Hand and arm pain: A pictorial guide to injections

Treatment: Select an approach based on symptom severity

In a retrospective analysis, Lane et al concluded that classification of patients with de Quervain’s disease based on pretreatment symptoms may assist physicians in selecting the most efficacious treatment and in providing prognostic information to their patients (TABLE 3³⁴). Patients with mild to moderate (Types 1 and 2) de Quervain’s may benefit from immobilization in a thumb spica splint, rest, NSAIDs, and physical or occupational therapy. If work conditions played a role in causing the symptoms, they need to be addressed to improve outcomes. Types 2 and 3 can be initially treated with a corticosteroid injection, but may eventually require surgery.³³

Treatment with NSAIDs or corticosteroid injections (see TABLE 1^2-4 for choices) in the first compartment of the extensor retinaculum (FIGURE 7) is usually adequate to provide relief. Peters-Veluthamaningal et al performed a systematic review in 2009 and found only one controlled trial of 18 participants (all pregnant or lactating women) who were either injected with corticosteroids or given a thumb spica splint.³⁵ All 9 patients in the injection group had complete pain relief, whereas no one in the splint group had complete resolution of symptoms.³⁵ Typical anatomic placement of corticosteroid injections is shown in FIGURE 7.

More complicated injection methods have been described, but injecting the first dorsal compartment is usually satisfactory. Patients will feel the tendon sheath filling with the injection material. The 2-point technique, implemented by Sawaizumi et al, which involves injecting corticosteroid into 2 points over the EPB and APL tendon in the area of maximum pain and soft tissue thickening, is more effective than the 1-point injection technique.³⁶

Severe, recalcitrant cases. Professional and college athletes may be prone to recalcitrant de Quervain’s tenosynovitis. A 2010 study by Pagonis et al showed that recurrent symptomatic episodes commonly occur in athletes who engage in high-resistance, intense athletic training. In these severe cases, a 4-point injection technique offers better distribution of corticosteroid solution to the first extensor compartment than other methods.³⁷ Consider referring severe cases to a hand surgeon.

Check for carpal tunnel syndrome when examining a patient with trigger finger; the 2 conditions often co-occur.

Surgical release of the first dorsal compartmental sheath around the tendons serves as a final option for patients who fail conservative treatment. Care should be taken to release both tendons completely, as there may be at least 2 tendon slips of the APL or there may be a distinct EPB sheath dorsally.³⁸

“Tennis elbow”— you don’t have to play tennis to have it

Lateral epicondylitis (tennis elbow) is a painful condition involving microtears within the extensor carpi radialis brevis muscle and the subsequent development of angiofibroblastic dysplasia.³⁹ According to Regan et al who studied the histopathologic features of 11 patients with lateral epicondylitis, the underlying cause of recalcitrant lateral epicondylitis is, in fact, degenerative, rather than inflammatory.⁴⁰

Determine whether cervical spin disease and/or peripheral neuropathy are contributing to the patient's symptoms, as patients with carpal tunnel syndrome may have more than one condition at play.

Although the condition has been nicknamed “tennis elbow,” only about 5% of tennis players have the condition.⁴¹ In tennis players, males are more often affected than females, whereas in the general population, incidence is approximately equal in men and women.⁴¹ Lateral epicondylitis occurs between 4 and 7 times more frequently than medial-sided elbow pain.⁴²

Making the Dx: Look for localized pain, normal ROM

The diagnosis of lateral epicondylitis is based upon a history of pain over the lateral epicondyle and findings on physical examination, including local tenderness directly over the lateral epicondyle,⁴³ pain aggravated by resisted wrist extension and radial deviation, pain with resisted middle finger extension, and decreased grip strength or pain aggravated by strong gripping. These findings typically occur in the presence of normal elbow range of motion.

Treatment: Choose from a range of options

Since lateral epicondylitis was first described, researchers have proposed a wide variety of treatments as initial interventions including rest, activity, equipment modification, NSAIDs, wrist bracing/elbow straps, and physical therapy. If initial treatment does not produce the desired effect, second-line treatments include corticosteroid injections (FIGURE 8), prolotherapy (injection of an irritant, often dextrose; see “Prolotherapy: Can it help your patient?” J Fam Pract. 2015;64:763-768), autologous blood injections, platelet-rich plasma injections (see “Is platelet-rich plasma right for your patient?” J Fam Pract. 2016;65:319-328), and needling of the extensor tendon origin. Refer patients who do not improve after one corticosteroid injection to an orthopedic surgeon for consideration of open or arthroscopic treatment.

CORRESPONDENCE
Gregory R. Waryasz, MD, Rhode Island Hospital, Department of Orthopaedic Surgery, 593 Eddy St., Providence, RI 02903; gregory.waryasz.md@gmail.com.