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TENNIS ELBOW
100 THE JOURNAL OF BONE AND JOiNT SURGERY
R. S. GARDEN, PRESTON, ENGLAND
From the Orthopaedic Department, Preston Royal Infirmnari
The condition which is so inaptly known as tennis elbow is chiefly an affliction of middle age (Fig. 1). Many patients seek relief from this complaint, but few are found to be active participants in the game from which this syndrome has derived its name. The term “ epicondylitis “ which Continental writers have preferred is equally unsatisfactory, and it is unlikely that an acceptable name NUMBEROF for this condition will be found until its true pathology is known. Tennis elbow is widely re- garded as a minor ailment which causes little more than an incon- venience to the patient. It is well known, moreover, to be a self- limiting condition which seldom persists for longer than twelve months under the age of sixty, and which, once cured, is unlikely to return (Cyriax 1936). Although this may generally be true, there are occasions when the disability is more serious. The workman who is prevented from earning his uPs livelihood by pain over the outer (Ycars) aspect of his elbow regards the FIG. I condition as an economic calamity. Age incidence of tennis elbow in 131 patients (total number of He finds little comfort in the in- elbows affected I 37 : women eighty-two ; men forty-nine). The symptoms were bilateral in six patients. formation that spontaneous cure is to be expected in time, and demands more active measures to hasten his relief. Many methods of treatment have been suggested, but much has been done in the past to discredit these measures by inaccurate diagnosis. In present-day practice, however, the label of tennis elbow is no longer applied to all manner of vague discomforts in the upper limb, but is reserved only for those cases which satisfy well established diagnostic criteria.
DIAGNOSIS The syndrome of tennis elbow is characterised by pain over the outer aspect of the elbow and by aggravation of this pain on radial extension of the wrist. The essential features in diagnosis are : I ) tenderness on pressure over the region of the radio-humeral gap, and 2) acute discomfort during resisted extension ofthe wrist. In the absence ofthese findings the diagnosis of tennis elbow should not be made. Such actions as raising a cup, using a hammer or lifting a shovel typify the particular movement which initiates the pain, and the wrist extension test is but a convenient way of reproducing this movement. This test is best performed with the elbow in extension, but it may sometimes be found that the patient who suffers from tennis
TENNISELBOW 101
elbow is unable to extend this joint fully (Mercer 1959), and an elastic resistance to the last few degrees of extension is encountered by the examiner comparable to that found with a locked semilunar cartilage in the knee.
PATHOLOGY With such clearly defined clinical and diagnostic features the continued obscurity of the pathology in tennis elbow is surprising. This problem would doubtless have long been clarified had the surgeon been less reluctant to explore the elbow in a condition which scarcely warrants such interference with this unusually sensitive joint. Since the condition was described by Runge in 1873 a bewildering list of suggestions in regard to causation and to treatment has appeared. Local inflammation, muscular or ligamentous strain, bursal irritation, nipping of synovial fringes, teno-periosteal tears, disturbances of local metabolism, degenerative changes in the orbicular ligament and cervical root irritation have each been held responsible for the symptoms. Further confusion has followed the attempts that have been made to classify this syndrome into different categories according to the site of greatest tenderness over the outer aspect of the elbow. The tender point may be found to lie along the epicondylar ridge, over or in front of the lateral epicondyle, in the region of the radio-humeral joint, or more distally in the extensor muscle mass. Such variation does not necessarily support the assumption that different types of lesion exist. The most constant feature of the syndrome is the production of pain during extension of the wrist in radial deviation. This movement is performed by the extensor carpi radialis longus and brevis. Cyriax (1954) pointed out that, since the tenderness in tennis elbow is most frequently situated in the region of the lateral epicondyle, the fault is more likely to lie in the short radial extensor, which arises mainly from this epicondyle, than in the long extensor which arises more proximally along the lateral epicondylar ridge. A tear between the common extensor origin and the underlying periosteum is still the most popular conception ofthe lesion in tennis elbow. Despite the accessibility ofthe epicondyle no indisputable evidence of such a tear in these tough structures has ever been forthcoming. A lesion in this situation should cause pain during the contraction of any, or all, of the muscles which derive from the common extensor origin. Since this does not occur, it would suggest that the origins peculiar to the extensor carpi radialis brevis are alone involved. This muscle is the only member of the superficial extensor group which arises from the lateral ligament which, in turn, blends with the capsule ofthe elbow and is inserted into the orbicular ligament.
