Corticosteroid, Autologous blood or Polidocanol injections guided by ultrasound in the management of tennis elbow: a randomised clinical pilot trial. (The CAP trial)

Ultrasound Guided Injection techniques: Corticosteroid injection The Common extensor tendon is assessed with ultrasound for tear and tendinopathy and if required the skin is marked with a texta over the abnormal area. The skin is prepared with a chlorhexidine wash. With Ultrasound guidance, using a 25 g needle the CEO tendon substance and superficial surface is infiltrated with 3ml of 0.5% Xylocaine. With a second 25 g needle and syringe, 1 ml Celestone chronodose and 1ml of Marcaine is inject with ultrasound guidance into the abnormal tendon substance and also along the superficial tendon surface. Autologous Blood Injection (ABI) The Common extensor tendon was assessed with ultrasound for tear and tendinopathy and if required the skin was marked with a texta over the abnormal area. The skin is prepared with a chlorhexidine wash. Using Ultrasound guidance a 25 g needle is inserted and 3ml of 0.5% Xylocaine is injected into the abnormal area and superficial to the tendon. Multiple dry needling punctures of the tendon are performed at this time to cause local bleeding. 3 ml of autologous blood is drawn from a cubital fossa vein of the other elbow. This blood is mixed with 1ml of Marcaine and injected into the tendon with ultrasound guidance via a second 25 g needle and syringe targeting the abnormal area. Sclerosant Injection The Common extensor tendon is assessed with ultrasound for tear and tendinopathy. The distribution of neovascularity is assessed. The neovascularity arises medial to the CEO from the radial collateral branch of the profunda artery and radial recurrent artery. The neovascularity then courses from medial to lateral superficial to the CEO. The sites of neovascularity are marked on the skin with a texta. The skin is prepared with a chlorhexidine wash. With ultrasound guidance between 2-4ml of Polidocanol is injected via a 25 g needle into the neovascularity superficial to the tendon. The neovacularity is targeted from lateral to medial back to the normal artery. Care is taken to inject the only the neovascularity outside the tendon. Polidocanol is not injected into the tendon substance and also is not injected too superficially to avoid causing skin necrosis. In the sclerosant and ABI groups, injections are repeated at four weeks. Physiotherapy Protocol: All participants will be given an information sheet outlining activity modification and taught a home eccentric exercise program.