# Ultrasound-Guided Procedures in Common Tendinopathies at the Elbow: From Image to Needle
## 3 Common Elbow Pathologies
### Golfer's Elbow
#### 3.2.2 US scanning and Guided Injection  
For US scanning of the CFT, the patient may be positioned semi-supine on the examination bed while the patient's arm is resting on the bed with the forearm hanging over the bed's edge. As an alternative, the patient may sit facing the examiner, leaning to the ipsilateral side with the supinated forearm resting on an examination bed. To obtain the longitudinal view of the CFT, the transducer is placed at the medial humeral epicondyle (ME) along the forearm's long axis. The important bony landmarks would be the ME and coronoid process of the ulna. Superficial to these bony structures, the anterior bundle of the MCL and CFT can be identified (Figure 6a). Compared to CET, the CFT is broader and shorter. Normally, the CFT is proximally noncompressible and compressible distally while the softer muscle tissue prevails the stiffer tendon. A sensitivity and specificity of 95% and 92%, respectively, have been reported for the detection of clinical golfer's elbow. Characteristic US images of medial epicondylitis show focal areas of hypoechogenicity [59]. Typically, the swelling in a golfer's elbow is located very proximally (Figure 6b) [15]. Fur  
Figure 5: Common origin of flexors from the medial epicondyle. (**a**) Common flexor tendon originating from the medial epicondyle. Muscles are covered by antebracchial fascia. (**b**) The same specimen without fascial covering; the lacertus fibrosus was removed. Black arrow: medial epicondyle, yellow arrowhead: median nerve, red arrowhead: brachial artery, black arrowhead: distal biceps tendon, CFT: common flexor tendon, FCR: flexor carpi radialis muscle, FDS: flexor digitorum superficialis, FCU: flexor carpi ulnaris muscle, LF: lacertus fibrosus (aponeurosis of the biceps brachii), PL: palmaris longus muscle, and PT: pronator teres muscle. ther signs, such as tendon thickening, cortical irregularities, intratendinous calcifications, and hypervascularity, are also common (Figure 6c,d). Notably, lesions of the anterior bundle of MCL can mimic or be concurrent with medial epicondylitis. In such a scenario, US imaging would reveal MCL structural abnormalities, e.g., thickening and discontinuity. Notably, the dynamic US valgus stress test might be beneficial to demask MCL rupture, coupled with elbow instability [19]. There is a lack of evidence for injections in medial epicondylitis. To the best of our knowledge, no meta-analysis was performed, and there are only a few RCTs. [PERSON] et [PERSON] [64] performed RCT on 60 elbows comparing CS injection with placebo and concluded that CS injection has only short-term (6 weeks after the injection) benefit in pain reduction. The long-term effect was the same for CS and placebo. [PERSON] et al. [65] performed a prospective study on 20 subjects assessing pain reduction after dry-needling and autologous blood injection under US control. They found this combined method effective in reducing pain ten months after the procedure. [PERSON] et al. [66] found in their cohort study (level of evidence 3) that PRP injection had a similar clinical effect as surgical treatment. For the golfer's elbow injection, the patient may be positioned in the prone while his or her forearm also rests pronated on the examination bed (Figure 7). The probe is positioned on the medial epicondyle perpendicular to the long axis of the forearm. The needle is inserted from lateral to medial. Again, depending on the particular procedure plan, the injection can be performed peri- or intratendinous. The parallel course of the needle to the probe provides excellent needle visibility along its whole path (Figure 6e). Alternatively, the needle can be inserted from distal to proximal (Figure 6f). When injecting a golfer's elbow, one should take caution not to pierce the ulnar nerve, particularly in cases of ulnar nerve anterior dislocation [67] or in patients who underwent ulnar nerve anterior transposition surgery. Using US imaging, the safe needle route can be determined proceeding with the intervention.