Ultrasound-Guided Cortisone Injections and Hyaluronic Acid for Tennis Elbow

 

Introduction

Tennis elbow, also known as lateral epicondylitis, is a common condition affecting the tendons on the outer part of the elbow. It typically develops due to repetitive strain or overuse, leading to pain and inflammation in the affected area. Despite its name, tennis elbow is not limited to athletes; it can affect individuals who engage in repetitive wrist and arm movements, such as painters, carpenters, and office workers.

Various treatment options are available for managing tennis elbow, including physiotherapy, pain relief medications, and injections. Ultrasound-guided cortisone and hyaluronic acid injections have been used to manage symptoms by targeting inflammation and promoting lubrication within the joint and tendons.

This blog provides a comprehensive overview of tennis elbow, including its anatomy, pathology, symptoms, diagnosis, and treatment options, with a specific focus on the role of cortisone and hyaluronic acid injections in managing the condition.

Anatomy of the Elbow and Extensor Tendons

The elbow joint is a complex structure formed by the humerus (upper arm bone), radius, and ulna (forearm bones). The lateral epicondyle, a bony prominence on the outer side of the humerus, serves as the attachment point for the extensor tendons that control wrist and finger movements.

The key structures involved in tennis elbow include:

  • Extensor Carpi Radialis Brevis (ECRB) tendon – The most commonly affected tendon in lateral epicondylitis.
  • Common extensor tendon – A group of tendons that originate from the lateral epicondyle and help extend the wrist and fingers.
  • Radial nerve – A nerve that runs near the lateral epicondyle and may contribute to pain if irritated.

When these tendons undergo excessive strain, they develop microscopic tears, inflammation, and degeneration, leading to the characteristic symptoms of tennis elbow.



Pathology of Tennis Elbow

Tennis elbow is primarily a tendinopathy rather than a traditional inflammatory condition. The pathological process involves:

1. Tendinosis (Degeneration of Tendons)

  • Repetitive stress on the ECRB tendon leads to microtears, disrupting the normal structure of collagen fibres.
  • Over time, this results in tendon degeneration rather than an acute inflammatory response.

2. Angiofibroblastic Hyperplasia

  • Instead of normal healing, the affected tendons show abnormal blood vessel growth and fibroblast proliferation, which contribute to persistent pain and poor tendon quality.

3. Mechanical Overload and Biomechanical Factors

  • Improper technique, repetitive wrist extension, and weak forearm muscles contribute to excessive strain on the tendons.

Due to these underlying changes, tennis elbow can be a chronic and persistent condition if not managed appropriately.

Symptoms of Tennis Elbow

Individuals with tennis elbow often experience:

  • Pain on the outer elbow, particularly near the lateral epicondyle.
  • Weak grip strength, making activities like shaking hands or lifting objects difficult.
  • Pain during wrist extension movements, such as typing, writing, or using tools.
  • Tenderness over the lateral epicondyle, which may worsen with activity.
  • Occasional radiation of pain down the forearm towards the wrist.

Symptoms may develop gradually over weeks to months and can persist if left untreated.

Diagnosis of Tennis Elbow

A diagnosis of tennis elbow is based on a combination of clinical examination and imaging.

1. Clinical Examination

  • Cozen’s Test – Resisted wrist extension causes pain at the lateral epicondyle.
  • Mill’s Test – Passive wrist flexion with elbow extension provokes symptoms.
  • Maudsley’s Test – Resisted middle finger extension reproduces pain.

2. Ultrasound Imaging

  • Identifies tendon thickening, hypoechoic areas (degenerative changes), and neovascularisation (abnormal blood vessel growth).
  • Assesses the severity of the tendon injury and guides targeted injections.

Management of Tennis Elbow

Treatment strategies focus on pain relief, tendon healing, and restoring function.

1. Conservative Management

  • Rest and Activity Modification – Avoiding repetitive wrist movements that exacerbate symptoms.
  • Physiotherapy – Eccentric strengthening exercises for the forearm muscles.
  • Bracing – Use of counterforce straps to reduce strain on the tendons.
  • Pain Relief Medications – Non-steroidal anti-inflammatory drugs (NSAIDs) for short-term relief.

2. Ultrasound-Guided Injections

For individuals with persistent symptoms, ultrasound-guided cortisone or hyaluronic acid injections may be considered.

Ultrasound-Guided Cortisone Injections for Tennis Elbow

Cortisone injections contain corticosteroids, which act as anti-inflammatory agents. When injected under ultrasound guidance, they ensure precise delivery to the affected tendon, reducing local inflammation and pain.

Mechanism of Action of Cortisone Injections

  • Inhibits inflammatory mediators such as prostaglandins and cytokines.
  • Reduces swelling and pain, providing temporary symptom relief.
  • Suppresses immune response, limiting further tendon irritation.

Benefits of Cortisone Injections

  • Provides short-term pain relief, allowing individuals to participate in rehabilitation exercises.
  • Reduces inflammation in acute cases of tennis elbow.
  • Improves function and mobility by decreasing discomfort.

Ultrasound-Guided Hyaluronic Acid Injections for Tennis Elbow

Hyaluronic acid (HA) is a naturally occurring substance found in synovial fluid, responsible for lubrication and shock absorption in joints and tendons. HA injections for tennis elbow aim to improve tendon gliding and reduce friction in the affected area.

Mechanism of Action of Hyaluronic Acid Injections

  • Enhances tendon lubrication, reducing mechanical stress.
  • Improves viscoelastic properties of the tendon.
  • Supports tissue healing and regeneration by promoting cell proliferation and reducing oxidative stress.

Benefits of Hyaluronic Acid Injections

  • Helps reduce pain and stiffness.
  • Enhances tendon healing by improving hydration and elasticity.
  • Provides a longer duration of symptom relief compared to cortisone in some cases.

Conclusion

Tennis elbow is a common condition that can significantly impact daily activities and work-related tasks. Ultrasound-guided cortisone and hyaluronic acid injections offer targeted pain relief and functional improvement by reducing inflammation and enhancing tendon healing.

At Alton Pain Clinic, expert ultrasound-guided techniques are used to ensure precise and effective injection therapy for individuals with persistent tennis elbow symptoms.

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