Common Extensor Tendon Origin Research Articles

Technical modifications to elbow interposition arthroplasty

Interposition arthroplasty of the elbow involves the interposition of afascia lata or dermis autograft or allograft between the distal humerus and the ulna or radius, while preserving the original form of articulation. Interposition arthroplasty is indicated for young patients with high functional demands who suffer from end-stage elbow arthritis and associated pain or joint stiffness. Contraindications include acute or subacute infection, skeletal immaturity, bone loss, deformity, or gross instability. Once the ulnar nerve has been secured, joint access is established via aposterior approach. The radial collateral ligament (RCL) and the common extensor tendon origin (CEO) are detached, while preserving the anconeus muscle and the lateral ulnar collateral ligament (LUCL). Subsequently, a capsular release is required to maintain adequate joint exposure and address the accompanying stiffness. Three to four transosseous drill holes are placed at the level of the distal humerus to secure the graft. After the graft has been positioned successfully within the joint space using two guide sutures, it can be secured to the distal humerus using ahorizontal mattress stitch. Finally, the detached tendon and ligament structures are reconstructed. After initial immobilization, early functional exercise of the elbow is performed in the motion orthosis, avoiding valgus or varus stress. The efficacy of elbow interposition arthroplasty has been demonstrated, particularly for young and active patients with severe inflammatory or post-traumatic osteoarthritis. Despite the results in terms of postoperative function and pain reduction are satisfactory, the current literature reports high complication, subsequent treatment, and revision rates. In the event of interposition arthroplasty failure, revision with another interposition procedure or conversion to endoprosthesis may be considered.

Outcomes of Autologous Blood Injection for Treatment of Tennis Elbow

Introduction: Lateral tendinosis of the elbow, sometimes called tennis elbow, refers to the degenerative process in the common source of the extended group of forearm muscles. In orthopedic clinics, it is the most prevalent cause of elbow discomfort and pain. The condition caused by repeated muscular motions is a typical cause of elbow discomfort.
 Objectives: To assess the clinical and functional outcomes of autologous blood injection for the treatment of tennis elbow.
 Methodology: This is a hospital based cross-sectional study, conducted in Birat Medical College teaching hospital. Here, the patients diagnosed with a Tennis elbow in orthopedic OPD during the study duration of September 2020 to August 2021 were included in the study. Total 93 samples were studied. Two ml of the patient's blood has withdrawn from the right antecubital vein and has been injected around the affected common extensor tendon origin. Data was analyzed using SPSS version 23.
 Results: Total Ninety Three (59% females, 41% male) patients were treated with the diagnosed concerned disease. The mean age of the patients was 45.39 ± 10.109 years. At the end of the trial, 90% of the patients were satisfied fully with the treatment. The overall performance of the regression model is significant in all scenarios.
 Conclusion: Given the satisfactory results, the blood injection in question can be deemed a suitable medication alternative to the conventional therapy.

Ultrasound-Guided Injection Approach of Treating Tennis Elbow and Elbow Joint Synovitis Simultaneously Under One Needle Insertion Point.

