomical Landmarks

When performing a lateral epicondylitis (tennis elbow) injection, the following landmarks should be used:

1. Primary landmark: Point of maximum tenderness over the lateral epicondyle

   • This is typically located at the origin of the extensor carpi radialis brevis tendon
   • Usually 1-2 cm distal to the lateral epicondyle

2. Important anatomical considerations:

   • Medial to the lateral epicondyle are the radial nerve and radial recurrent artery 1
   • These structures must be avoided during injection

Injection Technique

The recommended technique for lateral epicondylitis injection includes:

1. Patient positioning: Seated with elbow flexed at 90 degrees and forearm pronated

2. Palpation: Identify the point of maximum tenderness over the lateral epicondyle

3. Needle insertion:

   • Insert the needle at the point of maximum tenderness
   • Use a 25-27 gauge needle
   • Direct the needle perpendicular to the skin surface

4. Peppering technique:

   • After inserting the needle, the tender area should be "peppered" with multiple small injections
   • This involves injecting, withdrawing, redirecting, and reinserting without emerging from the skin
   • 40-50 small injections in the affected area 2
   • This technique has shown excellent results in clinical studies 2

Medication Considerations

For corticosteroid injections:

• Initial dose: 5-10 mg of triamcinolone acetonide for this small joint area 3
• Mix with local anesthetic (lidocaine) prior to injection
• Care should be taken to ensure injection into the tendon sheath rather than the tendon substance 3
• For epicondylitis specifically, infiltrate the preparation into the area of greatest tenderness 3

Common Pitfalls and Cautions

1. Avoid injecting too deeply: This may lead to injection into the radiohumeral joint

2. Avoid injecting directly into the tendon: This may cause tendon rupture

   • Target the area around the tendon origin, not the tendon itself

3. Avoid the radial nerve: Located medial to the lateral epicondyle

4. Tissue atrophy risk: Care should be taken to avoid injecting into surrounding tissues, as this may lead to tissue atrophy 3

5. Limited corticosteroid use: Multiple injections should be avoided due to potential tendon weakening

Remember that lateral epicondylitis is a degenerative condition (tendinopathy) rather than an inflammatory process 4, which affects the proper approach to treatment. The peppering technique appears to be particularly effective, with studies showing excellent results regardless of whether corticosteroid or local anesthetic alone is used 2.