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Sonographic-Guided Injection of Corticosteroid in theTreatment of Lateral Epicondylitis
Zeliha Unlu, MDSerdar Tarhan, MD
Gulgun Yilmaz Ovali, MDYuksel Pabuscu, MD
ABSTRACT. Objective: In this study the advantage of ultrasonography [US] in diagnosis andtherapy of lateral epicondylitis [LE] was investigated in patients with lateral elbow pain andclinically diagnosed as LE.
Methods: Fifty-two patients with LE were examined using sonography. For the patients inwhom normal US examination was found, a blind injection of methylprednisolone 20 mg and 0.5ml one percent lignocaine was performed [Group 1]. The patients whose clinical diagnosis wasconfirmed with US received a sonographic-guided injection of methylprednisolone 20 mg and0.5 ml one percent lignocaine [Group 2]. Outcome measurements were performed at baseline,two weeks, one month, and three months. Pain and functional status were assessed using a visualanalog scale, physical functioning and bodily pain scales of the Medical Outcomes Study 36 ItemShort-Form Health Survey, a patient-rated forearm evaluation questionnaire, and a patient-specificfunctional scale. Painless grip strength bilaterally was also measured.
Results: Twenty-four [46.2 percent] patients had a normal-appearing common extensor originon US. The group in which diagnosis of LE was confirmed on US and sonographic-guidedcorticosteroid injections improved significantly from the baseline to the third month follow up[P < 0.000] in both clinical assessment and physical examination findings.
Conclusions: Our case series suggested that sonography of the common extensor origin can beused to confirm LE in patients with lateral elbow pain. Although sonographic-guided injectionsproduced more clinical improvement, further studies are needed to determine effectiveness ofsonographic-guided injections.
KEYWORDS. Lateral epicondylitis, corticosteroid, ultrasonography
INTRODUCTION
Lateral epicondylitis [LE] is a diagnostic termthat describes a pattern of pain and localizedtenderness at the lateral epicondyle of distalhumerus (1, 2). In a patient presenting withlateral elbow pain, the differential diagnosis
Zeliha Unlu, MD, Department of Physical Medicine and Rehabilitation, Celal Bayar University School ofMedicine, Manisa, Turkey
Serdar Tarhan, MD, Gulgun Yilmaz Ovali, MD, and Yuksel Pabuscu, MD, Department of Radiology, CelalBayar University School of Medicine, Manisa, Turkey
Address correspondence to: Dr. Zeliha Unlu, Posta Kutusu 141, TR-45010 Manisa, Turkey, Tel: +90 –533–4137130, Fax: +90 236 –2370213. E-mail: [email protected]
includes cervical spine disorders, fibromyalgiasyndrome, myofascial trigger points, posteriorinterosseus nerve entrapment, lateral synovialfringe, loose bodies, chondromalacia or os-teochondritis of the radiocapitellar joint, pos-terolateral impingement, posterolateral rotatoryinstability, radial head fracture, radiocapitellar
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Journal of Musculoskeletal Pain, Vol. 17(1), 2009Available online at http://jmp.haworthpress.com
C© 2009 by Informa Healthcare USA, Inc. All rights reserved.doi: 10.1080/10582450802679995
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arthrosis, and bursitis (1–5). Until recently, al-though it was recognized that the variable sitesof local tenderness could imply different pathol-ogy, tennis elbow was considered a single entity.Although LE remains a clinical description, ul-trasonography [US] can confirm the diagnosisand gives a detailed image of the structures in-volved in the disease (4, 6). Sonography of thecommon extensor origin can confirm the clin-ical suspicion of LE and exclude other causesof lateral elbow pain. Ultrasonography can pro-vide useful information about the location, ex-tent, and severity of LE before treatment (4).