If the lesion were to lie in the lateral ligament, forced adduction of the elbow should be
accompanied by the discomfort which is associated with the tennis elbow syndrome. This manoeuvre, however, seldom reproduces faithfully such discomfort, and may on occasion be followed by complete and permanent relief of symptoms. The curative value of forced adduction of the elbow may be related to the traction which the tautened lateral ligament must exert upon its distal and relatively mobile anchorage, the orbicular ligament. This ligament is believed to play a significant role in tennis elbow. Bosworth (1955) and Meyer (1957) advised its resection for the reliefof pain when conservative measures failed, and Bosworth stated that microscopic examination revealed evidence of hyaline degeneration and disorganisation of its structure. Compere (1956) reported that he had resected the orbicular ligament when operating for tennis elbow and had usually found a button-hole split in its substance. These observations, together with the finding that tennis elbow is commonly associated with middle age, support the belief that degenerative changes in the orbicular ligament constitute the underlying pathology in this condition. However this may be, contraction of the extensor carpi radialis brevis must still be singled out as the factor that produces pain in tennis elbow.
VOL. 43B, NO. 1, FEBRUARY 1961
INCISION
TENNIS ELBOW 103
VOL. 43 B, NO. 1, FEBRUARY 1961
lengthening of the tendon was then undertaken just distal to the musculo-tendinous junction. The same relief of symptoms followed this procedure and persistent tenderness at the site of operation was no longer troublesome. In an attempt to simplify the interruption of the action of extensor carpi radialis brevis the tendon ofthis muscle was sutured to the overlying tendon ofextensor carpi radialis longus, but the improvement which followed this procedure was clearly less positive than the relief of symptoms which accompanied actual lengthening of the tendon itself.
EXTENSOR POLLICIS BREVIS ABDUCTOR POLLICS LONGUS
FIG. 2 Incision for Z-lengthening of the extensor carpi radialis brevis tendon above the level of its synovial sheath.
Operative technique-Open lengthening of the tendon of extensor carpi radialis brevis may be
carried out under local anaesthesia, but general anaesthesia in conjunction with a pneumatic tourniquet is to be preferred. A small incision is made over the dorsi-lateral aspect of the forearm just proximal to the point at which the thumb extensors cross the radius obliquely (Fig. 2). The incision is deepened to show the flattened tendon of extensor carpi radialis longus, which is then drawn gently aside to expose the underlying tendon of extensor carpi radialis brevis. This tendon is also flattened and may consist of as many as five distinct sub- sections. lfthe incision is correctly placed 110 muscular fibres will be exposed, and the tendon can be cleanly divided by a Z-shaped tenotomy (Fig. 3). When division is complete and the cut ends have separated a catgut suture is inserted to hold the divided ends loosely together, and the wound is closed. No restrictions need be placed upon FIG. 3 the (^). patient’s activities. other than the Open lengthening ofZ-shaped the extensortenotomy. carpi radialis brevis by avoidance of vigorous use of the arm during the first few days after operation. Early in the series one patient insisted upon returning to work immediately and the distal end of the divided tendon was later found curled up in a nodule at the wrist. A second patient used a wood chopper on the day of operation and the distal end of the tendon worked itself downwards in the same way. Since then the precaution has been taken ofinserting a catgut holding suture, and this complication has not again been seen. Results-The relief from pain which may be expected from lengthening of the extensor carpi radialis brevis tendon would be offset if weakness in the forearm or hand persisted. Such weakness in radial extension or in the power of the grip has never been a troublesome feature
Case number ex
Duration Side of affected symptoms (months)
Date of operation
3 4 5 6 7 8 9
10 II 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
F M M F M M M F F F M M M F M M M F M F M M M M F F F M M F F M F F M M F F M F F F F F M M F M M M R R L R R R R R R R
L L R R R R R L L R L R R L R R R L R R R R R R R L R R R R R R R R R R R R R*
104 R. S. GARDEN
THE JOURNAL OF BONE AND JOINT SURGERY
TABLE I CLINICAL DETAILS IN FIFTY PATIENTS TREATED BY DIVISION OF THE EXTENSOR CARPI RADIALIS BREvI5 TENDON
Age Occupation (years)
