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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