Disorders of the contractile structures

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Disorders of the contractile structures

Unlike the shoulder, combined lesions of the elbow are quite rare. Therefore positive resisted movements usually indicate a lesion of one contractile structure only.

Resisted flexion of the elbow

The therapist grasps the muscle belly at the point of the lesion with the ipsilateral hand in a pinching grip, holding the fingers well flexed, which enables the posterior aspect of the muscle to be reached (Fig. 19.2). The hand is then pulled anteriorly. This results in a transverse friction to the muscular fibres, which can be felt to pass under the fingers. The hand is then brought back to the starting position without losing contact with the patient’s skin. The manœuvre thus has two phases: an active phase, when the hand is pulled anteriorly, and a passive phase, when the hand is brought backwards again.

Fig 19.2 Deep friction to the biceps muscle belly.

Pain at the lower arm

Palpation with a pinching grip shows the lesion to lie at the musculotendinous junction but again it is only possible to be sure of this after diagnostic infiltration with a local anaesthetic. Tendinitis at the body of the lower tendon of the brachial biceps does not occur.

Deep transverse friction is, in our experience, the only treatment. Without proper treatment the lesion may cause pain indefinitely, having occurred at a point where the natural mobility of muscle is restricted by the presence of tendinous strands.

Technique

The same technique is used as described earlier. The position of the hand and fingers, as well as the amplitude of the movement, are adapted to the volume of the structure at the musculotendinous junction.

Pain at the elbow

When pain is felt at the anterior aspect of the elbow, probably with some radiation down the front of the forearm as far as the wrist, a lesion at the tenoperiosteal insertion to the radial tuberosity should be suspected.

Apart from the usual signs on examination, a localizing sign is present – pain at full passive pronation. This is the result of the bicipital insertion being pinched between the radial tuberosity and the shaft of the ulna as the radius turns over the ulna during pronation.⁸ Palpation is not necessary and would even be negative, as tenderness cannot be elicited by probing with a finger.

The treatment of choice is infiltration with triamcinolone. Because it is difficult to infiltrate the entire lesion accurately in the absence of localizing tenderness, up to three infiltrations may be necessary.

The alternative treatment is deep transverse friction. Cure takes about 2 weeks, and the treatment is quite painful, in that the lesion lies deeply and is difficult to reach.

Technique: infiltration of the distal insertion of the biceps

The patient lies prone on the couch. The upper arm is passively held in external rotation by the side. The forearm is put in full pronation, which turns the radius so that the radial tuberosity, where the insertion lies, points upwards.

The joint line between humerus and radius is palpated. The posterior edge of the ulna is easily felt. A point is chosen 2–3 cm further distally from the joint line and just laterally to the ulna. A 2 mL syringe is filled with triamcinolone and a thin needle, 2 cm long, is fitted. The needle is inserted at the chosen point and pushed vertically downwards until it hits the shaft of the radius, either directly or through a tendinous structure (Fig. 19.3). In the former case, the needle has to be partly withdrawn and reinserted in a slightly different direction in order to feel the tendinous resistance. Then a series of droplets is infiltrated at the tendinous insertion according to the usual infiltration technique.

Fig 19.3 Infiltration of the distal insertion of the biceps.

The patient should be warned of moderate after-pain and to avoid flexion and supination movements for a week. Follow-up is after 2 weeks and, if the tests are not completely negative, a second infiltration is given. In most cases, one or two infiltrations suffice.

Technique: friction to the distal insertion of the biceps

The patient sits on the couch with the elbow bent at a right angle and supinated. The therapist sits and with the contralateral hand palpates for the radial tuberosity, searching the radiohumeral joint line and descending 2 cm along the shaft of the radius. At that level the thumb is moved anteriorly to identify the tuberosity deeply under the muscles of the forearm. The thumb is held well flexed and placed medially to the biceps tendon. The fingers apply counterpressure at the dorsal aspect of the elbow.

The ipsilateral hand, which grasps the patient’s forearm about the wrist, is used to perform a pronation movement. The forearm is pronated until the biceps tendon passes under the therapist’s thumb. The tendon now lies medial to it. Friction is thus performed by this indirect movement. During this part of the movement, the pressure on the tendon is augmented (active phase). The forearm is then brought back to the supinated position, while the pressure is released (passive phase). These repeated movements result in a transverse friction (Fig. 19.4), which is continued for 15 minutes.

Fig 19.4 Deep friction to the distal insertion of the biceps.

The therapist must make sure that neither the median nerve nor the brachial or radial arteries are compressed during the manœuvres.

Brachialis muscle

Resisted flexion of the elbow is painful, certainly with the forearm in pronation, the position in which the biceps does not work. Resisted supination is negative.

Again, the tender area is difficult to find but usually lies in the distal third of the muscle belly, just dorsal to the bicipital tendon. It is therefore not impossible for passive flexion to hurt too because this pinches the injured part of the muscle. Diagnostic infiltration may prove necessary.

