CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 398, pp. 127–130
Local Injection Treatment for
Lateral Epicondylitis
T. Altay, MD*; I. Günal, MD*; and H. Öztürk, MD**
In a prospective randomized study of lateral
epicondylitis, 120 patients were treated with 2
mL lidocaine (Group A, n
60) or 1 mL lido-
caine combined with 1 mL triamcinolone (Group
B, n
60). All injections were done using the
peppering technique: after inserting the needle
the tender area was peppered with 40 to 50 in-
jections by injecting, withdrawing, redirecting,
and reinserting without emerging from the skin.
All patients were followed up for 1 year. Fifty-
six patients in Group A and 57 patients in Group
B had excellent results. There was statistically
no difference between the groups. Both groups
had excellent results and because the injection
of local anesthetics is known to have no long-
term effect in the treatment of lateral epi-
condylitis, the peppering technique seems to be
a reliable method of treatment.
Although numerous treatment modalities have
been described for lateral epicondylitis, many
lack sound scientific rationale.2,11 The preferred
method of treatment most often is local cortico-
steroid injection with or without the addition of
a local anesthetic,2,11,17 but the recurrence of
From the Departments of Orthopedics, *Social Security
and **Dokuz Eylül University Hospitals, Izmir, Turkey.
Reprint requests to Dr. Izge Günal, Ruzgar Sokak,
Cankaya Apt. No: 51/20, 35330, Balcova, Izmir, Turkey.
Received: March 29, 2001.
Revised: July 2, 2001; October 2, 2001.
Accepted: October 11, 2001.
127
© 2002 Lippincott Williams & Wilkins, Inc.
symptoms after initial reduction or disappear-
ance of pain have been reported5,15,17,19 and the
effectiveness of corticosteroid injections has
not been established.
In the current study, the effect of local
corticosteroid injection with a local anesthetic
was evaluated by comparing its effect with the
effect of a local anesthetic alone, in a prospec-
tive controlled trial.
MATERIALS AND METHODS
The series consisted of 120 patients with lateral
epicondylitis. The criteria for inclusion were: pain
on the lateral side of the elbow, tenderness over the
extensor origin in the forearm, a positive tennis el-
bow pain test (Mills’ sign) with pain the lateral epi-
condyle when the elbow is actively moved from
flexion to full extension with the forearm in the
prone position and the wrist in flexion,7 and posi-
tive chair test with pain in the region of lateral epi-
condyle when a chair is lifted with one hand in a po-
sition with the forearm pronated and the wrist is in
flexion.8 Patients with associated conditions in-
volving the upper limb such as injury to the elbow,
carpal tunnel syndrome, medial epicondylitis, ra-
dial tunnel syndrome, and effusion about the an-
coneal triangle, indicating an intraarticular disease,
were excluded from the study. Also, patients with
previous injections for lateral epicondylitis were
not included in the study. Throughout the trial, the
criteria of Chalmers et al3 were used.
The trial was approved by the local ethical com-
mittee and every patient gave informed consent.
The first 60 consecutive patients were treated by in-
 Clinical Orthopaedics
128 Altay et al and Related Research

jection of 1 mL triamcinolone with 1 mL lidocaine
(Group A) and the next 60 patients by 2 mL of li-
docaine alone (Group B). The patients were blinded
to the type of injection. The patients in the groups
were well-matched for age and duration of the
symptoms. The mean age of the patients in the two
groups was 43.4 and 44.1 years, and the duration of
the symptoms was 8.3 and 7.9 months, respec-
tively. Thirty-six patients in Group A and 41 pa-
tients in Group B previously were treated unsuc-
cessfully with antiinflammatory medication.
Injection Technique
The elbow is flexed 90
with the palm down.
Pronation of the hand is preferred to supination be-
cause it is more readily fixed in this position. An
18-gauge needle is introduced immediately ante-
rior and distal to the lateral epicondyle at the point
of maximum tenderness. By inserting, injecting,
withdrawing, slightly redirecting, and reinserting
without emerging from the skin, the area literally is
peppered with small injections.16 During the injec-
tion a sensation like crepitation or cracking is felt
and the injections are continued until this sensation
is lost. This requires 40 to 50 shots.
The needle should be handled lightly and in-
serted gently to avoid damage if the bone is con-
tacted, as is frequently the case.16
A third group of patients also was included in the
trial using the same technique but with saline injec-
tion, however this attempt was discontinued after
two patients because the procedure was too painful.
The patients in the trial were seen 2 weeks after
the start of the treatment and a second injection was
given if there were persistent symptoms. No med-
ication was given and no restriction of activity was
advised. The patients were evaluated by a reviewer
who was blinded to the study at 2, 6, and 12 months
after the injection. The results were assessed using
the modified criteria of Verhaar et al18 (Table 1). A
hand dynamometer was not used in the current
study, because the validity of the measurements is
questionable, and the nonstandardized verbal in-
structions may substantially affect the results.4 Sta-
tistical analysis was done using Student’s t test.
RESULTS
Three patients in Group A and four patients in
Group B were given second injections 2 weeks
after the first injection. In these patients 10 to
15 shots were enough to end the crepitation or
cracking. The contents of the second injec-
tions were the same as the first injections.
At the second control (2 months after the
first injection) 56 patients in Group A and 57
patients in Group B had excellent results, as as-
sessed using the criteria of Verhaar et al.18 The
patients were completely satisfied with the re-