A 52-yr-old man with right elbow pain for 6 mos visited an outpatient rehabilitation clinic. An obvious tender spot at the lateral epicondyle area was palpated with positive Cohen test.1 The patient had received autologous platelet-rich plasma injection but without much improvement.2 Musculoskeletal ultrasound images revealed thickening of the common extensor tendon, combined with diffuse heterogeneity and focal hypoechogenicity. Bony irregularity was observed at the tendon insertion site. The diagnosis of lateral epicondylitis, also known as “tennis elbow,” is a common cause of elbow pain. The exact pathogenesis remains elusive and is often difficult to treat. Ultrasound-guided injection to the bone and common extensor tendon interface may not be effective as many patients are also bothered with elbow joint synovitis.3 As a result, this article describes an important ultrasound-guided injection approach to treat tennis elbow and joint synovitis simultaneously under one needle insertion point. When applying ultrasound-guided injection to treat tennis elbow, the elbow is flexed at a 90-degree angle. The ultrasound linear probe is placed over the lateral epicondyle, along the longitudinal axis of the common extensor tendon origin. Under this sonographic view, the common extensor tendon, the lateral epicondyle, and the elbow joint can be observed. Conventionally, injection can be done under the longitudinal view, in a distal-to-proximal or proximal-to-distal direction, by guiding the needle to the bone tendon (extensor carpi radialis brevis tendon) interface.4 For patients who are also bothered with elbow joint synovitis, simultaneous injection to the bone-tendon interface, and aspiration of the joint fluid followed by the injection of an injectant may be needed (Figs. 1A, B).3 However, under the in-plane or longitudinal view, needle insertion into the elbow joint can be difficult because of the convex curvature of the radial head (Fig. 1B). Therefore, a different injection approach is recommended. Similar to the conventional method, the linear probe is placed longitudinally on top of the elbow joint. The needle is then inserted in a lateral-to-medial direction under the out-of-plane approach or short-axis view into the elbow joint (Figs. 2A, B). The needle is observed as a hyperechoic dot inside the elbow joint. Aspiration of the joint fluid followed by injection can then be performed. Still under the short-axis view, the needle is retracted and then guided in a slightly obliqued direction to the bone-tendon interface to commence subsequent injection treatment (Figs. 3A, B). Steroid was the injectant used. Elbow pain was greatly improved after the treatment.FIGURE 1: A, The linear ultrasound transducer is placed longitudinally on top of the right elbow to visualize the lateral epicondyle, common extensor tendon, bone-tendon (extensor carpi radialis brevis) interface, and the elbow joint. Conventionally, injection can be done under the longitudinal view and in a distal-to-proximal direction by guiding the needle to the bone-tendon interface. B, The needle is accurately guided to the bone-tendon (extensor carpi radialis brevis) interface (*). Due to synovitis, increased hypoechogenicity (resembling fluid accumulation) can be observed in the elbow joint (+). Using the distal-to-proximal direction needle approach, insertion into the elbow joint can be difficult because of the convex curvature of the radial head.FIGURE 2: A, With the linear ultrasound transducer placed longitudinally on top of the right elbow, the needle is inserted in a short-axis or out-of-plane view relative to the transducer and guided into the elbow joint (pink area). B, Under the short-axis view, the injection needle can be visualized as a hyperechoic dot inside the elbow joint.FIGURE 3: A, After completing elbow joint injection, the needle is then retracted and the syringe is moved slightly in a distal direction to guide the needle to the lateral epicondylar area (curved white arrow). B, Still under the short-axis view or slightly obliqued short-axis view, the needle is guided to the bone-tendon interface.

Elbow Pain in an Adolescent Pitcher

HPI: Patient is a 16 year old right-hand dominant male baseball pitcher with past medical history of partial tear of the right UCL and OCD of the right lateral trochlea managed with casting 9 months prior. He presented to our clinic with insidious onset right posterolateral elbow and arm pain 2 months after returning to pitching in summer baseball in May. He described sharp pain in the right lateral elbow with radiation into the posterolateral arm exacerbated with push-ups and bench press. He noticed a painless popping sensation with elbow extension, but denied weakness or sensory changes. The pain was not specifically associated with baseball or pitching and was different from his previous pain. PHYSICAL EXAM: Mild tenderness at right common extensor tendon origin worsened with 5 push-ups and improved with rest. Mild tenderness at right posterolateral triceps border. Slight weakness of the right triceps with pain. Varus and valgus stress caused no pain, but there was asymmetry with minimally increased laxity during valgus stress on the right. Negative extensor wad stress tests including Cozens, middle finger extension and Mills. No pain with flexor-pronator stretching. No pain with resisted pronation or supination. DIFFERENTIAL DIAGNOSIS: 1. Triceps tendinitis 2. Lateral epicondylosis 3. Radial nerve irritation 4. OCD radiocapitellar joint 5. Intraarticular loose body 6. Stress reaction/stress fracture distal humerus 7. Bony tumor/infection TEST AND RESULTS: Right elbow non-contrast MRI- Bone marrow edema within the olecranon and distal humerus medially as a result of stress reaction from excessive valgus stress. Thickening of the UCL. Healed osteochondral lesion of the right elbow trochlea. FINAL DIAGNOSIS: Valgus overload stress injury to distal humerus TREATMENT AND OUTCOMES: 3 months of rest from pitching followed by throwing progression via a pitching rehabilitation program. The program consists of focused strength training (RTC, scapular stabilizers) followed by normalizing throwing mechanics with gradual return to pain free baseball. We discussed with the patient the harmful effects on single sports athletes, particularly pitchers. We recommended he watch his pitch counts closely in the future (he admitted he hadn’t been doing that) and take at least 2 months off of baseball during the year.

Extracorporeal Shock Wave Therapy Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study.

Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology). This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy). There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions. Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.