Treatment consists of 2 or 3 weeks’ deep transverse friction.

Technique: deep friction

The same technique is used as for the brachial biceps muscle. The distal part of the brachialis muscle can be palpated just dorsally to the bicipital tendon. The muscle is well relaxed and friction performed with a pinching grip.

During treatment, the therapist should make sure that no nervous (paraesthesia) or arterial (paleness of fingers) symptoms arise, which would indicate that either the ulnar nerve or the brachial artery is being contacted. In such a case, the position of the hand must be altered.

The brachialis muscle and heterotopic ossification

Myositis ossificans is a benign condition, characterized by heterotopic bone formation, which occurs after injury to muscle fibres, connective tissue, blood vessels and underlying periosteum.⁹ It occurs most often in males aged between 15 and 30 years and presents with the following triad of symptoms: pain in the affected muscle, a palpable mass and a flexion contracture.¹⁰ The history of severe contusion is helpful in the early evaluation of these patients, before radiographic changes are evident.¹¹

When, after an injury, usually fracture,¹² pain in the elbow region increases and the range of movement gradually decreases,¹³ this may indicate the development of myositis ossificans. An increasing firm mass in the brachialis muscle is mostly palpable in the middle or distal segment of the arm and becomes visible on the radiograph in the course of a few weeks.¹⁴ A technetium bone scan is clearly positive.¹⁵ When myositis ossificans has fully developed, only a little movement to either side of the right angle is possible and even rotations are markedly limited.

Warning

Osteogenic sarcoma may also present with the formation of a mass invading the muscle.¹⁶ The characteristic radiographic appearance of the sarcoma (presence of periosteal elevation and cortical destruction) provides the diagnosis.

Myositis ossificans does not respond to conservative treatment and may disappear spontaneously over the course of 2 years. Lipscomb et al¹⁷ have stated that myositis ossificans in the upper extremity is very likely to resorb completely. If not, surgical excision may be performed, but only when the lesion is completely ossified, because removal of immature bone may cause extensive local recurrence.¹⁸

Because some authors attribute the occurrence of myositis to previous treatments, massage and mobilization to the brachialis muscle should only be given when there is a full passive range of movement at the elbow joint and radiographic evaluation shows no heterotopic bone formation.

Brachioradialis muscle

We have never encountered a lesion of the brachioradialis muscle but a case has been described by Barbaix.¹⁹ The patient, following exertion, experienced supracondylar pain at the radial aspect of the elbow occurring during activities which included elbow flexion and simultaneous rotations. The pain could be elicited on passive extension, which was slightly limited, and on resisted flexion of the elbow. Accessory examination showed resisted supination with the forearm in full pronation more painful with a flexed elbow than with an extended one. Diagnosis was confirmed with echography and the patient responded well to infiltration with triamcinolone acetonide.

These clinical findings are compatible with an earlier electromyographic study showing electrical activity with flexion, especially with the forearm rotated in pronation.²⁰

Weakness

Neurological conditions

Weakness of elbow flexion usually results from a cervical root palsy, either C5 or C6. In palsy of the fifth cervical root, resisted abduction and external rotation of the shoulder are also weak. In sixth cervical root palsy, resisted extension of the wrist is also weak.

Rupture

A distal biceps tendon rupture is usually at the tendinous insertion and sometimes accompanies an avulsion of the radial tuberosity.²¹ The lesion is reported increasingly in the current literature.^22–26 The mechanism of injury is most commonly an eccentric load applied to a flexed elbow. On physical examination there may be swelling, haematoma and a ‘Popeye’ deformity of the upper arm. However, the normal contour of the distal biceps may still appear to be intact if the lacertus fibrosus is not torn.²⁷ Range of motion is usually full unless there is severe swelling. Strength testing reveals weakness in forearm supination and, to a lesser extent, elbow flexion. The biceps squeeze test and the hook test are two physical examination manœuvres that have been shown to be sensitive and specific in diagnosing distal biceps tendon ruptures. The biceps squeeze test involves compression of the biceps muscle belly, which results in forearm supination if the tendon is intact.²⁸ In the hook test, with the elbow actively flexed and supinated, an index finger should be able to ‘hook’ under a cord like structure in the antecubital fossa if the tendon is intact.²⁹

The treatment of choice is surgery: anatomic repair of distal biceps tendon rupture provides consistently good results and early anatomic reconstruction can restore strength and endurance to the elbow.30–32

Resisted extension of the elbow

Pain

Triceps muscle

Lesions of the triceps muscle are rare. Three possible localizations can be differentiated by palpation (Fig. 19.5): the musculotendinous junction, which is the most common site; the body of the tendon; and the tenoperiosteal junction at the olecranon.

Fig 19.5 Sites of lesions of the triceps: 1, musculotendinous junction; 2, body of the tendon; 3, tenoperiosteal insertion.

