Corticosteroid Injection Technique for Lateral Epicondylosis
For lateral epicondylosis, inject 5-15 mg triamcinolone acetonide (or 40 mg methylprednisolone acetate) directly into the area of maximum tenderness at the lateral epicondyle using strict aseptic technique, infiltrating the preparation into the region of greatest tenderness rather than into the tendon substance itself. 1
Preparation and Equipment
- Use triamcinolone acetonide 10 mg/mL concentration, which may be diluted with sterile normal saline to 5 or 3.3 mg/mL if desired 2
- Shake the vial before use to ensure uniform suspension and inspect for clumping or granular appearance (agglomeration) 1
- After withdrawal, inject without delay to prevent settling in the syringe 1
- Strict aseptic technique is mandatory 1
Dosing Specifications
- For lateral epicondyle injection: 5-15 mg triamcinolone acetonide for larger joints like the elbow 1
- Alternative dosing: 40 mg methylprednisolone acetate has been used successfully 3
- 5 mg triamcinolone is as effective as 10 mg with comparable adverse effect rates (9.8% vs 13.2%), so lower doses are preferred 4
Injection Technique
Location and Approach
- Palpate to identify the point of maximum tenderness at the lateral epicondyle 1
- Infiltrate the preparation into the area of greatest tenderness rather than injecting into the tendon substance itself 1
- The injection should target the common extensor origin at the lateral epicondyle where repetitive wrist extension activities cause pathology 2
Technical Execution
- If excessive synovial fluid is present, aspirate some (but not all) to aid pain relief and prevent undue dilution of the steroid 1
- Avoid injecting into surrounding tissues, particularly avoiding the tendon substance itself, as this may lead to tissue atrophy 1
- Use careful technique to avoid entering a blood vessel or introducing infection 1
Image Guidance Considerations
Ultrasound guidance does not improve clinical outcomes compared to blind injection and is not necessary for lateral epicondylosis 3. A prospective randomized study found no statistically significant difference in Q-DASH, VAS, or grip strength scores between USG-guided and blind injection at 6 weeks, 3 months, and 6 months follow-up 3.
Critical Warnings About Efficacy
- Corticosteroid injections provide only short-term benefit (4 weeks) but result in worse long-term outcomes compared to placebo at 26 weeks and 1 year 5
- At 1 year, corticosteroid injection resulted in lower complete recovery rates (83% vs 96% for placebo) and greater recurrence (54% vs 12%) 5
- Corticosteroid injections are more effective than NSAIDs in the acute phase but do not change long-term pain outcomes 2
Expected Adverse Effects
- Injection-site soreness occurs in approximately 13% of patients, making it the most common delayed adverse event 6
- Skin atrophy and whitening occur in approximately 7.6% of patients 7
- Patients may experience a temporary pain flare during the first 24-48 hours before improvement 6
- Vasovagal reactions occur in 2.1-2.5% of cases 6
Post-Injection Management
- A single local injection is frequently sufficient, but several injections may be needed for adequate symptom relief 1
- For repeat injections, use alternative sites for subsequent administrations 1
- At 6-month follow-up, only 47% of corticosteroid-treated patients achieve complete pain relief, compared to 90% with autologous blood injection 8