TABLE 1. Scoring System for the Results of Treatment of Lateral Epicondylitis19

Excellent Complete relief of pain of the lateral epicondyle

Patient satisfied with the results of treatment
No subjective loss of grip strength
No pain provoked by resisted dorsiflexion of the wrist
Good Occasional slight pain on the lateral epicondyle after strenuous activities
Patient satisfied with the result of treatment
No or slight subjective loss of grip strength
No pain provoked by resisted dorsiflexion of the wrist
Fair Discomfort on the lateral epicondyle after strenuous activities but at a more tolerable level than
before treatment
Patient satisfied or moderately satisfied with the result of treatment
Slight or moderate subjective loss of grip strength
Slight or moderate pain provoked by resisted dorsiflexion of the wrist
Poor No decrease of pain of the lateral epicondyle
Patient dissatisfied with the result of treatment
Severe subjective loss of grip strength
Severe pain provoked by resisted dorsiflexion of the wrist

(Reprinted with permission from Verhaar JAN, Walenkamp GHIM, van Mameren H, Kester ADM, van der Linden AJ: Local cortico-
steroid injection versus cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg 78B:128–132, 1996.)
Number 398
May, 2002
sults of the treatment including the provocative
tests (chair test and Mills’ sign) which became
negative. There was no difference statistically
between the groups (p  0.05).
Two of the remaining four patients in
Group A had good results and two had fair re-
sults, and one patient each had good, fair, and
poor results in Group B. The only patient with
a poor result was treated by open release of the
common extensor origin. Patients with fair re-
sults refused additional treatment.
The results were not changed at 6 and 12
months after the injection. The three patients
with a good, fair, or poor result were advised
to participate in a physiotherapy program.
No complications attributable to injections
such as hypopigmentation of the skin, postin-
jection flare, facial flushing, or infection were
observed during the study. Additionally, no
complications attributable to local effects of
corticosteroids, such as tendon rupture, were
observed in Group A.
DISCUSSION
Although the peppering technique of injection
in the treatment of tennis elbow was described
almost 40 years ago,16 evidence suggests that
it is a forgotten technique because a careful re-
view of the literature revealed no citation or
use of the technique.
In the current study, no difference was found
between cortisone and local anesthetic injec-
tion (Group A) or local anesthetic alone injec-
tion (Group B), using the peppering technique.
However, excellent results were achieved in
93% of the patients in Group A and 95% of the
patients in Group B. When good results are
added, the success rates are even better. These
results are superior to the results of other pub-
lished series. Dijs et al6 reported a 91% disap-
pearance or improvement in symptoms 1 week
after injection of corticosteroid, but symptoms
recurred in 1⁄2 of the patients after 3 months. No
recurrence was detected in the current patients,
although they were followed up for 12 months.
It is possible that this high rate of success is at-
tributable to the technique of injection. Injec-
Local Infection Treatment for Lateral Epicondylitis 129
tion of local anesthetics should not be used for
treatment of lateral epicondylitis, except for
diminishing the irritative effects of cortico-
steroids; the effects of local anesthetics are
equal to that of a placebo.5,17 However, the role
of corticosteroids in the treatment of lateral epi-
condylitis also is questionable because the ef-
fectiveness of corticosteroids is not well estab-
lished by controlled studies and is based more
on practical experience.2,11,17 Some authors
prescribe injections of corticosteroids only on
occasions when the pain is so severe that it pre-
vents the patient from doing rehabilitative ex-
ercises.10 According to Boyer and Hastings, “if
corticosteroid has any effect on patients with
lateral tennis elbow, it is of a short duration.”2
This conclusion also has been supported by
clinical studies.1,6,12
The best method for evaluating the effects
of the peppering technique is to administer it
with saline injections but, as in the two pa-
tients in the current study, this is a painful pro-
cedure, probably because of the damage to the
periosteum.2,16
The results of the current study are compa-
rable with results of open or percutaneous re-
lease of the common extension origin.9,14,18 or
excision of abnormal tissue which consisted of
tears involving the extensor origin and granu-
lation tissue deep to the common extensor ori-
gin.4,13 In all types of operative procedures,
the aim is to revitalize, debride, and bypass the
area of tendinosis.10 The peppering technique
probably simulates these procedures by creat-
ing new channels through the degenerative
myxoid tissue, in which bleeding occurs; this
may initiate the mode of healing in lateral epi-
condylitis.10 A cadaver study may be helpful
in explaining the exact mechanism.
In the current study, three patients in Group
A and four patients of Group B needed second
injections possibly because of insufficient pen-
etration of the degenerative tissue at the first at-
tempt. Fewer shots (10 to 15 compared with 40
to 50) were enough at the second occasion, and
the patient’s symptoms resolved.
The results of the current study, the largest
series in the literature with a sufficient fol-

130 Altay et al
lowup beyond the limits of recurrence, sug-
gest that the peppering technique is a reliable
method for treatment of lateral epicondylitis.
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