For all the sites, treatment consists of deep transverse friction. The tenoperiosteal junction responds equally to deep transverse friction and infiltration.

Technique: infiltration at the tenoperiosteal junction

The patient lies prone with the arm slightly flexed by the side. A small pillow is placed under the elbow.

A 1 mL syringe is filled with triamcinolone acetonide and a 2 cm needle is fitted. The tip of the olecranon is palpated and the tender point located. The needle is inserted 1 cm proximal to it and directed towards the olecranon (Fig. 19.6). Tendinous resistance should be felt before hitting bone. Infiltration is then carefully performed by several withdrawals and reinsertions of the needle and maintaining bony contact.

Fig 19.6 Infiltration at the tenoperiosteal junction of the triceps.

Technique: friction to the musculotendinous junction, body of tendon and tenoperiosteal junction

The patient sits next to the couch with the arm rested, the elbow held in 90° flexion. The therapist sits at a right angle to the patient’s arm. With the contralateral hand the patient’s elbow is grasped, while the other hand stabilizes the patient’s forearm. The tender spot in the triceps tendon is palpated and then the index finger, reinforced by the middle finger, is placed at the medial side of the tendon. Counterpressure with the thumb is then applied at the lateral aspect of the proximal part of the forearm (Fig. 19.7). The therapist abducts the arm and then brings it back into the side. This is the active phase and is followed by relaxation while bringing the arm back into abduction. Such repeated movement results in a transverse friction to and fro over the lesion.

Fig 19.7 Deep friction to the triceps.

Resisted extension of the elbow and painful arc

Another possibility is that resisted extension of the elbow elicits pain at the shoulder in the C5 distribution. This has the same significance as a painful arc at the shoulder. As a result of contraction of the triceps muscle, the humerus is pulled upwards towards the acromion. A tender structure, lying between the head of the humerus and the roof of the joint, especially an inflamed subacromial bursa, may be painfully squeezed by this movement.

Anconeus compartment syndrome

Abrahamsson et al³³ reported a case of lateral elbow pain caused by a chronic compartment syndrome of the anconeus muscle. The symptoms were lateral elbow pain and muscular dysfunction during heavy work. The pain was reproduced by repeated extension of the elbow and pronation of the forearm. There was a slightly bulging mass and pronounced tenderness of the anconeus muscle, which were successfully treated by fasciotomy.

Weakness

Painful weakness

Total or partial rupture of the triceps tendon

This has been reported as a rare injury.34,35 The most common form is an avulsion from the osseous tendon insertion.³⁶ Injury at the musculotendinous junction occurs less often.³⁷ The most common mechanism of injury is a deceleration stress superimposed on a contracted triceps muscle.³⁸ A palpable gap, with complete weakness of arm extension, is pathognomonic of triceps rupture. In many cases, however, the palpable defect is not noted initially because of swelling and ecchymosis.³⁹ Early surgical repair of the injury is the treatment of choice and gives predictably good results.^40,41 Sometimes the same mechanism of injury causes a triceps avulsion fracture. Apart from the same symptoms and signs, the lateral radiograph will show the presence of flecks of avulsed osseous material from the olecranon (‘flake sign’), which is almost pathognomonic of this lesion.⁴²

Fracture of the olecranon

If the pain is the result of an injury and resisted extension of the elbow is painful and weak, the possibility of a fracture of the olecranon must be considered. Local tenderness and marked articular signs at the elbow joint will also be present: warmth, swelling and limitation of passive movements in the capsular pattern. In most cases, conservative treatment is sufficient.⁴³

Painless weakness

A radial palsy and a C7 root palsy are the most common of the other neurological disorders.

Radial palsy

Apart from known traumatic causes, a radial palsy is quite often the result of pressure from a crutch or sleeping with the inner side of the arm pressed against a hard edge (‘Saturday-night paralysis’). In this case, resisted extension of the wrist is also very weak and may even result in wrist-drop. The condition is painless and recovers spontaneously over the course of 3–6 months. Some severe cases require neurosurgical repair (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

C7 root palsy

This is the most common cause of a weakness of elbow extension and usually results from a C6 disc protrusion, compressing the C7 nerve root. The history points towards a neck problem, and cervical examination is positive. The triceps muscle may be found to be weak in isolation or in conjunction with weakness of the flexor muscles of the wrist and, in severe cases, the adductors of the shoulder.

Resisted supination

Painful resisted supination usually occurs in conjunction with pain on resisted flexion, in which case the lesion lies in the biceps muscle. If resisted flexion is not positive, the supinator brevis muscle must be at fault. The latter condition is quite rare.

To confirm the diagnosis, the test is repeated with the elbow held actively in full extension – a position which inhibits the function of the biceps. The muscle is not found to be particularly tender and therefore an infiltration with a local anaesthetic should be given (Fig. 19.8). This may effect a cure, but treatment with deep transverse friction (Fig. 19.9) is usually necessary. It is successful in 1 or 2 weeks.

