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Common Flexor Tendon Injection

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Other Names

  • Common Extensor Tendon Peritendinous Injection
  • Tennis Elbow Injection
  • Common Extensor Tendon Injection
  • Medial Epicondyle Injection

Background

Anatomy of the common flexor tendon

Key Points

  • This page refers to injections of the Common Flexor Tendon
  • The best approach is ultrasound guided, long-axis, in-plane

Anatomy

Palpation vs Ultrasound Guidance

  • To date, there are no studies comparing ultrasound-guided and palpation-guided approaches

Indications


Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Tendon tear or rupture
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Needle and probe position for long axis, in plane approach[1]
Long-axis, in plane technique showing (A) ultrasound and needle position and (B) needle in plane[2]
Probe and needle position for short axis, in plane technique[3]
Short axis, in-plane approach of CFT injection anterior to posterior. Needle trajectory depicted by arrow, CFT (common flexor tenodn) and medial epicondyle (ME).[3]
Needle and injection location marked for palpation guided approach[4]

Equipment

  • Sterile including chloraprep, chlorhexadine, iodine
  • Ultrasound with sterile probe cover
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid/ injectate

Ultrasound Findings

  • Common ultrasound findings include:
    • Cortical irregularities
    • Focal loss of visualization
    • Generalized hypoechogenicity
    • Thickening of the tendon
  • Can compare to contralateral elbow

Ultrasound Guided: Long Axis, In-Plane

  • Patient Position
    • The patient is seated or supine
    • The arm is externaly rotated, elbow in varying degrees of flexion
    • Medial compartment faces the proceduralist
  • Probe Position and Needle Orientation
    • Transducer is in long axis to the common flexor tendon
    • Needle is in-plane, distal to proximal
    • Target is CFT and medial epicondyle
  • Pearls and Pitfalls
    • Try to keep steroids superficial to the common flexor tendon

Ultrasound Guided: Short Axis, In-Plane

  • Patient Position
    • The patient is seated or supine
    • The arm is externaly rotated, elbow in varying degrees of flexion
    • Medial compartment faces the proceduralist
  • Probe Position and Needle Orientation
    • Transducer is in short axis to the common flexor tendon
    • Needle is in-plane, anterior to posterior
    • Target is superficial to the common extensor tendon at the interface of the lateral epicondyle
  • Pearls and Pitfalls
    • Trauma to normal tissue may be reduced

Palpation Guided

  • Patient Position
    • The patient is supine or seated
    • Arm is externally rotated, exposing the medial elbow
  • Landmarks
    • Palpate the lateral epicondyle and identify the center
    • The point of maximal tenderness may be useful
  • Procedure
    • Advance the needle either perpendicular to the skin or at a 45°
    • The depth is typically betwenen 0.5 and 1.5 cm
    • If resistance is met, the needle is too deep and within the body of the tendon
    • Inject slowly while withdrawing slowly until flow of the injecta

Aftercare

  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Tendon, nerve or blood vessel injury
  • Tendon rupture
    • Frequency unknown
    • Using ultrasound guidance, the tendon should never be injected

See Also


References

  1. Ergönenç, Tolga. "Ultrasound-Guided Elbow Injection Techniques." Musculoskeletal Ultrasound-Guided Regenerative Medicine. Cham: Springer International Publishing, 2022. 109-118.
  2. Sussman, Walter I., Christopher J. Williams, and Ken Mautner. "Ultrasound-guided elbow procedures." Physical Medicine and Rehabilitation Clinics 27.3 (2016): 573-587.
  3. 3.0 3.1 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  4. Image courtesy of https://emedicine.medscape.com/, "Medial Epicondyle Injection Technique"
Created by:
John Kiel on 27 April 2023 05:43:21
Authors:
Last edited:
30 August 2023 13:45:26
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