Primary Ligament Repair for Acute Elbow Dislocation.

The elbow is the second most common site for joint dislocation after the shoulder. Elbow dislocations are classified according to the direction of dislocation, with most (80%) being posterolateral. A spectrum of soft-tissue injury may also be present, depending on the direction of dislocation and the energy applied. Most dislocations of the elbow can be treated nonoperatively, but recurrent instability and/or stiffness occur in up to 10% and 40% of patients, respectively. The aim of early surgical stabilization is to prevent these long-term complications. To avoid overtreatment, magnetic resonance imaging is used to identify patients at a greater risk of complications by determining the grade of soft-tissue injury. Those with grade-3 or 4 injuries are managed with fluoroscopic examination under anesthesia. (1) The patient is positioned supine. Fluoroscopic examination is performed with the elbow in full extension and in 30° of flexion. Varus stress is applied with the forearm in pronation. If >10° of joint opening is found, open surgical repair of the lateral ligament complex and common extensor origin is performed. (2) A 5-cm incision is made using a direct lateral approach centered on the lateral epicondyle. The tough lateral fascia may be intact and should be incised in line with the anconeus interval. (3) A rent in the common extensor origin may be found, which can be used for the approach; otherwise, proceed with a Kocher approach to identify the sleeve avulsion of the lateral ligament complex from the humerus. (4) A number-2 synthetic braided suture is used to whip-stitch the lateral ulnar collateral ligament, which is repaired to the lateral epicondyle with use of a bone anchor. The trailing suture ends from the anchor are used to repair the common extensor tendon origin with use of a Mayo needle. (5) With the forearm in supination to externally rotate the humerus and lock the shoulder, valgus instability is assessed with the elbow in full extension and in 30° of flexion. If the medial joint line opens >10°, repair the medial structures in the same manner as the lateral ligament complex through an incision posterior to the medial epicondyle while protecting the ulnar nerve. (6) The patient is referred to physiotherapy for immediate hourly overhead exercises. This approach should prevent complications of recurrent instability or stiffness, as early results have been encouraging with no complications recorded.

Elbow MRI Findings Do Not Correlate With Future Placement on the Disabled List in Asymptomatic Professional Baseball Pitchers.

Background:Injury rates among professional baseball players may reach as high as 5.8 per 1000 encounters, with pitchers being most vulnerable on account of the excessive biomechanical load on the upper extremity during the throwing motion. Anatomically, the shoulder is the most common site of pitching-related injury, accounting for 30.7% of injuries, closely followed by the elbow at 26.3%. Characteristic valgus loading imparts a predictable constellation of stresses on the joint, including medial tension, lateral compression, and posterior medial shearing. The degenerative cohort of tissue changes that result are readily detected on magnetic resonance imaging (MRI). It is not yet known whether such findings predict future placement on the disabled list (DL) in asymptomatic Major League pitchers.Hypothesis:Abnormal soft tissue and osseous changes detected on MRI of the throwing elbow in asymptomatic professional pitchers will impart an increased risk of subsequent transfer to the DL in the season after MRI.Study Design:Retrospective cohort study.Level of Evidence:Level 3.Methods:The study aimed to examine a potential association between the total number of innings pitched (approximate lifetime valgus load) and the typical MRI degenerative changes, hypothesizing a rejection of the null hypothesis. A total of 26 asymptomatic professional pitchers from a single Major League Baseball (MLB) organization and its various minor league affiliates underwent MRI of their dominant elbow from 2003 to 2013 as a condition of their contract signing or trade. Twenty-one of those pitchers played at the Major League level while 5 played with the team’s minor league affiliates including both the AA and AAA levels. Asymptomatic was defined as no related stints on the DL due to elbow injury in the 2 seasons prior to MRI. A fellowship-trained musculoskeletal radiologist reevaluated the studies after being blinded to patient name, injury history, and baseball history. A second investigator collected demographic data; this included total career number of innings pitched and any subsequent DL reports for each subject while remaining blinded to the MRI results.Results:The mean age at the time of MRI was 29.6 years (range, 19-39 years). The mean number of innings pitched was 1111.7. Of the 26 pitchers, 13 had scar remodeling of the anterior bundle of the ulnar collateral ligament (UCL). Of those, 4 had partial-thickness tears of the anterior bundle of the UCL, ranging from 10% to 90% of the total thickness. Twelve had articular cartilage loss within the posteromedial margin of the ulnohumeral joint, and 12 had posteromedial olecranon marginal osteophytes. Seven pitchers had degeneration of the common extensor tendon origin, 10 had degeneration of the flexor pronator mass, 9 had insertional triceps tendinosis, 2 had enthesopathic spurs at the sublime tubercle, 3 had osteochondral intra-articular bodies, and 2 subjects had joint effusions. In the year after MRI, 6 pitchers were placed on the DL for elbow-related injuries. There was no robust correlation between any single MRI finding and subsequent transfer to the DL, and no statistically significant correlation between number of innings pitched and MRI findings, although some trends were observed for both.Conclusion:MRI findings in asymptomatic MLB pitchers were not associated with placement on the DL within the subsequent year. While a trend was observed with olecranon osteophytes and subsequent DL placement (P = 0.07), this finding did not reach statistical significance. Furthermore, there was no robust correlation between the number of innings pitched with the presence of any of the aforementioned degenerative changes on MRI.Clinical Relevance:The characteristic structural transformation that occurs in the throwing elbow of professional pitchers is predictable and readily detectable on MRI. However, this study suggests that these changes are not predictive of near-term placement on the DL in those who are asymptomatic. Abnormal findings on MRI, even high-grade partial UCL tears, do not correlate with near-term placement on the DL, mitigating their potential negative impact on signing decisions.

Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis

Background: Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up. Hypothesis: Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up. Results: A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment. Conclusion: ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.

Platelet-Rich Plasma Therapies in Lateral Epicondylitis: Are we Asking the Right Questions?

Greater understanding of the pathophysiology underlying musculoskeletal conditions provides the opportunity for more targeted, advanced treatment options. When lateral epicondylitis was first described by Runge in 1873 it was thought to represent inflammation of the common extensor origin of the forearm [1]. This has been subsequently disproved histopathologically, and the term epicondylitis is now itself a misnomer [2-4]. It is instead a form of tendinosis, resulting from repetitive stress-mediated degeneration of the common extensor tendon origin [5,6]. The formation of microtears triggers a complex collagen-mediated histopathological reaction; known as angiofibroblastic hyperplasia [2-5].

The effect of lateral epicondylosis on upper limb mechanical parameters

BackgroundLateral epicondylosis is a prevalent and costly musculoskeletal disorder characterized by degeneration of the common extensor tendon origin at the lateral epicondyle. Grip strength is commonly affected due to lateral epicondylosis. However, less is known about the effect of lateral epicondylosis on other functional parameters such as ability to react to rapid loading. MethodsTwenty-nine lateral epicondylosis participants and ten controls participated in a case-control study comparing mechanical parameters (mass, stiffness and damping), magnetic resonance imaging signal intensity and grip strength of injured and uninjured limbs. A mixed effects model was used to assess the effect of dominance and injury on mechanical parameters and grip strength. FindingsSignificant effect of injury and dominance was observed on stiffness, damping and grip strength. An injured upper limb had, on average, 18% less stiffness (P<0.01, 95% CI [9.8%, 26%]), 21% less damping (P<0.01, 95% CI [11%, 31%]) and 50% less grip strength (P<0.01, 95% CI [37%, 61%]) than an uninjured upper limb. The dominant limb had on average 15% more stiffness (P<0.01, 95% CI [8.0%, 23%], 33% more damping (P<0.01, 95% CI [22%, 45%]), and 24% more grip strength (P<0.01, 95% CI [6.6%, 44%]) than the non-dominant limb. InterpretationLower mechanical parameters are indicative of a lower capacity to oppose rapidly rising forces and quantify an important aspect of upper limb function. For individuals engaged in manual or repetitive activities involving the upper limb, a reduction in ability to oppose these forces may result in increased risk for injury or recurrence.

Clinical and Ultrasonographic Results of Ultrasonographically Guided Percutaneous Radiofrequency Lesioning in the Treatment of Recalcitrant Lateral Epicondylitis