Fig 19.8 Infiltration of the supinator brevis.

Fig 19.9 Deep friction to the supinator brevis.

Technique: friction to the supinator brevis

The patient sits beside the couch. The elbow is bent at a right angle, pronated and placed on the couch. The therapist sits at a right angle to the patient’s arm and palpates for the shafts of radius and ulna. The tender spot is found in between the two bones. The supinator, being a flat muscle, cannot be felt on palpation, so anatomical knowledge is required to be able to palpate in that region. The therapist then places the thumb on the most tender area and applies counterpressure with the fingers at the medial aspect of the forearm. The friction is performed by an oblique movement perpendicular to the course of the muscular fibres, a movement that starts proximally on the radius and ends more distally on the ulna.

Resisted pronation

Pain on resisted pronation usually indicates golfer’s elbow – a lesion in the common flexor tendon – in which case, resisted flexion of the wrist must also be painful. The fact that the pronator teres muscle partly originates from this tendinous complex at the medial epicondyle explains why resisted pronation may be positive (see golfer’s elbow).

Very occasionally, the lesion lies in the pronator teres muscle itself. Palpation discloses tenderness in the muscle belly, usually at its midpoint. In this unusual lesion, treatment consists of a few sessions of deep transverse friction.

Technique: friction to the pronator teres muscle

The patient sits with the arm rested on the couch. The therapist sits at a right angle to the patient’s arm. The elbow is held in 90° flexion and the forearm in neutral position between pronation and supination. The therapist palpates at the anterior aspect of the forearm for the muscle belly, which may be facilitated by an active contraction by the patient. The fingertips of two or three fingers of the contralateral hand are then placed on the tender area and counterpressure is applied with the thumb at the lateral aspect of the forearm. The forearm is stabilized with the other hand (Fig. 19.10). The friction movement is begun underneath the muscle and the fingers are pulled over the muscle towards the therapist. This is the active phase. The fingers are then brought back to the previous position (passive phase). The sequence is repeated.

Fig 19.10 Deep friction to the pronator teres.

Pain on resisted extension of the wrist

Tennis elbow

The term ‘tennis elbow’ has been used to describe a multiplicity of conditions of the elbow.

Renton,⁴⁴ in 1830, was the first to describe a patient with pain along the outer forearm which increased on using the hand. In 1873, Runge, a German physician, wrote an article on ‘writer’s cramp’. He distinguished the condition from a case of 2 years’ inability to write, associated with tenderness on the lateral condyle of the humerus. Rest and electrotherapy had no effect and he then cauterized the skin over the tender area, after which the patient became well. He thought the cramp was the result of traumatic inflammation of the periosteum in this location, originally caused by a forcible supination effort and made chronic by the continual pull of the extensor muscles attached to the lateral condyle.⁴⁵ Morris (1882)⁴⁶ compared a condition named ‘lawn-tennis arm’ to rider’s sprain – a lesion of the adductor longus muscle at the hip – and Major also called the condition ‘lawn-tennis elbow’.⁴⁷ An annotation in The Lancet (1885) drew attention to the number of people suffering from ‘tennis elbow’, whose plaintive letters had recently appeared in the lay press. From then on, the term ‘tennis elbow’ has been used to describe symptoms at the outer aspect of the elbow. Remak (1894)⁴⁸ and Bernhardt (1896)⁴⁹ agreed that it was a periosteal tear from occupational overuse of the extensor muscles that arise from the lateral condyle. Couderé (1896)⁵⁰ called it a ‘ruptured epicondylar tendon’, Féré (1897)⁵¹ ‘épicondylalgie’, Franke (1910)⁵² ‘epicondylitis’. In 1921, Schmidt⁵³ suggested superficial epicondylar bursitis, thereby incriminating the bursa described by Schreger in 1825.⁵⁴ In 1922, Osgood⁵⁵ and, in 1932, Carp⁵⁶ believed the lesion to lie in the radiohumeral bursa, and extra-articular bursa under the extensor tendons, which was first described by Monro in 1788.⁵⁷

In 1936, Cyriax ⁵⁸ compiled a list of no fewer than 26 different types of lesion to which the name tennis elbow had been given by 91 authors during the previous 63 years. He presented a synopsis of opinion as to the cause of tennis elbow and stated that a condition, the symptoms and signs of which are as constant as those of tennis elbow, may well be supposed to have but one background and, as a corollary, but one type of treatment.