Treatment and its outcome in LE have varied,perhaps in part because of uncertain diagnos-tic procedures and poor reliability of assessmenttechniques to identify the specific site of lesion(3, 7, 8). High frequency US might provide ben-efit in this point. It is a readily available, safe,and easy method for guiding musculoskeletalfluid aspiration, infiltration, or biopsies. Real-time US enables correct needle placement, medi-cation delivery, and correct post-injection steroidlocation (9). However, there is a lack of knowl-edge on its role in treatment of LE.
In this study, the role of US in diagnosis andtherapy of LE was investigated in patients withLE pain. For this purpose, the patients who werediagnosed as LE solely by physical examinationand treated with blind injection of corticosteroidand the patients whose diagnosis were confirmedusing US and treated with sonographic-guidedcorticosteroid injections were evaluated.
MATERIALS AND METHODS
Patients with pain in the lateral aspect of theelbow referred to our physical medicine and re-habilitation department for evaluation and whoagreed to undergo US only for the purpose ofthis prospective study were enrolled. Partici-pants were considered to have a diagnosis ofunilateral LE and were eligible for inclusion inthe study if they had tenderness on or near the lat-eral epicondyle and if pain was present on at leasttwo of three pain provocation tests: gripping, re-sisted wrist extension performed with the elbowin an extended position, and resisted middle fin-ger extension performed with the elbow in an ex-tended position. These criteria are described instandard textbooks and were used specifically innumerous clinical trials (3, 10). Duration of the
symptoms was at least three weeks, and the con-dition of the patient was flared with activity andexhibiting constant pain. Participants who had ahistory of elbow fracture or surgery, congenitalor acquired deformities of the elbow, bilateralsymptoms, prior treatment of elbow complaintswith physiotherapy or injections, systemic mus-culoskeletal or neurological disorders or concur-rent upper quadrant pathology, or symptoms notdirectly related to their LE symptoms were ex-cluded. Cervical spine was examined by assess-ing all active, passive, and combined movementsinto extension-rotation and flexion-rotation todetermine end-feel and pain provocation. A jointwas determined to be symptomatic using the pre-viously described decision rules by Waugh et al.(3). Therapy-resistant patients and patients whohad been treated with local corticosteroid injec-tions in any musculoskeletal location in the lastthree months prior to the study were also ex-cluded. The study was approved by the univer-sity ethics committee, and informed consent wasobtained from each patient.
Ultrasonography Evaluation
All patients were examined with commercial,real-time equipment [Sonoline G50, Siemens,Seattle, Washington, United States] using an 8–12 MHz linear phased array transducer by a ra-diologist experienced in US [ST]. They werepositioned comfortably in a chair with the el-bow placed on the examination table in a flexedposition. The common extensor origin was ex-amined in both the longitudinal and transverseplanes with respect to morphology and echotex-ture. The examination included comprehensiveimaging of the four muscles that form the com-mon extensor origin. Comparison was made withthe opposite elbow in all patients.
Tendon echotexture was accepted to be nor-mal if a uniform fibrillar pattern could be fol-lowed between the muscle and the attachment tothe lateral condyle. Tendinopathy was describedif there was a loss of this normal fibrillar patternseen as focal areas of hypoechogenicity. A par-tial tear was defined as a focal anechoic area withno fibers intact or an echogenic irregular bandthat could run either horizontally or longitudi-nally in the common extensor origin. A completetear was defined as a distinct complete intervaltraversing or extending through the full width of
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the common extensor origin. Confirmation of ab-normality was performed by at least an imagingof two planes. Enthesiopathy was diagnosed ifthe proximal part of the common extensor originwas enlarged and there were echogenicity alter-ations. Focal areas of calcification and a thick-ening of the peritendonous lining [peritenonitis]were recorded, and bursitis on the inferior sur-face of the tendon of the extensor carpi radialisbrevis was noted (4, 6, 11).
For blind injection, a standard defined tech-nique was performed by the clinician (12). Theinjection was done with the patient’s arm restingflexed on a firm surface. The methylprednisoloneand lignocaine were drawn up in separate sy-ringes. After the skin was cleaned, lignocainewas injected deep into the subcutaneous tissuesand muscles 1 cm distal to the lateral epicondyle,aiming towards the tender spot. The syringeswere then exchanged and methylprednisolonewas injected. The needle was withdrawn andfirm pressure applied.