Background: In patients with lateral epicondylitis recalcitrant to nonsurgical treatments, surgical intervention is considered. Despite the numerous therapies reported, the current trend of treatment places particular emphasis on minimally invasive techniques. Purpose: The authors present a newly developed minimally invasive procedure, ultrasonographically guided percutaneous radiofrequency thermal lesioning (RTL), and its clinical efficacy in treating recalcitrant lateral epicondylitis. Study Design: Case series: Level of evidence, 4. Methods: Thirty-four patients (35 elbows), with a mean age of 52.1 years (range, 35-65 years), suffered from symptomatic lateral epicondylitis for more than 6 months and had exhausted nonoperative therapies. They were treated with ultrasonographically guided RTL. Patients were followed up at least 6 months by physical examination and 12 months by interview. The intensity of pain was recorded with a visual analog scale (VAS) score. The functional outcome was evaluated using grip strength, the upper limb Disability of Arm, Shoulder and Hand (QuickDASH) outcome measure, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow. The ultrasonographic findings regarding the extensor tendon origin were recorded, as were the complications. Results: At the time of the 6-month follow-up, the average VAS score in resting (from 4.9 to 0.9), palpation (from 7.6 to 2.5), and grip (from 8.2 to 2.9) had improved significantly compared with the preoperative condition (P < .01). The grip strength (from 20.6 to 27.0 kg) and QuickDASH score (from 54.3 to 21.0) had also improved significantly (P < .01). The MMCPI score improved from “poor” to “excellent.” The ultrasonographic finding revealed that the thickness of the common extensor tendon origin did not change significantly. At the final follow-up (mean, 14.3 months; range, 12-21 months), the patients reported a 78% reduction in pain compared with the preoperative status. No major complications were noted in any patient. Conclusion: Ultrasonographically guided RTL for recalcitrant lateral epicondylitis was found to be a minimally invasive treatment with satisfactory results in this pilot investigation. This innovative method can be considered as an alternative treatment of recalcitrant lateral epicondylitis before further surgical intervention.

The posterior transtriceps approach for elbow arthrography: a forgotten technique?

To evaluate the technical feasibility of performing elbow MR arthrography via a posterior approach through the triceps. The images of 19 patients with elbow MR arthrography via a posterior transtriceps approach were retrospectively studied. The injections were performed by four musculoskeletal radiologists, using fluoroscopic guidance and a 22- or 25-gauge needle. The fluoroscopic and subsequent MR images were reviewed by two musculoskeletal radiologists and evaluated for adequacy of joint capsular distention, degree and location of contrast leakage, and presence of gas bubbles. The injection was diagnostic in all 19 patients, with a sufficient amount of contrast agent seen in the elbow joint. No significant contrast leakage occurred in 12 patients who received injections of 8 cc or less of contrast agent, but moderate contrast leakage occurred in 6/7 patients who received injections of greater than 8 cc. Contrast leakage generally occurred within the triceps myotendinous junction. No gas bubbles were identified in the injected joints. Patients often present for MR arthrography of the elbow with medial or lateral elbow pain. Contrast leakage during a radiocapitellar approach may complicate evaluation of the lateral collateral ligament or the common extensor tendon origin. Transtriceps MR arthrography offers an alternative to the more commonly used radiocapitellar approach. With injected volumes not exceeding 8 cc, the risk of significant contrast leakage is small. An advantage of the transtriceps injection is that contrast leakage through the posterior needle tract does not interfere with evaluation of the lateral structures.

FRACTIONAL LENGTHENING OF FOREARM EXTENSORS FOR RESISTANT LATERAL EPICONDYLITIS

This study presents the surgical technique of fractional lengthening of extensor carpi radialis brevis, extensor digitorum communis and the superficial head of supinator, for chronic lateral epicondylitis. The anatomical basis for this surgical approach is reviewed. The results of surgical treatment in a consecutive series of patients with severe chronic lateral epicondylitis are reviewed. Twenty-one elbows in 17 subjects underwent surgery. All elbows had severe resistant symptoms, unresponsive to a minimum 6 months (mean 14 months) of a non-operative treatment protocol. All elbows showed either tendonopathy or a partial tear in the common extensor tendon origin at preoperative imaging. All subjects were examined at a minimum of 1 year after surgery. The mean visual analogue pain (VAS) score reduced from 7.6 (maximum 10) preoperatively to 1.3 postoperatively (P<0.01). The mean preoperative ability to carry out normal work duties reduced from 4.3 (maximum 5) preoperatively to 1.5 postoperatively (P<0.01). Grip strength improved or remained equivalent following surgery. The mean VAS for patient satisfaction with surgery was 8.8 (maximum score 10). Using the Roles and Maudsley classification, 14 patients (82%) were rated good or excellent. Three subjects were rated fair or poor, were undergoing treatment for other pathology in the ipsilateral extremity and had ongoing compensation claims. Fractional lengthening of forearm extensors is effective treatment for severe and chronic lateral epicondylitis. Outcomes following fractional lengthening surgery are less predictable when other pathology in the upper extremity requires concomitant treatment.