An enormous number of articles on tennis elbow have been published in the ensuing years, describing different pathological entities such as radiohumeral bursitis, radiohumeral synovitis, irritation of the synovial fringe, degeneration of the annular and collateral ligaments, fibrillation of the articular cartilage, osteoarthrosis of the radiohumeral joint, osteochondritis dissecans, aseptic necrosis of the radial head, stenosis of the orbicular ligament, chondromalacia of the radial head and capitellum, calcific tendinitis of the extensor muscles, myofasciitis, traumatic periostitis of the lateral epicondyle, and enthesopathy of the lateral epicondyle of the humerus, among others.59–68

A new concept was introduced in 1972 when Roles and Maudsley described the ‘radial tunnel syndrome’⁶⁹ (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

The most encompassing classification is perhaps that of O’Neill et al,⁷⁰ who state that ‘tennis elbow or lateral epicondylitis consists clinically of pain localized in the region of the lateral aspect of the elbow with tenderness in the vicinity of the lateral epicondyle’. This vague description illustrates how unsure most authors are about the pathogenesis of tennis elbow.

Most authors consider tennis elbow as a local condition in relation to the lateral epicondyle of the humerus. However, some authors have described this condition as resulting from a cervical problem and they claim curative results with treatment to the neck. Gunn et al⁷¹ considered a tennis elbow to be caused by a reflex localization of pain from radiculopathy at the cervical spine. Several authors agreed with this point of view.^72–74 Weh⁷⁵ believes that the idea of a local clinical assessment of tennis elbow should be broadened to an overall vision of a functional chain consisting of cervical spine, shoulder and elbow, in which local reflex inhibition of muscles innervated by the seventh nerve root and a limitation of movement of the cervical spine are causative elements. It is quite certain that elbow pain may have a cervical origin. This should not be designated ‘tennis elbow’ but instead ‘referred elbow pain’ from the cervical spine. If clinical examination shows the elbow pain to be evoked by movements at the elbow, then the lesion must be sought there. In contrast, if cervical examination is positive, this means that cervical movements must be the cause of pain in the elbow region.

We agree with those who consider tennis elbow as a lesion in the radial wrist extensors at the elbow. This is a logical deduction from what is found at clinical examination of the elbow, the primary sign being pain on resisted extension of the wrist.

Tennis elbow is characterized by pain on resisted extension of the wrist.

Terminology

‘Tennis elbow’ is technically a misnomer, since it most often occurs in non-tennis players: less than 5% of the patients play tennis.76–78 Even in a population of 500 tennis players complaining of lateral elbow pain, Grachaw and Pelletier found tennis elbow present in only 39.7%.⁷⁹ This accords with Krämer’s findings.⁸⁰ Neither is the term ‘epicondylitis’ right: at least 10% of the lesions do not lie at the epicondyle itself. Furthermore, the suffix ‘-itis’ indicates an inflammatory process, but histological analysis shows only disruption of the collagen bundles with vascular and fibroblast proliferation and without inflammation. Therefore the term ‘tendinosis’ should be preferred over ‘tendinitis’.⁸¹

Of all the patients seen in a general medical practice, 0.5% suffer from ‘tennis elbow’.⁸² The condition is therefore important enough to try to define it properly. The lesion lies at the elbow, in the structures controlling wrist extension and radial deviation (extensores carpi radiales). Theoretically, the lesion could also lie in the ulnar deviators or in the extensors of the fingers but this is much less common and should be separately named: for example, lesion of the extensor carpi ulnaris muscle, lesions of the extensor digitorum muscle.

Pathological features

It is generally believed that tennis elbow is an overuse phenomenon caused by repeated contractions of the radial extensors of the wrist,61,83 and especially of the extensor carpi radialis brevis.⁸⁴ Post-traumatic causes have also been described.⁸⁵ In the early stages, when the tissue attempts repair, and often just as the tear begins to unite, continued muscular contraction pulls the healing surfaces apart once more. This results in the formation of a painful scar with self-perpetuating inflammation (Cyriax⁸⁶: p. 178). Cyriax’s view was confirmed by Coonrad and Hooper in 1973.⁷⁶

More recent observations during surgery have led Nirschl to classify this condition mostly under the heading ‘tendinosis’ rather than tendinitis: surgical inspection shows a typically ‘grayish color and homogenous and generally edematous and friable tissue’ indicating angiofibroblastic invasion – fibroblasts and vascular granulation-like tissue.87–89 Inflammatory cells are not usually found.⁹⁰

History

The patient is usually between 30 and 60 years,91,92 and seldom under 20 or over 70. As the lesion is the result of overuse, the patient does not notice the pain the moment a tennis elbow develops but rather a few days later. A pain is described starting at the outer aspect of the elbow and radiating down the posterior aspect of the forearm, very often as far as the dorsum of the hand. Pain may be felt in the long and ring fingers. It is evoked by grasping, pinching and lifting – the movements that involve extension of the wrist and in which the wrist extensors merely act as stabilizers of the joint.

In a few weeks, the symptoms develop to the point that even light objects are dropped as the result of sudden painful twinges. Patients may be encountered who have constant pain, which may be worst at night and followed by waking in the morning with the elbow feeling stiff.

Functional examination

Nine out of the 10 tests of the elbow are negative and one is positive: resisted extension of the wrist. It should be remembered that the elbow must be held in full extension in order to avoid a false-negative result.

