To the Editor:
Medial and lateral epicondylitis are the most common elbow problems in adults. Corticosteroid injection for the treatment of medial epicondylitis is a frequently used method of conservative management.
A 34-year-old right-handed woman was referred to our clinic with a 4-month history of pain along the medial side of her right elbow. She had been treated for medial epicondylitis with oral nonsteroidal anti-inflammatory drugs, activity modification, and local cold application for 1 month, and then had a 40 mg injection of methylprednisolone acetate to the right elbow for medial epicondylitis due to the resistance of pain. In 3 months’ time, her pain worsened. She could not wear short sleeves due to severe tenderness at the medial elbow, occurring even after contact with the torso. Examination revealed atrophy of the skin and subcutaneous fat over the medial epicondyle causing the epicondyle to become prominent like an osseous mass (Figure). Marked tenderness was observed over the prominent medial epicondyle by palpation.
Figure: The appearance of skin and subcutaneous fat atrophy after corticosteroid injection into the medial epicondyle.
Intraoperatively, the atrophied skin and subcutaneous fat tissue were excised from an ellipsoid incision. Two chalky, whitish deposits of corticosteroid were observed over the flexor aponeurosis. The deposits were excised. The common flexorpronator origin was partially detached by sharp dissection and reflected without disturbing the medial collateral ligament. The underlying fibrous tissue was debrided. The medial epicondyle was drilled, creating multiple bleeding small holes, and then the flexorpronator origin was reattached. The adjacent subcutaneous tissue and skin were released and brought over the epicondyle, forming good soft tissue coverage. Three years postoperatively, the patient had unlimited range of elbow motion with no epicondylar pain, and no pathologic bony prominence of the epicondyle was observed.
Although steroid injection for the conservative treatment of medial epicondylitis is an alternative method, previously reported complications of periarticular injections and the case presented here demonstrate related adverse effects or complications. Injection into the medial site of the elbow may not be as innocent as expected if appropriate injection technique is disregarded.
Tahsin Beyzadeoglu, MD
Halil Bekler, MD
Alper Gokce, MD