Ultrasound-Guided Tennis Elbow Injections

What is tennis elbow?

Tennis elbow refers to inflammation of the tendons attaching to the outer aspect of the elbow. It has other names, including “lateral epicondylitis”, referring to inflammation of the lateral epicondyle (the bony attachment of the tendon at the outer aspect of the elbow), and “common extensor tendinitis” refers to inflammation of the tendon attachment. It is not necessarily seen in Tennis players and can be seen in other sports like weightlifting and manual workers.

Relevant anatomy

Tennis elbow affects the common extensor tendon attaching to the outer aspect of the elbow. This tendon is formed by the muscles running at the outside of the forearm and attaches to a certain part of the arm bone (humerus) called the lateral epicondyle.

When there is an increased load on the tendon, it will be acutely inflamed, a process referred to as tendonitis. If this continues, repeated episodes can lead to chronic thickening of the tendon, referred to as common extensor tendinopathy, referred to as tennis elbow.

What are the causes of tennis elbow?

The most common cause of tennis elbow is repetitive arm movements that can put extra stress upon the extensor muscles' attachment to the elbow.
It is commonly seen in racket sports, weightlifting and manual workers.
This condition can occur in individuals of any gender and age range.

What are the symptoms of tennis elbow?

The symptoms of tennis elbow include:
The main symptom of tennis elbow is pain and tenderness at the outer aspect of the elbow where the muscles attach to the bone.
The pain is usually worsened by movements that stress the elbow, like lifting heavy objects or rotational movements of the elbow and the wrist. The pain can also be exaggerated if you directly hit the area.

How to tell if I have tennis elbow?

The condition typically begins with pain on the outer side of the elbow and is not usually linked to any previous injuries. Initially, the pain may be mild and easy to ignore. However, with frequent and repetitive motions of the elbow and wrist, the discomfort usually worsens. While "tennis elbow" may suggest it only affects tennis players, this condition can develop in anyone who consistently places excessive strain on their elbow and wrist, such as lifting heavy objects or repetitive rotational and forceful arm movements. The pain can affect grip strength and other daily activities.

What conditions can mimic tennis elbow?

Conditions that can be mistaken for tennis elbow include:

Golfer’s elbow. Tennis elbow results in pain at the outer aspect of the elbow, while golfers elbow results in pain at the inner aspect of the elbow.
Posterior Interosseus Nerve (PIN) entrapment. This rare condition happens when there is pressure on a small nerve within the forearm called the posterior interosseus nerve. Ultrasound examination is very useful as it will show a normal appearance of the tendon. Sometimes, we perform an ultrasound-guided steroid and numbing medicine injection around the nerve for diagnostic +/- therapeutic purposes.
Distal biceps tendon pain

How to diagnose tennis elbow?

An ultrasound examination is useful for the assessment when the condition is suspected clinically. The following information can be obtained from a specialist musculoskeletal ultrasound:

Confirm the diagnosis of tennis elbow.
Assess the severity of the condition. In severe cases of tennis elbow, the entire common extensor tendon will be heterogenous and lose its normal fibrillar pattern.
Assess for neovascularity. This refers to forming small new vessels within the thickened and inflamed tendon. It is one of the signs indicating the severity of the condition. Doppler ultrasound can accurately assess for neovascularity.
Assess for the presence of a tear within the tendon. In severe cases of tennis elbow, there could be a tear within the tendon. Ultrasound is very sensitive in assessing the size and type of tear to decide the appropriate treatment.
Ultrasound is also useful in follow-up to assess the status of the tendon after treatment.
Ultrasound is usually used to guide injection therapy to the common extensor origin. Using ultrasound ensures the accuracy and safety of the procedure.

What is the treatment for tennis elbow?

Tennis elbow treatment usually starts with conservative measures that include physiotherapy, activity modification and elbow support. Topical anti-inflammatory medicines can be used. Please ask a doctor or pharmacist before starting any new medicine.

Ultrasound guided tennis elbow injection

What if conservative management is not helping?

If the above treatment options are not helping, other treatment options include:

Extracorporeal Shockwave Therapy (ESWT)

ESWT is often used in the management of tendon pain. It uses strong ultrasound waves to induce micro traumas within the chronically inflamed tendon to initiate natural healing. Usually, a few sessions, a few weeks apart, are needed.

Ultrasound-Guided Injection for tennis elbow

If your pain is not responding to the measures above, then an ultrasound-guided injection might be helpful in the management. Indications for an injection include:

Pain that interferes with sleep.
Pain interfering with normal daily tasks.
Pain limiting your ability to undergo effective physiotherapy.

Ultrasound-guided tennis elbow steroid injection

Steroid or cortisone is a potent anti-inflammatory medicine that reduces the inflammation in the injected area, thus improving the symptoms of tennis elbow. It is usually injected with local anaesthetic (numbing medicine) to enhance the pain relief effect. The resultant pain relief is usually rapid, starting within a few days following the injection and lasting for months. Ultrasound guidance is very important when performing these injections. The steroid is injected into the soft tissues immediately adjacent to the inflamed tendon to help reduce inflammation and provide pain relief to help you achieve effective rehabilitation. Injecting steroids into the tendon can weaken and interfere with healing. Thus, ultrasound guidance is necessary when performing these injections. Significant evidence shows that ultrasound-guided injections result in superior pain relief compared to injections without guidance. Please see our FAQs for more information about steroid injections.

Platelet-rich plasma (PRP) injections

PRP injections are an effective treatment option for patients with chronic tendon pain, including common extensor tendinopathy (tennis elbow). In PRP injections, blood is taken from an arm vein and spun in a special centrifuge to separate its components. The plasma rich with growth factors is then taken and injected into the inflamed tendon accurately under ultrasound guidance. This aims to promote tendon healing with good evidence supporting the use of PRP injections in chronic tendinopathies. Some studies showed that a series of 3 injections a few weeks apart achieved better results when compared to a single injection, which can be considered for maximum effect. Please see our article for more information about PRP injections.

What if the above treatment is not helping in tennis elbow?

In resistant cases of tennis elbow, it is important to rule out the presence of a tear within the tendon, as this might require surgical treatment and further referral to a specialist elbow surgeon. Also, it is important to rule out other causes of pain at the outer aspect of the elbow, for example, posterior interosseus nerve compression syndrome. Ultrasound is extremely useful for assessment in such cases.