Tennis elbow = 9 tests negative + 1 test (resisted extension of the wrist) positive.

Our experience has shown that, if resisted extension of the wrist causes such a sharp twinge that the patient has to drop the hand, this points to a lesion at the tenoperiosteal junction. Resisted extension of the wrist, with and without the fingers held actively flexed, is then compared. Active flexion of the fingers inhibits the action of the finger extensors. In most instances both versions will be equally positive, which shows the wrist extensors to be at fault. Rarely, resisted extension of the wrist with the fingers held actively flexed will be negative, which implicates the finger extensors. If one or more finger extensors are strained, resisted extension of the different fingers will show which tendon is involved.

The next approach is to differentiate the radial extensors from the ulnar extensor using two accessory tests. Resisted radial deviation is compared with resisted ulnar deviation, the wrist being held in the neutral position between flexion and extension. In the rare circumstance that resisted ulnar deviation is painful, the lesion lies in the extensor carpi ulnaris muscle. Much more frequently, resisted radial deviation is painful, which indicates a lesion in either the extensor carpi radialis longus or the extensor carpi radialis brevis – the structures involved in tennis elbow (Fig. 19.11).

Fig 19.11 Clinical examination of tennis elbow.

Palpation

The exact location is revealed by palpation. The palpatory manœuvres must be confined to the structures at fault: the extensor carpi radialis longus and brevis. In that the lateral aspect of the elbow is very often tender to the touch, even in those without a lesion, palpation is sometimes misleading. One elbow should be compared with the other, as should possible locations. In corpulent women, it may be difficult to define the lateral epicondyle. The palpation techniques are identical to the friction techniques (see Treatment, below) although it might sometimes be necessary to put the elbow further into extension to be able to reach the tender spot.

Practice shows that a tennis elbow has four different localizations (Fig. 19.12). Double lesions, however, are not at all uncommon. On palpation from proximal to distal, a tender spot can be found at one of the following places:

Fig 19.12 Localizations of tennis elbow: 1, supracondylar (type I); 2, tenoperiosteal (type II); 3, tendinous (type III); 4, muscular (type IV).

• just proximal to the epicondyle along the supracondylar ridge at the anterior aspect – i.e. the origin of the extensor carpi radialis longus. This structure feels like a muscular rather than a tendinous tissue (type I).

• at the anterior aspect of the lateral epicondyle – the tenoperiosteal origin of the extensor carpi radialis brevis. In this instance palpation must be precisely at the origin of the tendon itself. Palpation of the lateral or posterior aspect of the epicondyle may also be positive, which is merely ‘associated’ tenderness. This disappears as soon as the lesion is cured. The tenoperiosteal variety at the epicondyle itself is by far the most common localization of tennis elbow (type II).

• level with the radiohumeral joint line and over the head of the radius – the body of the tendon of the extensor carpi radialis brevis, lying in between other tendinous structures (type III).

• level with the neck of the radius and a few centimetres distally – the upper part of the muscle bellies of extensor carpi radialis longus and brevis (type IV).

Experience shows that type I occurs in 1% of cases, type II in 90%, type III in 1% and type IV in 8% (Cyriax ⁸⁶: p. 178).

Treatment of type I (supracondylar) tennis elbow

Treatment of this type is quite simple. It responds very well to deep transverse friction and should be cured in 3–6 treatments, performed two or three times a week. Infiltrations are futile.

Technique: deep friction

The patient sits with the arm resting on the couch. The elbow is held in 90° flexion and in supination. The therapist sits lateral to the patient and uses the contralateral hand, with the tip of the thumb placed on the anterior aspect of the humerus just proximally to the lateral epicondyle. The thumb is kept well flexed and is held perpendicular to the shaft of the humerus.

The fingers apply counterpressure at the posterior aspect of the arm (Fig. 19.13).

Fig 19.13 Deep friction in supracondylar tennis elbow.

Friction is imparted by an up-and-down movement of the entire hand, resulting in a movement of the thumb parallel to the axis of the humerus. The manœuvre has two phases: an active phase during the downwards movement and a passive phase when the hand is brought upwards again.

Treatment of type II (tenoperiosteal) tennis elbow

Treatment of the tenoperiosteal type of tennis elbow varies from very easy to very complicated. The choice of treatment depends on different factors, such as age, activities and duration of the symptoms. As the condition tends to resolve spontaneously, this possibility should be presented to the patient. Active treatment consists of infiltration with triamcinolone and Mills’s manipulation. Recurrent or refractory cases may need other approaches, including infiltration with a sclerosant solution, percutaneous tenotomy and partial immobilization – taping and bracing (see Treatment procedures, p. 312).

