Randomized Prospective Evaluation of Injection Techniques for the Treatment of Lateral Epicondylitis

Abstract

Lateral epicondylitis is a commonly made diagnosis for general practitioners and orthopedic surgeons. Corticosteroid injection is a mainstay of early treatment. However, conflicting evidence exists to support the use of steroid injection, and no evidence in the literature supports an injection technique. Nineteen patients diagnosed with acute lateral epicondylitis were evaluated to compare the peppered- and single-injection techniques using the Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analog score (VAS), and grip strength. For elbows with a single injection, mean grip strength increased from 22.9 to 27.8 (P=.053), mean VAS pain score decreased from 4.8 to 3.6 (P=.604), and mean DASH score decreased from 2.6 to 1.8 points (P=.026). For elbows with peppered injections, mean grip strength increased from 28.7 to 32.8 (P=.336), mean VAS pain scores decreased from 3.7 to 2.3 (P=.386), and mean DASH score decreased from 2.6 to 1.3 (P=.008).No studies have directly compared the peppered-injection technique to the single-injection technique. Our results suggest that patient outcome is improved with the single injection. The biomechanical or chemical reason for the distinction is yet unknown, but we postulate that the peppered technique may actually further damage the already compromised tendon. The theory that the peppered injection stimulates blood flow may be overestimated or false. Histochemical studies of the pathologic tissue must be performed to further delineate the reason for improved outcomes with the single-injection technique.

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

“…18,[167][168][169][170][172][173][174][175][176][177][178][179][180][181][182][183][184][185][188][189][190][191][192][193][194][195][196][197][198] The majority of studies had small sample sizes (≤ 50 participants, n = 18; 51-100 participants, n = 15; > 100 participants, n = 3).…”

“…However, given the need to update the systematic reviews on which these findings are based, 56,60 and the subsequent publication of 10 new RCTs, 165,168,169,173,176,181,183,184,191,193 the overall level of evidence, as determined using the GRADE principles, is low (see Table 24). All of the subsequent RCTs were head-to-head comparisons, and all but one study (Gosens et al,…”

A Systematic Review to Compare Three Injection Modalities in the Management of Pain and Function for Patients with Chronic Lateral Epicondylalgia

“…Most researchers in these four trials performed a single skin entry with 5 to 7 peppering penetrations. In 2011 a study was conducted comparing the singleinjection with the peppering technique [21]. They concluded that the single-injection technique has a better outcome than the peppering technique.…”

Randomised, prospective, non-blinded pilot study comparing the effect of intramuscular steroid injections and intralesional steroid injections in the management of tennis elbow

“…The technique used was a conventional pepper pot technique in case of the intralesional procedure involving multiple insertions of the injecting needle around the teno-periosteum junction. 19 This was performed through multiple movements of the inserted needle aiming to infiltrate the epicondylar region from different angles. 20 The intramuscular injections were given into the gluteal muscle.…”