Posterolateral Rotatory Instability of the Elbow in Association with Lateral Epicondylitis

Lateral stability of the elbow depends on the integrity of the lateral collateral ligament and secondary soft-tissue restraints1-4. Posterolateral rotatory subluxation of the elbow has been recognized in association with elbow trauma, surgery for epicondylitis, and congenital cubitus varus deformity4-9. While abnormal signal changes on magnetic resonance imaging have been shown to include the lateral collateral ligament in patients with tennis elbow10, we are aware of no reports of elbow instability detected in patients in whom epicondylitis had been managed nonoperatively. We describe the cases of three middle-aged women who presented with atraumatic lateral epicondylitis and subsequently had clinical findings consistent with posterolateral rotatory instability of the elbow. Two of the patients had a visible synovial fistula and magnetic resonance imaging studies indicative of insufficiency of the lateral collateral ligament. All three patients eventually underwent an examination of the elbow under anesthesia, which confirmed the posterolateral rotatory subluxation. All were treated with debridement and reconstruction of the common extensor tendon origin and the lateral collateral ligament. The potential role of corticosteroid injections in the pathogenesis of combined lateral epicondylitis and rotatory instability of the elbow is discussed. Each patient was informed that data concerning her case would be submitted for publication. Case 1. A fifty-one-year-old, healthy, right-hand-dominant female administrative assistant presented with pain in the lateral aspect of the left elbow of unknown cause. She reported no elbow trauma, unusual musculoskeletal pain, or prior use of fluoroquinolone antibiotics (which has been reported to be associated with degenerative tendon conditions11). A diagnosis of tennis elbow was made by the treating hand surgeon on the basis of tenderness over the lateral epicondyle that was exacerbated by wrist extension against resistance. Conservative treatment measures, including the use of a forearm counterforce …

Arthroscopic Release of the Stiff Elbow

Arthroscopic Release of the Stiff Elbow

Hydrocortisone in tennis elbow

T ENNIS elbow, known also as radiohumera1 bursitis, epicondylitis or epicondylaIgia, is a common and troublesome afhiction. It is characterized by pain originating around the outer side of the elbow joint at or beIow the lateral epicondyle. Radiation is frequent down the forearm. It is said to occur principahy in individuaIs who are carrying out frequent pronation-supination movements of the almost fully extended elbow. It may be reJated to athIetics or it may be occupational in nature. The exact pathoIogy of this entity is still debatable as is probabJe in many similar entities: The pathologic findings are muItipIe in nature since many changes in the soft tissues could be responsibIe for the symptoms attributed to this condition. The most commonly favored etiologic theory is that the symptoms result from an incompIete tear of the Iateral epicondylar origin of the forearm extensor tendons. It is beheved that the partial rupture may occur acutely or may be more gradua1 in onset. Another form is on the basis of a bursitis with or without amorphous calcium, and an actual bursal sac iying between the common extensor tendon and the lateral epicondyIe has been described in 16 per cent of cases. In most cases conservative treatment is successful in alleviating or completely relieving the painful symptoms. PhysicaI therapy is a useful adjuvant. LocaI procaine injections are occasionahy successful in some hands. However, a very acute and painful JIare-up of symptoms usuahy results from procaine infihrations; when such a reaction occurs, the rest& is usually poor. Many people favor the support of the wrist in the cock-up position in order to relieve the strain on the extensor tendon origin. Various specific manipulations under anesthesia have been described. BasicaIIy, these attempts are to convert what is believed to be a partiaI tear of the extensor tendon into a compIete and painJess tear. MiIJs forces the elbow into extension while the wrist and Jingers are fIexed and the forearm is fuIIy pronated. Cyriax extends the elbow with the forearm in supination and forcibly adducts it. Certain intractabre cases must be expIored. OccasionaIIy, a smaI1 bursal sac is found between the externa1 epicondyIe and the common extensor tendon origin. Excision of this results in complete relief. When a bursa1 sac is not found, the surgery invoIves a scratching of the origin of the tendon over the humera epicondyIe. Watson-Jones has described it as “a hen scratching in the barnyard.” Surgery usually resuJts in compIete and permanent cure. The success of hydrocortisone in the IocaI inhibition of mesenchymal proliferation prompted us to use it in tive cases of tennis eIbow. No other adjuvant therapy was given to these patients. In four cases relief was dramaticaIIy obtained. One patient failed to respond to two injections of hydrocortisone.