Epicondylar Injections: Picking Between Viscosupplementation and Corticosteroids

What are Epicondylar Injections?

An epicondylar injection is a minimally invasive procedure during which medication, often a combination of local anesthetics and corticosteroids, is injected into the elbow area. The local anesthetic provides immediate but short lasting pain relief while the corticosteroids help to provide lasting pain relief and reduced inflammation. Candidates for epicondylar injections are typically patients who have not responded to more conservative treatments for elbow pain such as rest, ice, over the counter medications, and physical therapy. Many patients that receive epicondylar injections have developed pain from overuse of the elbow during sports such as tennis, baseball, golf, racquetball, or weight lifting. 

Corticosteroid Injections

The primary treatment for ongoing elbow pain has typically been corticosteroid injections. Steroids have a wide range of effects including inflammation reduction and promotion of pain relief from chronic injuries. They can therefore be used to treat a wide range of painful elbow conditions including arthritis, tendonitis, bursitis, or non specific joint pain. The duration of pain relief following treatment usually ranges from weeks to months and depends greatly on the patient and their pathology. Some patients may even have their pain permanently resolved. Due to the side effects of prolonged steroid use, a patient is typically limited to receiving three or four corticosteroid injections in a year. 

Viscosupplementation Injections

More recently, an alternative to steroid injections, viscosupplementation, has become an increasingly popular treatment option. Often used in patients with cartilage injuries and conditions like osteoarthritis, hyaluronic acid is injected into an affected joint. In joints, such as the elbow, the ends of the adjacent bones are covered with cartilage to allow for smooth range of motion. This cartilage is naturally coated with hyaluronic acid, which acts as both a lubricant and shock absorber for the joint. 

In patients with cartilage conditions such as osteoarthritis, there is often less hyaluronic acid, which can lead to increased friction at the joint and, ultimately, increased pain and swelling. Injecting hyaluronic acid directly into the elbow joint is therefore a means of restoring a patient’s normal hyaluronic acid levels to decrease friction and inflammation at the joint. 

Pain relief with hyaluronic acid is not immediate, however. It may take a few or even several injections for a patient to feel significant relief from their chronic elbow pain. Fortunately, receiving a series of hyaluronic acid injections can also stimulate the body to begin producing its own natural hyaluronic acid over time and further contribute to the experienced pain relief. The specific impacts of hyaluronic acid include improved joint lubrication and increased range of motion for the joint. As a result, viscosupplementation is useful in treating a more limited number of conditions, such as elbow arthritis, in comparison to the wider array that steroid injections seek to treat. 

Deciding Between Corticosteroids and Viscosupplementation

For a steroid injection, the elbow will first be cleaned to reduce the chance of infection occurring after the injection. Next the provider will likely apply an anesthetic to numb the elbow area where the needle for the injection is going to be inserted. The provider will then likely use a combination of ultrasound and X-ray imaging to confirm appropriate placement of the needle at the injection site. Once the needle placement is confirmed, anesthetic and steroids will be injected into the elbow joint. Overall, the procedure is short, requires no recovery time, and individuals can usually return to activity without restriction. Though some patients experience immediate pain relief, it can take up to a few days before the anti-inflammatory effects are noticed and pain subsides.

The procedure for viscosupplementation is very similar to steroid injections. The elbow will first be cleaned to reduce the risk of infection and then a small amount of anesthetic will be applied to numb the injection area. If there is excess fluid in the joint, a provider may choose to drain some of the fluid before proceeding with the injection. Ultrasound and x-ray imaging are then used to confirm appropriate placement of the needle before injecting. Once placement is confirmed, the provider will slowly inject hyaluronic acid into the joint space. Depending on the brand of injection used, a patient may need to receive one to four more injections spread out over a number of weeks. It is common for some patients to experience warmth and swelling at the injection site immediately after the procedure, but these symptoms should resolve quickly and may be managed with use of an ice pack. After the procedure, it is typically recommended that a patient avoids strenuous activity for 24-48 hours. The amount of time it takes for a patient to experience relief varies, but the duration of pain relief is often reported to last longer for viscosupplementation injections than corticosteroid injections.

Make the Final Decision with a Pain Specialist

Overall, both treatments for epicondylar and other joint pain have proven successful in many patients and have allowed for quality of life to be restored. If you are suffering from chronic elbow pain  or joint pain and want to explore the treatment benefits of viscosupplementation or corticosteroid injections, book your initial consultation at Ospina Medical today! 

Written By: Ashley Knebel

Edited By: Camden Rowe