Under US guidance, peri or intralesional in-jections were performed as follows by the sameradiologist [ST]. The transducer and the patient’sskin were sterilized with alcohol. Sterile gel wasapplied to the probe. The transducer was held in
one hand and the syringe with drug in the otherhand. The needle was placed under the probe andits route was visualized in real-time by US, asa hyper-reflective line, often with reverberation,from the skin to the target (9). Intralesional injec-tion was performed when bursitis or peritenonitiswas found. Peri and intralesional injection wasperformed when calcifications were detected (9).Immediately after injection, a US examinationwas performed to search for steroid deposit ashyperechoic foci or lines, with or without acous-tic shadowing [Figure 1].
Outcome assessments were performed atbaseline, two weeks, one month, and threemonths. Radiologists were blinded to clinicalinformation. The baseline assessment also in-cluded age, sex, duration of symptoms, elbowinvolved, dominance of arm, and cervical spinesigns variables. No medication was given andno restriction of activity was advised during thefollow-up period.
At follow up we assessed severity of pain[visual analog scale scale: 0 mm = no pain, 100mm = maximum pain], local tenderness of lat-eral epicondyle [0 to 3 point scale: absent, mild,moderate, severe], pain on resisted extensionof middle finger and wrist with arm extended
FIGURE 1. Hyperechoic steroid suspension [arrow] in the common extensor origin is seen after corti-costeroid injection.
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[0 to 3 point scale: absent, mild, moderate,severe], and pain-free grip strength in affectedarm [average of two readings with hand helddynamometer] in each patient. Grip strengthof the uninvolved limb was also evaluated.Grip strength was measured in kilograms withthe elbow extended and the forearm pronatedbecause this position was thought to be the mostsensitive for testing (13, 14).
Pain and functional disability were assessedusing physical functioning and bodily painscales of the Outcomes Study 36 Item Short-Form Health Survey [SF-36] (15) and a patient-rated forearm evaluation questionnaire [PRFEQ]for use in LE (16). Overall score of the SF-36 scales ranging from 0–100 where higherscores indicate “better” function were used. ThePRFEQ was designed to assess average arm painand function over a one-week period. Five itemswere used to assess pain and ten items to as-sess function. The items on the pain subscaleof the PRFEQ were scored using a 10 cm vi-sual numeric rating scale with anchors of 0 [nopain] and 10 [worst pain imaginable]. The itemson the function subscale were also scored us-ing a 10 cm visual numeric rating scale withanchors of 0 [no difficulty] and 10 [unable todo]. No other descriptors were placed alongthe line. Mean scores for the pain and func-tion sections and the overall PRFEQ score werecalculated.
Patient-specific changes in function wereassessed according to a method developed byStratford et al. (17) called the patient-specificfunctional scale [PSFS]. In the PSFS, patients
were asked to identify up to five important ac-tivities that they are having difficulty with orare unable to perform. In addition to specifyingthe activities, patients were asked to rate, on an11-point scale, the current level of difficulty as-sociated with each activity. The scale anchorswere 0 [unable to perform activity] to 10 [ableto perform activity at same level as before injuryor problem] (17).
The assessment included the presence ofany immediate or late adverse effects of theinjection.
Statistical Analysis
We compared groups with chi-square testfor nominal variables. Ordinal variables werecompared by Mann-Whitney U tests. Within-group changes between the baseline and follow-up visits were investigated using Wilcoxon’ssigned rank test and McNemar tests. Data wereexpressed as median [minimum-maximum] inTables 2, 3, and 4. The critical value for sta-tistical significance for all tests was set at P <0.05. Analyses were carried out with the Sta-tistical Package for the Social Sciences version10.0.
