Download tennis elbow-a radial tunnel syndrome?

TENNIS
J.
ELBOW-A
VAN
ROSSUM,
0.
From
The
hypothesis
that
RADIAL
J.
the
S.
BURUMA,
University
the chronic
H.
Hospital,
tennis-elbow
Refractory
and
cases
Maudsley
of “tennis
(1972)
elbow”
who
were studied
put
forward
hypothesis
which
at first sight seemed
attractive.
argued
that there
was an entrapment
neuropathy
radial
nerve
produced
by the fibrous
edge
supinator
muscle
relieved.
was
I.
Details
*
branch
nerve
muscle,
this
of
the
nerve
results
of
“tennis
J. van
Rossum,
To
D.Sc.,
7
60-B,
No.
2. MAY
1978
neuropathy
In the
resistant
period
May
diagnosed
Duration
complaints
(months)
until
as suffering
orthopaedic
from
surgeon
physiologically.
which
started
radiated
and
along
upwards
radicular
December
1976 ten
tennis
the
also.
nature.
radial
The
It
and
was
of the
was
increased
Gardener
Operation
3
F
41
10
Clerk
Steroid
4
M
49
10
Bricklayer
Immobilisation
5
F
31
36
Waitress
Operation
6
F
38
36
Housewife
Immobilisation
7
F
43
ii
Head
Operation
8
F
43
12
Housewife
Steroid
9
M
38
18
Carpenter
Operation
(at 9 m)
10
M
54
Mechanic
Operation
(at 24 m)
the
motor
Occupation
>36
posterior
before
operation
of the
interosseus
of the supinator
Entrapment
of
weakness,
and
is
test
Department
this
theory
not
a prospective
tennis-elbow
are presented
by an
investigated
longstanding
of the
pain,
humerus,
in many
instances
and
strictly
neuro-
localised,
pressure
on
nor
the
of a
lateral
of
15
division
consecutively
examined
elbow
29
(in months)
arm
by
M
of partial
were
never
2
consisted
were
suffered
from
lateral
epicondyle
side
pain
patients
elbow
a neurologist,
Steroid
operation
of complaints
of
MATERIAL
chronic
All the patients
in the region
of the
down
slightly
tennis
i975
AND
Carpenter
syndrome
here.
Previous
nurse
is given
extensor
injection,
(at 13 m)
(at
radialis
10 m)
injection
(at
20
m)
(at 4 m)
injection
in parentheses.
carpi
epicondyle,
extending
treatment
In all patients
brevis
muscle.
by stretching
of the extensor
the fingers
against
resistance.
shown
in Table
I.
definite
cause,
and
particular
professional
No
patient
no
was
able
relationship
or domestic
muscles
Details
of the forearm,
of the patients
to provide
could
be
activity
clues
to suggest
established
despite
or by
are
with
exhaustive
a
any
history-
taking.
The
orthopaedic
the elbow
attention
nerve
brevis,
and a
was
paid
(triceps,
supinator,
investigation
radiological
to the
included
testing
examination.
power
brachioradialis,
extensor
of the
muscles
extensor
digitorum
of the
function
Neurologically,
innervated
carpi
and
radialis
extensor
of
particular
by the
longus
digiti
radial
and
quinti,
of Neurology
H. J.
A. S.C. Buruma,
Kamphuisen,M.D., M.D.,
D.Sc.,
Department
0.
Department
of Neurology
G. J. Onvlee,
M.D.,
Department
of Orthopaedic
VOL.
by an entrapment
16
with persistent
and the results
M.D.,
is caused
46
nerve,
elbow”.
Netherlands
METhODS
by
an
by sensory
loss or by pain (Haymaker
and
1953),
the latter
being
the prominent
feature
study
of patients
was carried
out,
ONVLEE
M
operation
in
J.
1
which
passes
along
the border
is wholly
motor
in distribution.
accompanied
Woodhall
The
G.
Sex
Duration
radial
KAMPHUISEN,
put to the test prospectively
in ten patients.
