What is the efficacy of using triamcinolone (corticosteroid) and lidocaine (local anesthetic) 1% for injection in a patient with chronic tennis elbow who has not responded to conservative treatments?

Evidence for Triamcinolone and Lidocaine 1% Injection in Tennis Elbow

For chronic tennis elbow unresponsive to conservative treatment, a single injection of triamcinolone (10-20 mg) mixed with 1% lidocaine provides superior short-term pain relief (up to 8 weeks) compared to lidocaine alone or oral NSAIDs, though long-term outcomes at 6 months show no significant advantage over conservative management alone. 1, 2, 3

Evidence Supporting the Combination

Short-Term Efficacy (0-8 Weeks)

• Triamcinolone 10 mg combined with lidocaine produces significantly better pain relief than lidocaine alone during the first 8 weeks of treatment. 1

• In a randomized controlled trial, 73% of patients receiving triamcinolone 20 mg with lidocaine were pain-free at 6 weeks, compared to only 23% receiving oral and topical NSAIDs alone (p < 0.0001). 2

• The combination of triamcinolone with oral and topical NSAIDs resulted in 90% of patients being pain-free at 12 weeks versus 23% with NSAIDs alone (p < 0.0001). 2

• Triamcinolone 10 mg provides more rapid symptom relief and requires fewer repeat injections compared to hydrocortisone 25 mg or lidocaine alone. 1

Dosing Equivalence

• No significant difference exists between triamcinolone 10 mg and 20 mg in terms of pain improvement or time course of response. 1

• The optimal dose appears to be triamcinolone 10 mg mixed with 1-2 mL of 1% lidocaine. 1, 3

Long-Term Outcomes (Beyond 3 Months)

• At 24 weeks, all treatment groups (triamcinolone, hydrocortisone, and lidocaine alone) showed similar degrees of improvement, with many patients still experiencing pain. 1

• A 2013 randomized trial found no significant differences in pain reduction at 3 months between glucocorticoid injection, platelet-rich plasma, or saline groups, with a 58% dropout rate indicating inadequate pain control across all interventions. 4

• Corticosteroid injections do not alter long-term outcomes and should be used with caution, as they may inhibit healing and reduce tendon tensile strength. 5, 6

Surprising Finding: Lidocaine Alone May Be Comparable

• A 2018 double-blind randomized controlled trial found no significant differences between triamcinolone 10 mg and 1% lidocaine alone at 2 weeks and 2 months for pain, function, and grip strength. 3

• Both groups showed significant within-group improvement, suggesting lidocaine injection itself may provide therapeutic benefit beyond local anesthesia. 3

FDA-Approved Injection Technique

• For epicondylitis, the preparation should be infiltrated into the area of greatest tenderness. 7

• Prior use of a local anesthetic (such as lidocaine) is often desirable with intra-articular or soft tissue corticosteroid administration. 7

• The typical dose for local injection is 5-15 mg of triamcinolone for larger areas, with doses up to 40 mg used for larger joints. 7

• Strict aseptic technique is mandatory, and the injection should be made without delay after drawing up the suspension to prevent settling in the syringe. 7

Significant Adverse Effects

• Post-injection pain worsening occurs in approximately 50% of steroid-treated patients and can be severe and persistent. 1

• Post-injection pain is less frequent with lidocaine alone compared to corticosteroid combinations. 1

• Skin atrophy is more frequent with triamcinolone than with hydrocortisone or lidocaine alone. 1

• In one study, 13 patients developed injection site hypopigmentation and 3 developed subdermal atrophy after triamcinolone injection. 8

• Corticosteroids may predispose to spontaneous tendon rupture by reducing tensile strength of the tissue. 5, 6

Clinical Algorithm for Tennis Elbow Management

Initial Phase (0-6 weeks)

• Begin with conservative management: relative rest, activity modification, cryotherapy (10 minutes through wet towel), oral or topical NSAIDs, and counterforce bracing. 6, 9

• Start progressive eccentric strengthening exercises at 2-4 weeks. 6, 9

Second-Line Treatment (6-12 weeks)

• If symptoms persist after 6 weeks of conservative treatment, consider a single injection of triamcinolone 10 mg mixed with 1-2 mL of 1% lidocaine infiltrated into the area of greatest tenderness. 7, 1, 2

• Alternatively, lidocaine 1% alone (1 mL) may provide comparable benefit with fewer adverse effects. 3

• Warn patients about the high likelihood (50%) of post-injection pain worsening. 1

Refractory Cases (>6-12 months)

• Surgical consultation is warranted only after 6-12 months of failed conservative management. 6, 9

Critical Caveats

• Relapse after corticosteroid injection is common, and the benefit is primarily limited to the first 8 weeks. 1

• Complete immobilization must be avoided as it leads to muscle atrophy and deconditioning. 6, 9

• The role of inflammation in tendinopathies is unclear, and corticosteroids may only inhibit healing rather than address the underlying pathology. 5

• No evidence-based guidelines support optimal drugs, dosages, techniques, intervals, or post-injection care for corticosteroid injections in tendinopathy. 5