RESULTS
Fifty-two patients [39 women and 13 men]with a mean age of 47.5 years [standard devi-ation 9.6] with LE participated in this study.
TABLE 1. Initial Clinical Assessment
Group 1 [N = 24] Group 2 [N = 28] P
Age, years, mean [SD] 44.8 [8.9] 49.8 [9.6] 0.15Sex, N [percent]
Women 22 [91.7] 17 [60.7] 0.01∗Men 2 [8.3] 11 [39.3]Duration of symptoms, months, mean [SD] 8.5 [12.0] 8.2 [13.7] 0.86
Elbow involved, N [percent] 0.000∗Right 5 [20.8] 22 [78.6]Left 19 [79.2] 6 [21.4]
Dominance of arm, N[percent] 0.59Right 22 [91.7] 27 [96.4]Cervical spine articular signs, N [percent] 14 [58.3] 8 [28.6] 0.04∗
SD = standard deviation, P = P values for comparison between the Group 1 and Group 2.∗Statistically significant difference between the groups.
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Patient characteristics by treatment group arepresented in Table 1. The patients in the groupswere well-matched for age and duration of thesymptoms. Twenty-four [46.2 percent] of the pa-tients’ US examinations were found to be normaland a blind injection of methylprednisolone 20mg and 0.5 ml one percent lignocaine was per-formed in these patients [Group 1]. Initial clini-cal diagnosis of LE was confirmed by US in 28[53.8 percent] of the patients and they receiveda sonographic-guided injection of methylpred-nisolone 20 mg and 0.5 ml one percent ligno-caine [Group 2].
The Group 2 [US confirmed group and guidedinjection] contained more male patients thanGroup 1 [US negative and blind injection][39.3 percent versus 8.3 percent]. Dominant armwas reported as the right side for both groupsand US confirmed LE was found more oftenat in the dominant arm in Group 2 patients[Table 1]. A majority of patients [58.3 percent]in the Group 1 had symptomatic cervical signs,and the difference between the groups was sta-tistically significant [P < 0.05].
The US pathologic findings were: tendinopa-thy [N = 25, 89.2 percent], partial tear [N =
5, 17.9 percent], enthesiopathy [N = 4, 14.3percent], focal areas of calcification [N = 5,17.9 percent], peritenonitis [N = 3, 10.7 per-cent], and bursitis [N = 3, 10.7 percent] inGroup 2 patients [Figures 2(a) and (b)]. We didnot detect a complete tear of the common exten-sor origin.
Of the 52 participants, only one subject [inGroup 2] did attend the first and third monthvisits. In Group 2 patients’ median VAS scorefor pain was higher and lateral epicondyle wasmore tender than Group 1 patients at base-line evaluations. Severity of pain and pain dur-ing the physical examination were significantly[P = 0.000] improved compared to the base-line at the second week and first and thirdmonths in Group 2. Statistically less significantimprovements were observed during the three-month follow-up period in Group 1 patients[Table 2].
Table 3 shows the results of grip strength.The grip strength in the control arm was higherin Group 2 than in Group 1 at baseline measure-ments. The ratio of the painful arm and controlarm was found lower in Group 2 patients. Dur-ing the follow-up period, grip strength in the
FIGURE 2a. Longitudinal sonogram of the contralateral [normal] left elbow shows the common extensortendon inserting on the lateral epicondyle.
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FIGURE 2b. Longitudinal sonogram of the right elbow shows thickening of the tendon and increasedhypoechogenicity.
painful arm and the ratio between the arms weresignificantly increased in Group 2 patients. ForGroup 2, superiority of statistical significances[within-group comparison] over Group 1 wasfound throughout the follow-up period [Table 3].