52 Housework 39 Carpenter 46 Crane driver 42 Weaver 49 Brick burner 56 Company director 49 Farmer 60 Housework 36 Housework 47 Teacher 41 Painter 34 Butcher 47 Shoemaker 36 Bookkeeper 33 Representative 47 Labourer 53 Salesman 47 Housework 43 Fireman 62 Cook 49 Mechanic 44 Police officer 47 Labourer 36 Electrician 57 Housework 45 Weaver 46 Housework 45 Police officer 50 Overlooker 45 Clerk 36 Domestic help 36 Moulder 48 Housework 49 Housework 59 Planer 42 Foundry worker 48 Housework 50 Chemist 45 Packer 49 Weaver 43 Typist 37 Shop assistant 45 Shop assistant 44 Housework 61 Local Government officer 46 Clerk 45 Housework 45 Labourer 42 Electrician 42 Motor engineer
6 15654 4 31854 5 21954 6 21954 2 21954 4 12 1054 3 121054 3 2410/ 4 91154 3 301154 3 4155 3 18155 2 1/3/ 4 8355 4 22355 9 22355 3 105/ 2 24/5/ 3 31/ 3 7655 5 23855 3 23855 4 20955 5 4 1055 6 181055 9 25 10, 4 251055 3 21255 5 12756 4 10756 11 41256 5 8157 4 5:3, 9 2457 3 21557 3 28557 3 76/ 3 16/7/ 6 23/7/ 4 20:8; 7 20 857 5 25:9, 8 3, 9 12/12/ 4 12/ 6 2158 3 29558 3 198/ 8 9: 4 41158
106 R. S. GARDEN
of the recovery phase. As is not unusual after division of extensor tendons elsewhere, spontaneous healing has followed division of the extensor carpi radialis brevis as judged by palpation of its tendon at the wrist. Healing with some degree of lengthening must certainly occur, but this should be compensated for by adaptive muscle shortening. Theoretically permanent interference with muscle power is unlikely to be other than minimal, but if the advocacy of this procedure is to be justified fully it must be supported by a study of the late results of the operation in a sufficient number of patients observed over a reasonable length of time. For this purpose the first fifty patients treated by this operation were re-examined after nine months to five years. Each patient was subjected to dynamometer grip tests and to spring balance measurement of radial extension power (Table I). The tendon of the extensor carpi radialis brevis was examined at the wrist, and the patients were questioned about persistence of symptoms at the elbow or tenderness at the operation site. Analysis of these results suggested that no patient failed to benefit in some way from the operation, and most obtained full and lasting relief. Residual complaints were of a minor character, and the dynamometer and spring balance tests showed no significant reduction in the power of wrist extension or grip. The length of time lost from work after this operation varied considerably and was largely dictated by the presence of the wound dressing. The clerical worker was able to resume work almost immediately and the heavy worker within a few weeks of the operation. SUMMARY
- Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology.
- It has been shown that most patients may be relieved by either extra-articular or intra- articular injection of hydrocortisone, and operative intervention is required only in a minority of cases.
- Contraction of the extensor carpi radialis brevis is considered to be the principal pain- producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed.
- The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability. I wish to thank my registrars, Mr F. F. Silk and Mr D. G. Wray, who have conducted the trial series of intra-articular injections, and who have given much assistance with the follow-up review.
REFERENCES BoswoRTH, D. M. (1955) : The Role of the Orbicular Ligament in Tennis Elbow. Journal of Bone and Joint Surger.i’, 37-A, 527. COMPERE, F. L. (1956): Editorial Footnote. The Year Book ofOrthopedics and Trau,natic Surger. (1955- Year Book Series), p. 205. Chicago: The Year Book Publishers Inc. CYRIAX, J. (1936): The Pathology and Treatment of Tennis Elbow. Journal ofBone andfoint Surgery, 18, 921. CYRIAX, J. (1954): Text-Book of Orthopaedic Medicine. Third edition. Vol. 1, pp. 274-277. London: Cassell & Company Ltd. HOHMANN, G. (1926): (Jber den Tennisellenbogen. Verhandlungen der Deutsche,, Orthop#{228}dischen Gesc/l.s’c/za/ , 21, 349. HOLLANDER, J. L., Ed. (1953): Comroe’s Arthritis. Fifth edition, p. 332. London: Henry Kimpton.
HOYER, H. (1957): Kurze Mitteilung flber eine einfache Behandlungsmethode der Epicondylitis humeri mit
lokaler subkutaner Luftinsuffiation. Therapie der Gegenwart, 96, 3 1 1. KAPLAN, E. B. (1959): Treatment of Tennis Elbow (Epicondylitis) by Denervation. Journal of Bone and Joint Surgery, 41-A, 147. MERCER, Sir W. (1959): Orthopaedic Surgery. Fifth edition, p. 993. London: Edward Arnold (Publishers) Ltd. MEYER, R. (1957): The Painful Elbow. A New Approach. Acta Medica Orientalia, 16, 262. RUNGE, F. (1873): Zur Genese und Behandlung des Schreibekrampfes. Berliner Klinische Wochensc/irift, 10, 245. THE JOURNAL OF BONE AND JOINT SURGERY
