Causes and findings:
• Overuse
• Pain at front of elbow
• Painful: resisted flexion and supination of elbow plus full passive flexion, extension and pronation of elbow if bursa affected - a 'muddle' of signs
Equipment:
Syringe - Tendon 1ml bursa 1ml
Needle - 23G 1 inches (25mm) blue
Kenalog 40 - tendon 10 mg bursa 20 mg
Lidocaine - tendon 0.75 ml 2% bursa 1.5 ml 2%
Total volume - tendon 1 ml bursa 2 ml
Anatomy:
Although the biceps can be affected at any point along its length, the insertion into the radial tuberosity on the anteromedial aspect of the shaft of the
radius is particularly vulnerable. A small bursa lies at this point and can be inflamed together with the tendon or on its own. The insertion of the biceps is identified by following the path of the tendon distal to the cubital crease while the patient resists elbow flexion. The patient then relaxes the muscle and the tuberosity can be palpated on the ulnar side of the radius while passively pro- and supinating the forearm. The site is always very tender to palpation, even in the normal elbow.
Technique:
• Patient lies face down with arm extended and palm flat on table. Fix humerus on table and passively fully pronate forearm. This brings the radial tuberosity round to face posteriorly
• Identify radial tuberosity two fingers distal to radial head
• Insert needle perpendicularly to touch bone
• Pepper solution into tendon or bolus into bursa, or both, as necessary
Aftercare:
Rest for 1 week before beginning graded strengthening and stretching routine, followed by addressing the cause of the overuse.
Comments:
Differentiation between bursitis and tendonopathy is often difficult. If there is more pain on passive flexion and pronation of the elbow than on resisted flexion, together with extreme sensitivity to palpation, the bursa is more suspect.
Alternative approaches:
If a double lesion is suspected, infiltrate the bursa first and reassess 1 week later. The tendon can then be injected if necessary.
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