Table 4 shows scores for the SF-36, PRFEQ,and PSFS scales for pain and functional sta-tus at each follow-up assessment. Scores ofPRFEQ and PSFS scales in the Group 2 in-dicated more impairments than Group 1 at
TABLE 2. Results of Physical Examination at Baseline, Two Weeks, One Month, and Three Monthsfor the Blinded [Group 1] and Sonographic-Guided [Group 2] Injection Groups
Follow-up Group 1 P Group 2 P
Pain [VAS score], median [min-max] Initiation 30.0 [0–90] 50.0[10–95]2 weeks 7.5 [0–80] 0.002∗ 2.5 [0–90] 0.000∗∗1 month 0.0 [0–85] 0.01∗ 0.0 [0–75] 0.000∗∗3 months 12.5 [0–90] 0.08 0.0 [0–85] 0.000∗∗
Local tenderness, median [min-max] Initiation 2 [2–3] 3 [1–3]2 weeks 1 [0–3] 0.000∗ 1 [0–3] 0.000∗∗1 month 1 [0–3] 0.000∗ 1 [0–3] 0.000∗∗3 months 2 [0–3] 0.000∗ 1 [0–3] 0.000∗∗
Resisted extension of middle finger, median [min-max] Initiation 2 [1–3] 2 [1–3]2 weeks 1 [0–3] 0.000∗ 1 [0–3] 0.000∗∗1 month 1 [0–3] 0.000∗ 0 [0–3] 0.000∗∗3 months 1 [0–3] 0.001∗ 0 [0–3] 0.000∗∗
Resisted extension of wrist, median [min-max] Initiation 2 [1–3] 2.5 [1–3]2 weeks 1 [0–3] 0.001∗ 1 [0–3] 0.000∗∗1 month 1 [0–3] 0.001∗ 0 [0–3] 0.000∗∗3 months 1 [0–3] 0.001∗ 0 [0–3] 0.000∗∗
P = P values for within-groups comparison between the baseline and follow-up visits in Group 1 and Group 2, ∗ = significant decreasecompared to basal values in the Group 1, ∗∗ = significant decrease compared to basal values in the Group 2.
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TABLE 3. Grip Strength [kg] at Baseline, Two Weeks, One Month, and Three Months for the Blinded[Group 1] and Sonographic-Guided [Group 2] Injection Groups
Follow-up Group 1 P Group 2 P
Control arm, median [min-max] Initiation 21.0 [10–48] 26.0 [15–50]2 weeks 24.0 [10–53] 0.08 26.0 [12–54] 0.691 month 22.0 [10–51] 0.14 25.0 [16–50] 0.503 months 23.0 [8–50] 0.04∗ 25.0 [14–55] 0.68
Painful arm, Median [min-max] Initiation 16.0 [0–38] 17.5 [2–36]2 weeks 18.0 [7–50] 0.04∗ 22.0 [2–48] 0.000∗∗1 month 21.0 [0–44] 0.01∗ 22.0 [10–49] 0.000∗∗3 months 19.0 [1–32] 0.01∗ 23.5 [3–50] 0.000∗∗
Ratio of the painful arm and control arm, median [min-max] Initiation 0.7 [0.0–1.0] 0.5 [0.0–1.0]2 weeks 0.9 [0.3–1.5] 0.01∗ 0.8 [0.0–1.2] 0.000∗∗1 month 0.9 [0.0–1.2] 0.05 1.0 [0.3–1.3] 0.000∗∗3 months 0.9 [0.0–1.2] 0.02∗ 1.0 [0.1–1.3] 0.000∗∗
P = P values for within-groups comparison between the baseline and follow-up visits in Group 1 and Group 2, ∗ = significant decreasecompared to basal values in the Group 1, ∗∗ = significant decrease compared to basal values in the Group 2.