Detailed
examinations
did not reveal
any involvement
of the
cannot
be explained
by an entrapment
neuropathy.
They
of the
of the
with
SYNDROME?
Age
(years)
Case
the
of patients
C.
Leyden,
muscle
and that if the superficial
part of this
divided
longitudinally
the pain would
be
This
suggestion
is surprising,
as the deep
Table
A.
syndrome
the radial
nerve (Roles
and Maudsley
1972) was
orthopaedic,
neurological
and neurophysiologicai
radial
nerve.
It is concluded
that this syndrome
Roles
TUNNEL
of Clinical
Surgery
Neurophysiology
}
University
Hospital,
Leyden,
The
Netherlands.
197
I 98
J. VAN
extensor
carpi
longus
and
hand
was
muscle
ulnaris,
brevis,
of
for
and
changes
following
extensor
pollicis
brevis,
and
at
conduction
on the
latc’ncies
The
and
was
side
of the
radial
nerve
was
the
middle
of
elbow
on both
median
and
sides.
concentric
needle
temperature
potentials
nerves.
radial
above
were
the
and
as
was
the
and
(Erb’s
point),
at
below
and
examinations
31 degrees
The
the
tions.
ten patients
no
by the orthopaedic
None
of the
deficit
when
no clinical
skin
Celsius.
showed
neurologically.
entrapment
a motor
of
findings
patients
did
who
or more
four
not differ
in any
had had operations
months
who
to the permanent
neurological
deficit.
had
before
the
and
potentials
were
were
encountered
sides.
and
and
The
of the muscles
amplitude
and
a normal
duration
the
and
median
and
higher
velocity
sensory
beneficial
conduction
velocities
ulnar
nerves
on the affected
65 metres
per second,
were
side,
within
old,
velocity
of
The distal
the
wide
range
56
of values
confirmed.
ulnar
nerves
of the
of the
radial
same
nerve
subject
revealed
in every
a
case.
that
radial
in the syndrome
made
1963).
repeatedly
The
nerve
entrapment
plays
a
of resistant
tennis
elbow
(Capener
conclusion
1960,
Roles
of
results
by
patients
1966;
and
from
radial
their
own
who had
(1966).
A lipoma
notably
without
pain
interosseous
nerve
in their
of
or
described
a
tissues
of the
patients.
This
effect
hard
to understand,
as the anatomical
studies
of
Kaplan
(1959)
showed
that
the nerve
supply
to the
lateral
epicondylar
region
originates
from
the main
trunk
of the radial
nerve
about
four to five centimetres
proximal
to the
bi-epicondylar
line.
The
results
is
pattern
of action
of the
in
years
was found
the
and by several
times
disturbances.
Roles
and Maudsley
effect of dividing
the constricting
posterior
obtained
syndrome
within
normal
limits and no differences
between
the affected
and the normal
motor
those
fifty-four
phenomenon
several
Capener
(1966)
and Mulholland
this nerve
results
in paresis,
not.
contraction
The form,
in the
than
had
operative
treatment
showed
muscle
weakness,
which
is the most
outstanding
feature
of compression
of the deep
motor
branch
of the radial
nerve.
This
weakness
was
shown
clearly
in the case
reports
of
paresis
The
investigation
patient,
Maudsley
(1972)
that tennis
elbow
nerve
entrapment
is not substantiated
presentation:
none
of their
thirty-six
Electromyography.
The
muscles
innervated
by the
radial
nerve
did not show any abnormality
in any of the
patients.
Denervation
activity
(fibrillations,
positive
waves)
did not occur,
fasciculations
or myotonic
signs
were
neither
seen or heard.
During
slight and maximal
voluntary
was found.
where
this
was repeated
has
been
Somerville
respect
between
the six
for tennis
elbow
three
present
obtained
lower
nerve
showed
a motor
conduction
per second
for an unknown
reason.
The
suggestion
causative
part
There
were thus
the radial
nerve.
ness,
in our opinion,
is functional
and caused
by an
increase
of pain on testing.