Natural evolution

The tenoperiosteal variety is the only type of tennis elbow that has a tendency to spontaneous cure ⁹³ (Fig. 19.14); this may take a year in patients under 60 and up to 2 years when the patient is older than this. After full spontaneous recovery, a second attack is rare. However, infiltration of any steroid solution inhibits the mechanism of spontaneous cure. The patient should be told about the possibility of spontaneous recovery, certainly if symptoms have been present for some time. Waiting, meanwhile sparing the elbow as much as possible, may be the preferred option. Cyriax⁸⁶ (his p. 179) explains the mechanism of spontaneous recovery as follows: as the result of the many contractions of the extensors of the wrist, which put tension on the healing breach, the gap between the two edges gradually widens. Finally the two surfaces cease to lie in apposition and the tension on the scar ceases. The gap now fills with fibrous tissue. The painful scar is now embedded and heals with permanent lengthening of some tendinous fibres. In consequence, the strain no longer falls on that part of the tendon. Recurrence is prevented by this structural alteration. Because several muscles are attached here, slight permanent lengthening of the section of tendon relevant to only one muscle does not weaken the power to control the wrist.

Fig 19.14 Mechanism of spontaneous cure of tenoperiosteal tennis elbow.

Infiltration with triamcinolone suspension

Until 1952 there was no alternative to deep transverse friction in the treatment of tendinous lesions. For many years a means of reducing a localized area of unwanted traumatic inflammation had been sought. In 1952, Cyriax and Troisier ⁹⁴ suggested the use of steroid infiltration as a treatment for tennis elbow. After the infiltration, the scar remains in place but the inflammation ceases. Because the steroid is a suspension of insoluble particles, its action is confined to the structure which is infiltrated without much effect on or spread to the adjacent structures.

In the following decades, steroid infiltration gained a bad reputation. Some authors therefore advise that the injection be given in such a way that the solution will bathe the underlying tendon rather than being injected into the tendon itself.⁹⁵ This technique may easily lead to the development of lipoatrophy and depigmentation of the skin. All these side effects can be avoided by using the smallest possible amount of weak steroid and precise infiltration into the tendon itself.

Technique: infiltration

The patient sits with the elbow resting on the couch. The joint is flexed at a right angle and held in full supination. The boundaries of the lesion are now meticulously defined by palpation.

A 1 mL tuberculin syringe is filled with triamcinolone suspension and fitted with a thin needle 2 cm in length. The thumb is placed at the tender spot. The needle is thrust in vertically until it pierces the tendinous insertion and hits bone (Fig. 19.15). As one droplet is infiltrated, the appearance of a tiny bulge is felt for with the palpating thumb, confirming that the correct spot has been found. By half-withdrawing and reinserting the needle at slightly different angles, the entire lesion, which must be envisaged as a three-dimensional object, is infiltrated. Each time a droplet is injected, its exact position should be determined using the thumb. Considerable pressure sometimes has to be exerted on the syringe.

Fig 19.15 Infiltration in tenoperiosteal tennis elbow. Viewed (a) from behind and (b) from the front.

The patient is warned against possible severe discomfort for 24 hours, which may be possible to reduce by the application of ice. Complete rest should be taken for a week and relative rest for another week. Follow-up is after 2 weeks with careful retesting, even if cure appears to have been achieved. If the examination is negative, no more need be done. If the elbow still aches or if the clinical examination is not 100% negative, infiltration should be repeated.

Results

Our personal experience is that 1–3 steroid infiltrations give full relief in all cases of uncomplicated tennis elbow. However, only two-thirds of patients remain asymptomatic. The rest will relapse within 2–6 months. Although renewed infiltrations may be of most benefit, there will remain some refractory cases that are difficult to treat (see p. 310). The prerequisites for success are: accurate diagnosis and localization of the lesion, correct infiltration technique, and a completely negative test on re-examination. A similar success rate was found by Troisier in 1991⁹⁶: in a series of 257 patients, infiltration with corticosteroids gave full relief in all cases but the recurrence rate was 66.7%, although 67% of these recurred only once or twice.

Over the last few decades the effectiveness of steroid infiltration has been investigated via multiple controlled trials. All showed that steroid injections produced quick and significant pain relief in the short term, but that long-term outcomes are less clear. Hay et al performed a multicentre pragmatic randomized controlled trial of local corticosteroid injection and naproxen in 164 patients. They came to the conclusion that early local corticosteroid injection is much more effective in the first weeks than treatment with naproxen or placebo, but that the outcome at 1 year was the same in all groups.⁹⁷ This confirms the findings of Assendelft et al⁹⁸ and Verhaar et al.⁹⁹

In another randomized clinical trial, Smidt et al claimed that the long-term outcomes of steroid injections might be poor due to the high number of relapses.¹⁰⁰ The study by Tonks et al was very positive for steroid injections but did not follow up the patients beyond 7 weeks,¹⁰¹ while Altay et al reported that local steroid injection produced excellent pain relief at 1 year.¹⁰² In a prospective randomized study Dogramaci et al compared three different methods of injection: a local injection of triamcinolone, a peppering infiltration of local anaesthetic and a peppering infiltration of triamcinolone. The peppering infiltrations with triamcinolone produced superior clinical results with cure in 84% of cases, whereas corticosteroid injection was only effective in 36% and peppering with lidocaine alone gave good results in 48%.¹⁰³