baseline. Patients from Group 2 had better re-covery or improvement than those treated byblind injection [Group 1] from baseline tothe time points of two weeks and one and
three months. Significant improvements at thefirst visit were not sustained over subsequentmonths in Group 1. Globally statistical signif-icances were showed a tendency of decrease
TABLE 4. Results of the Outcomes Study 36 Item Short-Form Health Survey [SF-36],Patient-Rated Forearm Evaluation Questionnaire [PRFEQ] and the Patient-Specific FunctionalScale [PSFS] for the Blinded [Group 1] and Sonographic-Guided [Group 2] Injection Groups
Follow-Up Group 1 P Group 2 P
SF-36 Physical functioning, median [min-max] Initiation 60.0 [0–85] 50.0 [25–85]2 weeks 65.0 [0–100] 0.002∗ 70.0 [25–100] 0.000∗∗1 month 70.0 [0–100] 0.000∗ 80.0 [35–100] 0.000∗∗3 months 70.0 [0–100] 0.001∗ 85.0 [20–100] 0.000∗∗
SF-36 Bodily pain, median [min-max] Initiation 41.0 [0–51] 31.0 [0–62]2 weeks 46.0 [0–84] 0.001∗ 51.0 [10–100] 0.000∗∗1 month 51.0 [0–100] 0.002∗ 62.0 [0–100] 0.000∗∗3 months 46.5 [0–100] 0.02∗ 62.0 [21–100] 0.000∗∗
PRFEQ Pain, median [min-max] Initiation 6.0 [2.2–9.0] 6.6 [3.4–8.2]2 weeks 4.1 [0.0–9.0] 0.000∗ 3.3 [0.0–7.6] 0.000∗∗1 month 3.7 [0.0–9.0] 0.002∗ 1.8 [0.0–7.4] 0.000∗∗3 months 4.0 [0.0–9.0] 0.005∗ 0.6 [0.0–7.6] 0.000∗∗
PRFEQ Function, median [min-max] Initiation 5.5 [1.8–9.0] 6.4 [3.4–9.0]2 weeks 3.5 [0.2- 9.0] 0.000∗ 2.8 [0.0–9.0] 0.000∗∗1 month 3.1 [0.0–9.0] 0.002∗ 0.8 [0.0–6.1] 0.000∗∗3 months 3.7 [0.0–9.0] 0.002∗ 0.2 [0.0–7.4] 0.000∗∗
PRFEQ Total score, median [min-max] Initiation 5.6 [1.9–9.0] 6.6 [3.5–8.7]2 weeks 3.7 [0.1–9.0] 0.000∗ 2.7 [0.0–8.4] 0.000∗∗1 month 3.3 [0.0–9.0] 0.002∗ 1.1 [0.0–6.0] 0.000∗∗3 months 3.8 [0.0–9.0] 0.003∗ 0.3 [0.0–7.4] 0.000∗∗
PSFS, median [min-max] Initiation 3.0 [2.0–6.4] 2.3 [1.8–5.2]2 weeks 4.2 [2.0–9.0] 0.000∗ 8.0 [1.8–10.0] 0.000∗∗1 month 5.3 [2.0–9.0] 0.002∗ 8.8 [2.2–10.0] 0.000∗∗3 months 4.6 [2.0–9.0] 0.001∗ 9.0 [2.0–10.0] 0.000∗∗
P = P values for within-groups comparison between the baseline and follow-up visits in Group 1 and Group 2, Outcomes Study 36 ItemShort-Form Health Survey = SF-36, Patient-Rated Forearm Evaluation Questionnaire = PRFEQ, Patient-Specific Functional Scale =PSFS, ∗ = significant decrease compared to basal values in the Group 1, ∗∗ = significant decrease compared to basal values in theGroup 2.
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at the third month visit in this group [Table 4;P *].
In all patients of Group 2, the needle was ac-curately placed in the target and correct steroiddelivery was confirmed in real-time and after in-jection. No local or systemic side effects wereobserved in Group 2 patients during the study.But hypopigmentation of the skin at the lat-eral epicondyle was observed in only one pa-tient at three months from the Group 1 [blindinjection].
