Ultrasound-guided elbow injections
The elbow, a complex synovial hinged joint involving the humerus, radius, and ulna, facilitates essential movements such as flexion, extension, pronation, and supination. Due to its intricate structure and frequent use, it is susceptible to a range of injuries and conditions. These include various forms of arthritis, tendinopathies, bursitis, ligamentous injuries, and nerve entrapment syndromes, which can significantly impact mobility and quality of life.
With the advent of ultrasound technology in medical diagnostics and therapeutics, the precision in treating elbow conditions has remarkably improved. Ultrasound-guided elbow injections offer a real-time and non-invasive method to accurately target specific anatomical structures such as tendons, ligaments, bursae, and nerves. This approach enhances the effectiveness of treatments for conditions like lateral epicondylitis, medial epicondylitis, distal biceps tendinopathy, and ulnar neuropathy, among others.
| Joint/Structure | Pertinent Anatomy | Common Pathology | Equipment | Injectate & Volume | Patient Position | Transducer Orientation | Needle Orientation and Approach | Technique | Target |
|---|---|---|---|---|---|---|---|---|---|
| Elbow Joint | Synovial hinged joint; articulation between humerus, radius, ulna; allows flexion, supination, pronation | Arthritis: rheumatoid, post-traumatic, osteoarthritis; Joint effusion, synovitis, intra-articular bodies | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Local anesthetics, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate) 2. 2 to 5 mL (local anaesthesia + injectable steroid in ratio of 1:1) | 1. Lateral approach - Seated/supine; elbow flexed 40 degrees, forearm pronated, palm resting on table. 2. Medial approach - Prone; elbow flexed 90 degrees, forearm hanging over table | 1. Long-axis to radius over radiocapitellar joint 2. Short-axis to triceps tendon over olecranon fossa | 1. In-plane/Out of plane to transducer (depending upon probe orientation) | From posterior to anterior into radiocapitellar joint; short axis directly into joint (lateral to medial) | 1. Radiocapitellar joint 2. Underneath triceps tendon into joint |
| Lateral Collateral Ligament Complex | Consists of - Accessory Radial Collateral Ligament, - Annular ligament, - Lateral Radial Collateral Ligament, - Lateral Ulnar Collateral Ligament; LUCL primary stabiliser to varus and external rotation stress | Subtle instability, traumatic elbow dislocation | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Prolotherapy, orthobiologics (PRP, bone marrow concentrate) only 2. Minimal use of local anaesthesia for pain control | Seated/supine; elbow flexed 90 degrees, forearm pronated | Long-axis or longitudinal to ligaments | In-plane to transducer | 1. Distal to proximal for LRCL and LUCL; 2. Lateral to medial for ALCL and annular ligament | Hypoechogenicity, cortical irregularities; areas for regenerative injection |
| Medial Ulnar Collateral Ligament | Composed of anterior, posterior bands, transverse ligament; anterior band primary restraint to valgus stress | Common injury in overhead throwing athletes due to extreme valgus stress leading to partial or complete tear with resultant swelling and ulnar nerve irritation. | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Prolotherapy, orthobiologics (PRP, bone marrow concentrate) only 2. Minimal use of local anaesthesia for pain control | Supine; elbow in external rotation | Long-axis or longitudinal to ligaments | In-plane to transducer | 1. From distal to proximal | Hypoechogenicity within ligament; target areas for regenerative injection |
| Common Extensor Tendon (Tennis Elbow) | Originates from the lateral epicondyle; radial collateral ligament occupies 50% of footprint | Lateral epicondylitis; tendon thickening, calcifications, tears | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Local anesthetic ± corticosteroids, Orthobiologics (PRP, bone marrow concentrate) 2. 2 to 3 mL (local anaesthesia + injectable steroid in ratio of 1:1). To be used only for peritendinous injections. 3. Avoid intratendinous corticosteroids. | Seated/supine; elbow flexed 90 degrees, forearm prone | 1. Long-axis to tendon at the level of lateral epicondyle 2. Short-axis to tendon at the level of lateral epicondyle | In-plane | 1. From distal to proximal (long axis) 2. From posterior to anterior (short axis) | Hypoechoic cortical irregularities; fenestration of tendon, peri-tendinous location |
| Common Flexor Tendon (Golfer's Elbow) | Originates from the medial epicondyle, includes 4 group of muscles: pronator teres, palmaris longus, flexor carpi radialis and ulnaris | Overuse syndrome; less common than lateral epicondylitis; tendon thickening, calcifications, tears; associated valgus instability of UCL and ulnar neuritis | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Local anesthetic ± corticosteroids, Orthobiologics (PRP, bone marrow concentrate) 2. 2 to 3 mL (local anaesthesia + injectable steroid in ratio of 1:1). To be used only for peritendinous injections. 3. Avoid intratendinous corticosteroids | Seated/supine; elbow flexed 90 degrees, shoulder abducted 60-90 degrees, forearm supinated | 1. Long-axis to tendon at the level of lateral epicondyle 2. Short-axis to tendon at the level of lateral epicondyle | In-plane | 1. From distal to proximal (long axis) 2. From anterior to posterior (short axis) | Hypoechoic cortical irregularities; fenestration of tendon, peri-tendinous location |