Moreover
the variability
of
the muscular
strength
within
a few minutes
is typical
of a
deficit,
in contrast
from
a peripheral
one
values
a little
DISCUSSION
or sensory
Some
patients
initially
demonstrated
a varying
weakness
of hand
and finger
extension
but in all patients
a normal
muscle
strength
could
be produced.
This initial
weak-
functional
resulting
In the
anatomical
abnormality
was
and radiological
examina-
patients
examined
signs
of
nerve.
The
were
We are satisfied
that these fast velocity
figures
are due to
the impossibility
of measuring
the exact
length
of the
radial
nerve.
Comparison
of the velocities
of the radial,
RESULTS
In these
revealed
ulnar
oNvt.EE
one.
in general
investigators,
wrist
the
except
nerve
In all cases
measurement
the
not measured.
elbow
all subjects
J.
elbow,
showed
an impressive
variation,
ranging
from
to 300 metres
per second,
without
significant
asymmetry.
motor
measured.
as possible
were
During
were
clavicle
at the
at least
distal
(i.
latencies
were within
normal
limits
(less than 4.0 milliseconds)
in all subjects.
The motorconduction
velocities
of the radial
nerve,
in particular
over the region
of the
were
nerves,
The
nerve
low
latencies
stimulated
electrodes.
of all subjects
ulnar
carpi
The
radial
KAMPHUISEN,
the median
46 metres
abductor
contraction.
and
sensory
nerves
Action
for the
humerus
Distal
ulnar
quinti.
bilaterally
the
The
extensor
voluntary
of
for.
C.
median
investigation
brevis,
by the
stimulated
the
looked
of a bilateral
A.
in
and
Signs
pollicis
maximal
innervated
pollicis
vibration.
were
H.
in arm
brachioradialis,
for the median
about
with
at
extensor
extensor
digiti
measured
muscles
skin
triceps,
abductor
rest
affected
the
BURUMA,
sensibility
and
consisted
digitorum,
velocity
The
pinprick
in
muscles:
longus,
observed
touch,
J. S.
longus,
indicis).
examination
radialis
0.
pollicis
extensor
investigated
atrophy
the
abductor
and
electromyographic
ROSSUM,
in our
ten patients
have
shown
that
the
of resistant
tennis
elbow
cannot
be explained
by an entrapment
which
there was
median
evidence.
surgical
being between
51
the normal
range
of the posterior
interosseus
nerve,
neither
clinical
nor electromyographical
Thus,
exploration
in the absence
of neurological
appears
unfounded.
for
deficit,
REFERENCES
Capener,
N. (1960)
Biomechanical
studies
of sport.
British
Capener,
N. (1966)
The vulnerability
of the posterior
Haymaker,
W., and Woodhall,
B. (1953) Peripheral
Company.
Kaplan,
Mulholland,
48-B,
Roles,
E. B. (1959)
R. C.
781-785.
N. C.,
Surgery,
Somerville,
and
54-B,
E. %%.
Treatment
(1966)
Maudsley,
of tennis
interosseous
Nerve
Injuries:
elbow
(epicondylitis)
progressive
paralysis
Non-traumatic
R. H.
Medical
(1972)
Radial
tunnel
Pain
in the
Journal,
2, 130.
nerve
of the forearm.
Journal
of Bone
and
Principles
of Diagnosis.
Second
edition.
by denervation.
of the posterior
syndrome.
Resistant
Journal
of Bone
and
interosseus
nerve.
tennis
elbow
as a nerve
Joint Surgery,
Philadelphia:
48-B,
770-773.
W. B. Saunders
Joint Surgery,
Journal
of
41-A,
Bone
147-15!.
and Joint
entrapment.
Journal
of Bone
Surgery,
and
Joitit
499-508.
( 1963)
lii discussio,,
on
upper
limb.
Journal
of
Bone
aul
Joint
THE
Surgt’rv,
JOURNAL
45-B,
621.
OF BONE
AND
JOINT
SURGERY