DISCUSSION
There has been disagreement regarding theefficacy and effectiveness of corticosteroid in-jections in LE. In a recent study in which allpatients received a corticosteroid injection, pa-tients who had LE for less than three monthshad significantly more improvement in outcomevariables than those with chronic LE (18). Incontrast, other authors would not recommend acorticosteroid injection as a treatment for LE inpatients who have had symptoms for less thanone month (7). In a pragmatic trial a small pro-portion of patients failed to respond to the initialinjection, and some patients who had initiallyimproved had worse symptoms at six months.Authors concluded that these might be patientswhose primary disease lay within the cervicalspine or whose local injection was not accu-rately placed (12). In previous studies, diagnosisof LE was established according to the physicalexamination findings and blind injections wereperformed for the treatment. We thought two im-portant factors, accurate diagnosis of the diseaseand placement of corticosteroid injection, maybe important in respect to conflicting results tolocal steroid treatment.
Our results showed that diagnosis confirmedby US leads to more significant improvementsin patient care than no lesion on US when base-line evaluations were compared with each visitduring the follow-up period. At the last visit[third month], the group in which diagnosisof LE was confirmed on US and sonographic-guided corticosteroid injections were appliedshowed a clear advantage over manual exam-ination and palpation-guided injections withrespect to improvement in pain, local tenderness,grip strength, and functional status assessments.Our observations suggest that the efficacy of the
treatment may relate to accurate diagnosis ofthe common extensor origin lesions. These find-ings also support the reliability of US to detectpathologies of common extensor origin. In addi-tion our results showed that accurate placementof corticosteroid into the lesion may affect thetherapeutic response due to its anti-inflammatoryeffect. Recently, studies have shown evidence ofabnormal blood flow of inflamed tissue in thecommon extensor tendon on color Doppler USand laser Doppler imaging (19). Pedersen et al.(8) observed that vascularization in the area ofinterest significantly decreased 14 days after aguided injection of steroid.
For Group 2, superiority of statistical signif-icance [within-groups comparison] over Group1 was continued throughout the follow-up pe-riod. Investigating the longer-term effectivenessof corticosteroid injections in LE without anappropriate control of a high frequency of addi-tional treatments and work-related injuries is dif-ficult. A recent review article on corticosteroidinjections for LE evaluated in 12 available ran-domized clinical trials and concluded that injec-tions seemed to be more effective than placeboin short terms [two to six weeks], but not longterms (2, 20). The poor results of corticosteroidinjections after 12 weeks could be explained ina couple of ways by Smidt et al. (21) with-out depicted involved structures. First, corticos-teroid injections might be harmful to the tendon,although reported adverse reactions were gen-erally mild. Second, patients might not havefollowed the advice given by their family doc-tor and might have overtaxed their elbow af-ter receiving an injection. We agree with morereasonable explanations of studies performedguided injections that inaccurate lesional place-ment may allow sufficient steroid to diffuse intothe adjacent structures to yield only a partialor short-term response. Greater concentration ofdrug and less dispersal from the lesion would beexpected from accurate placement within the tar-get. If the anti-inflammatory effect of the drug isconsidered, the latter might be an important fac-tor in determining the therapeutic response (9,22).
Cutaneous thinning and subcutaneous at-rophy are well documented following localand intra-articular blind corticosteroid injec-tions (13). In contrast to blind injection, we didnot observe any side effects in Group 2 pa-tients. Sonographic-guided injection improves
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accuracy and reduces the risk of injecting intotendon, adipose tissue, muscle, nerve, or skinresulting in inefficacy and tissue damage (9,23). High frequency US allows careful intra orperilesional placement of the tip of the needle,even inside minimal fluid collections, into ten-don sheaths (24). Diffusion of the echoic steroidsuspension can be easily detected in real-timeduring and after the procedure (24). The suspen-sion appears as hyper-reflective foci or lines dueto its crystalline structure [Figure 1].
Some investigators believe that the naturalhistory of LE is that of resolution of symptomswithin six months, regardless of treatment (13,25). Because elbow pain was present before thestudy began for a mean of eight months, it seemsreasonable that the clinical outcome was due toaccurate diagnosis and corticosteroid injectionrather than to the natural progress of LE. Simi-larly to the report from Verhaar et al. (26), it maybe the source of prolonged pain and persistentimpairment of activities for many months.