| Distal Biceps Tendon | Inserts onto the radial tuberosity; adjacent to brachial artery, median, radial, and lateral antebrachial cutaneous nerves | Tendinopathy from repetitive injuries; bicipitoradial and interosseous bursa irritation | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Local anesthetic ± corticosteroids, Orthobiologics (PRP, bone marrow concentrate) 2. 2 to 3 mL (local anaesthesia + injectable steroid in ratio of 1:1). To be used only for peritendinous injections. 3. Avoid intratendinous corticosteroids | Seated/supine; various positions based on approach | Short-axis to tendon; dorsal forearm for posterior approach | In-plane | 1. From lateral to medial (posterior approach) | Intratendinous or peritendinous for regenerative injections; bicipitoradial bursa for corticosteroids |
| Triceps Tendon | Superficial layer (lateral and long heads) and deep layer (medial head) blends with posterior capsule, inserts on olecranon | Tendon fiber disruption, tendinosis, Overuse syndrome; | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Local anesthetic ± corticosteroids, Orthobiologics (PRP, bone marrow concentrate) 2. 2 to 3 mL (local anaesthesia + injectable steroid in ratio of 1:1). To be used only for peritendinous injections. 3. Avoid intratendinous corticosteroids | Seated/supine/prone, elbow flexed 90 degrees. | Long axis to triceps tendon | In-plane | 1. From lateral to medial 2. From Proximal to distal | Hypoechoic cortical irregularities; fenestration of tendon, peri-tendinous location |
| Olecranon Bursa | Adventitious bursa over olecranon process | Post-traumatic bursitis; associated with diabetes, gout, rheumatoid arthritis, HIV; septic bursitis, occupational. | 25- to 27-gauge 1.5- to 2.5-inch needle for anesthetic, 18- or 22-gauge for aspiration, High-frequency linear transducer | Aspiration, Anesthetic and corticosteroid, Sclerosing agents for recurrent bursitis - 1 to 2 cc | Supine/prone, elbow flexed 90 degrees. | Long-axis to bursa | In-plane | Any approach | Anechoic or hypoechoic collection superficial to olecranon process |
| Deep Branch Radial Nerve | Bifurcates into deep branch and superficial radial sensory nerve; passes through arcade of Frohse, between layers of supinator | Entrapment at arcade of Frohse or radial tunnel; deep aching pain, increased with forearm rotation/lifting | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Nerve block: local anesthetic ± corticosteroids - 2 to 5 cc; 2. Hydrodissection: saline/local anesthetic/5% dextrose/platelet lysate - 5 to 10 cc | Seated/supine; elbow flexed 90 degrees, forearm on table with thumb up | Long/Short-axis to deep branch of radial nerve | In-plane to transducer; | 1. Medial-to-lateral 2. Distal-to-proximal | Focal flattening or proximal swelling of nerve |
| Median Nerve at Pronator Teres | Crosses elbow beneath bicipital aponeurosis, between pronator teres heads | Pronator tunnel syndrome; entrapment at pronator teres; associated with medial epicondylitis | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Nerve block: local anesthetic ± corticosteroids - 2 to 5 cc; 2. Hydrodissection: saline/local anesthetic/5% dextrose/platelet lysate - 5 to 10 cc | Supine/seated; elbow extended, forearm supinated on table | Long axis to median nerve | In-plane to transducer; | 1. Medial-to-lateral 2. Distal-to-proximal | Focal flattening or proximal swelling of nerve |
| Ulnar Nerve | Crosses elbow in cubital tunnel posterior to medial epicondyle and Guyon's canal at wrist level | Ulnar neuropathy; entrapment between FCU heads, under Osborne’s ligament/MCL, medial head of triceps | 25- or 27-gauge needle, 1.5- to 2.5-inch needle, High-frequency linear transducer | 1. Nerve block: local anesthetic ± corticosteroids - 2 to 5 cc; 2. Hydrodissection: saline/local anesthetic/5% dextrose/platelet lysate - 5 to 10 cc | Supine/seated; elbow extended, forearm supinated on table | Short axis to ulnar nerve | In-plane to transducer; | 1. Medial-to-lateral | Focal flattening or proximal swelling of ulnar nerve |
- Tortora S, Messina C, Albano D, Serpi F, Corazza A, Carrafiello G, Sconfienza LM, Gitto S. Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures. J Ultrason. 2021 Jun 7;21(85):e169-e176. doi: 10.15557/JoU.2021.0027. Epub 2021 Jun 18. PMID: 34258043; PMCID: PMC8264808.
- Lin, Chia-Wei, Yan-Hao Chen, and Wen-Shiang Chen. “Application of ultrasound and ultrasound-guided intervention for evaluating elbow joint pathologies.” Journal of Medical Ultrasound 20.2 (2012): 87-95.
- Lorenzzoni, Pablo Longhi; Patel, Sanjay1. Ultrasound-Guided Joint Injections: Tips and Tricks. Journal of Arthroscopy and Joint Surgery 10(3):p 118-124, Jul–Sep 2023. | DOI: 10.4103/jajs.jajs_20_23