Recommended Injection Procedure for Golfer's Elbow
For treating golfer's elbow (medial epicondylitis), a single local injection of triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide, using strict aseptic technique and targeting the area of greatest tenderness at the medial epicondyle. 1, 2
Injection Technique
- Use strict aseptic technique for all injections to prevent infection 2
- Prior to injection, shake the vial to ensure uniform suspension and inspect for any clumping or granular appearance 2
- Consider using a local anesthetic (such as 1% lidocaine) prior to or mixed with the corticosteroid injection 2
- Identify the point of maximum tenderness at the medial epicondyle 2
- Infiltrate the preparation into the area of greatest tenderness, avoiding injection directly into the tendon substance 2
- For medial epicondylitis, the recommended dose is 5-10 mg of triamcinolone for this smaller joint area 2
Medication Selection
- Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide due to more complete and longer duration of clinical response 1
- This recommendation is supported by observational studies showing improved outcomes with triamcinolone hexacetonide in joint conditions 1
- If triamcinolone hexacetonide is unavailable, triamcinolone acetonide may be used at a dose of 5-10 mg 2
Post-Injection Care
- Advise patients that some mild pain may be experienced when injecting into normal tissue 1
- Patients should be informed that they may experience post-injection worsening of pain, which can sometimes be severe but is usually temporary 3
- Recommend relative rest and activity modification following injection to reduce repetitive loading of the damaged tendon 1
- Implement eccentric strengthening exercises as part of the rehabilitation process 1
Important Caveats
- Care should be taken to avoid injecting the suspension into the tendon substance, as this may lead to tendon weakening and potential rupture 2, 4
- Ensure injection is made into the peritendinous area rather than the tendon substance itself 2
- Be aware that skin atrophy is a potential side effect, particularly with triamcinolone 3
- A single injection is often sufficient, but several injections may be needed for adequate relief of symptoms 2
- While corticosteroid injections provide effective short-term relief, they may not alter long-term outcomes 1, 4
Comprehensive Treatment Approach
- Corticosteroid injections should be considered as second-line therapy after initial conservative management has failed 1, 5
- First-line treatment includes relative rest, activity modification, eccentric strengthening exercises, and NSAIDs 1
- Physical therapy with deep transverse friction massage and progressive strengthening exercises focusing on the flexor-pronator muscle group should be incorporated into the treatment plan 1
- Counterforce bracing/orthotics may be considered as an adjunct to other treatments 1
Remember that while corticosteroid injections can provide significant short-term relief for golfer's elbow, they should be part of a comprehensive treatment approach that includes addressing the underlying biomechanical issues to prevent recurrence 1, 6.