We investigated the subjects with lateral el-bow pain and diagnosed LE clinically in thisstudy. We evaluated common extensor origin forsonographic-diagnosis of LE. The US offers su-perior spatial resolution and is, therefore, sen-sitive in depicting focal areas of degeneration,macroscopic partial thickness tears, foci of cal-cification, and bony irregularities (4, 23). One ofthe limitations of US is its inability to identifyan intra-articular cause for the patient’s symp-toms (4). In this study, we did not examine el-bow joint in details and poorly described lesionsof posterior interosseous nerve entrapment andlateral collateral ligament by US. Lateral elbowpain in patients [46 percent] who had normalUS findings may resource from structures in-cluding the supinator muscle that we did notexamine.
Our study population represented the spec-trum of patients attending a rheumatologic out-patient clinic, and none of the patients weresports-related cases. The majority of patientswith normal US findings [Group 1] were fe-males [91.7 percent] and had positive cervicalsigns [58.3 percent; Table 1]. There were signif-icant differences between the two groups. Thesefactors could lead to misdiagnosis of LE in clin-ical examination and might have another effecton our normal sonographic findings.
Past studies of abnormal sonographic find-ings in LE included more male subjects with
repetitive injury from tennis or other sports (4, 6,8). Sex difference in the self-report of disabilityand pain has been found in populations. Womenare socialized to acknowledge pain and discom-fort and may recognize and interpret symptomsmore readily than men (3). “Illness behavior”was explored and found no evidence to sug-gest that individuals with soft tissue injuriesare different in their attitudes and beliefs (27).An almost similarly high incidence of cervicalsigns was reported in patients with LE [58.3 per-cent versus 57.0 percent]. Specifically, as noted,women were more likely than men to have work-related onsets, repetitive jobs, and/or positivecervical signs. Moreover, work related onsetswere associated with both repetitive jobs andcervical signs and, therefore, these factors werelikely to coexist. Authors (3, 12, 26, 28) havesuggested that cervical spine pathology maycontribute to a poor prognosis for women withLE.
It is possible that abnormalities around orwithin nerves [cervical radiculopathy or radialnerve] could bring about an alteration in jointproprioception and pain perception in patientswith LE (27). Altered nerve function could con-stitute another mechanism leading to protractedLE symptoms by cause painful trigger points inthe forearm musculature, weakness of the wristextensors, and formation of inadequate scar tis-sue (3, 28).
LE is equally distributed between men andwomen, and typically affects the dominant arm(29). Our results were similar; the majority of LEconfirmed on US was detected in the dominantarm [78.6 percent] and a bit more in females[60.7 percent; Table 1].
In conclusion, our findings emphasize dis-tinct aspects of the LE. First, this informationmay help direct both the assessment andmanagement of patients with this syndrome.The results of the present study showed thatdiagnosis confirmed on US and sonographic-guided injections provided better benefits thansolely manual examination and blind injections.While required formal evidence to support thecost-effectiveness of US in rheumatology iscurrently lacking, it is likely that improveddiagnostic and interventional skills will leadto improved patient care and clinical outcome.Second, other diagnosis that may mimic orpresent as LE must be considered, especially inwomen. For example, for a patient with positive
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cervical signs, cervical spine treatment mightbe appropriate. Third, the results of this studymay help improve the specificity of inclusioncriteria for future clinical trials and promote theevaluation of therapeutic interventions.
Study Limitations
Our study had some limitations. First, therewere differences between the groups in respectto sex and cervical symptoms. Therefore, within-group changes between the baseline and follow-up visits were investigated. Future studies com-paring blind and sonographic-guided injectioncan be conducted to confirm our results. Second,a double-blind study would have been desirableto avoid bias. However, blinding of patients andthe physician who performed medication injec-tion was not technically possible.
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Submitted: October 13, 2006Revision Accepted: December 14, 2006
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