CHAPTER 71 • COMMON INJECTIONS IN SPORTS MEDICINE: GENERAL PRINCIPLES AND SPECIFIC TECHNIQUES 431
- Lateral tennis elbow
- Indications: Lateral tennis elbow that fails to
improve with conservative therapy
2.Clinical anatomy/Landmarks: Key landmarks
include the radial head, appreciated by pronation
and supination of the elbow, and the humeral lat-
eral epicondyle. The most common location of
tennis elbow is at the extensor carpi radialis brevis
origin, which is one fingerbreadth inferior and
medial to the lateral epicondyle.
- Technique: The injection can be administered in a
supine or seated position. If seated, the elbow
should be comfortably resting at 90°with the fore-
arm supinated. The area of maximal tenderness is
identified, and the needle is inserted at an oblique
angle to infiltrate the soft tissues over the extensor
aponeurosis. There should be little resistance to the
injection; if encountered the needle should be
withdrawn until there is little resistance to flow.
- Needle size and dosage: A 1-in. 25-gauge needle is
recommended; 0.5 mL of corticosteroid should be
mixed with 1 to 2 mL of anesthetic.
- DeQuervain’s tenosynovitis
- Indications: This disorder is caused by an inflam-
mation and swelling of the tendons of the abductor
pollicis longus and the extensor pollicis brevis at
the level of the radial styloid process. Patients who
fail to improve with NSAIDs and wrist support
may be candidates for an injection.
- Clinical anatomy/Landmarks: The anatomic snuffbox
is the anatomic landmark. The anterior border is the
first dorsal compartment of the wrist (abductor polli-
cis longus and extensor pollicis brevis) and the poste-
rior border is the extensor pollicis longus tendon.
- Technique: This injection can be done in the seated
or supine position, with the wrist in a vertical posi-
tion, resting over a folded towel, with the thumb
flexed. The point of maximal tenderness is identi-
fied, which is generally over the radial styloid. The
needle is inserted bevel-up, directed in an oblique,
cephalad angle, nearly parallel to the tendons. If
the gap between the two tendons can be appreci-
ated, the needle should be placed in this gap. When
the needle is approximately^1 / 4 in., an attempt
should be made to aspirate, and then gently push
the plunger. If there is resistance, the needle should
be pulled back, and the process repeated.
- Needle size and dosage: 0.5- to 1-in., 25- to 27-
gauge needle; 0.5-mL anesthetic and 0.5 mL corti-
costeroid
- Carpal tunnel syndrome
- Indications: Carpal tunnel syndrome
2.Clinical anatomy/Landmarks: Key landmarks
include the palmaris longus and flexor carpi radialis
tendons, the distal wrist crease and the median
nerve. The median nerve lies deep to and between
the tendons of the palmaris longus and the flexor
carpi radialis at the wrist.
- Technique: The injection can be given in the
supine position or the seated position. The dorsum
of the hand should rest on a folded towel. The
needle is inserted just proximal to the distal wrist
crease at a 45°angle just ulnar to the palmaris
longus and angled toward the index finger. The
needle may be felt to pop through the dense trans-
verse carpal ligament. If pain or paresthesias are
reported in the palm or fingertips during needle
placement, the needle should be withdrawn and
reangled prior to reinsertion. Depth of penetration
should be approximately^1 / 2 in.
- Needle size and dosage: A 25- to 27-gauge needle
may be used, with 0.5 mL of steroid and a similar
dose volume of anesthetic.
- Indications: Trigger finger/stenosing tensosynovi-
tis
- Clinical anatomy/Landmarks: The key landmark is
the first annular pulley. This condition is secondary
to an inflammation and swelling of the flexor
tendon of the flexor digitorum superficiales.
Repetitive irritation leads to a nodule in this
tendon, which becomes obstructed as the nodule
passes beneath the pulley, which is proximal to the
metacarpal-phalangeal(MP) joint.
- Technique: The patient may be administered the
injection in the seated or supine position. The site
for the injection is the distal palmar crease, just
proximal to the MP joint. The needle is inserted
bevel-up, directed at an oblique angle parallel with
the tendon, toward the fingertips. When an increase
in resistance is felt, at approximately^1 / 4 -in. depth,
the plunger should be gently pushed. If there is
resistance, the needle may be in the tendon, and the
needle should be slightly withdrawn, aspirate, and
reinjected.
- Needle size and dosage: A 25- to 27-gauge needle
may be used; a preparation of 0.5 mL corticosteroid
with 0.5 mL of anesthetic can be mixed, with half
to all of this suspension injected.
- Indications: Recalcitrant trochanteric bursitis.
- Clinical anatomy/Landmarks: The key landmark is
the greater trochanteric prominence; most bursitis
is posterosuperior to this prominence. This promi-
nence is best appreciated with the patient in a lat-
eral decubitus position.
- Technique: The point of maximal tenderness is
palpated. The needle should be inserted