Mills’s manipulation

Several authors, such as Cyriax, Mills, Mennell, Stoddard and Kaltenborn, have proposed manipulation as a treatment for tennis elbow.58,104–108 Although it is based on different pathological premises, they found that manipulative treatment could lead to good results. Manipulation, preceded by deep transverse friction, was Cyriax’s treatment of choice before infiltration with steroids was found to be effective in 1952. He intended to stretch the extensor carpi radialis brevis tendon maximally in order to try to pull apart the two surfaces of the painful scar. This would thus imitate and speed up the mechanism of spontaneous recovery (see p. 307).

Several manipulations have been compared and it seems that Mills’s manipulation, as described by Cyriax and for the indications which he describes, has the greatest potential to stretch the affected tendon with the least potential for harm to the joint.¹⁰⁹ Mills was an orthopaedic surgeon who described his manipulation technique in 1928 with the intention of realigning a torn section of the annular ligament, which he regarded as out of place.¹⁰⁴ Cyriax later discontinued the use of his own initial manipulation method and advocated the use of his modification of Mills’s manœuvre.

The manipulation is preceded by deep transverse friction because of its desensitizing and softening effect, which makes the actual manœuvre less painful and therefore more tolerable. Friction alone is ineffective. This second type of tennis elbow is the only tenoperiosteal tear in the body that is not treated by deep transverse friction alone, and the only one for which manipulation has any effect. Some authors claim good results with stretching of the wrist extensors as home exercise following the treatment.¹¹⁰

Contraindication

Mills’s manipulation should not be performed when extension of the elbow is limited, either as the result of an existing capsular pattern (arthritis or arthrosis) or as the result of a limitation of extension in a non-capsular pattern (loose body disorder), because of the danger of provoking a traumatic arthritis. If the extension seems limited but is so because of pain alone, a careful manipulation may be tried and, if this does not set off an irritation or reaction of the joint, there is no danger in doing this at each treatment session.

Technique: preparative deep friction

The patient sits with the elbow flexed to 90° and in full supination. The therapist sits facing the patient’s arm and grasps the elbow with the contralateral hand. The fingers apply counterpressure at the medial aspect of the elbow.

The thumb is well flexed and the thumb tip placed on the tender spot at the lateral edge of the epicondyle. The thumb is then brought over the anterior aspect of the epicondyle and imparts friction by moving medially over the bone (Fig. 19.16). The amplitude of the friction is only a few millimetres. Pressure is exerted vertically downwards. The therapist should start gently, because of the painfulness of the condition, and gradually increase the pressure.

Fig 19.16 Preparative friction prior to Mills’s manipulation.

After 10–15 minutes’ friction the manipulation follows.

Technique: manipulation

The patient sits on a chair and the therapist stands behind. The patient’s arm is abducted and also put in internal rotation. The forearm is then fully pronated and the wrist flexed. The patient’s hand is grasped with the ipsilateral hand by bringing the thumb between the patient’s thumb and index finger, so that the therapist’s thumb is on the patient’s palm. Consequently the fingers come to lie at the dorsum of the hand. This position enables the therapist to maintain full flexion at the patient’s wrist at the moment of manipulation. The contralateral hand is then placed on top of the olecranon (Fig. 19.17). By moving both hands in opposite directions, the elbow is extended and the extensor muscles are thus stretched.

Fig 19.17 (a) Mills’s manipulation for tenoperiosteal tennis elbow. (b) Detail of hand position.

The therapist focuses attention on the patient’s hand, which should be forced into full flexion. As the manœuvre proceeds, the body weight is brought to the other leg, so that the body moves away from the elbow. In this position the therapist is able to keep the patient’s elbow and wrist in the required position.

A quick thrust towards elbow extension (Fig. 19.18) is then performed by moving both hands in opposite directions. A crack is very often heard, indicating the rupturing of some tendinous fibres. This manipulation is carried out once at each attendance. It usually takes 8–15 sessions for the patient to be cured but some cases require 20–30 treatments and not every tenoperiosteal tennis elbow responds well.

Fig 19.18 Mills’s manipulation for tenoperiosteal tennis elbow.

Troisier ⁹⁶ reported a series of 131 cases in which good and excellent results were achieved in 63% by deep transverse friction and manipulation. A recent randomized clinical trial compared the effectiveness of deep transverse friction massage with Mills’s manipulation versus phonophoresis with supervised exercise. Whereas both groups improved significantly from the initiation of treatment, a between-group comparison revealed significantly greater improvements regarding pain, pain-free grip and functional status for the experimental group compared to the control group.¹¹¹

Refractory tennis elbow

The great majority of patients with the commonest variety of tennis elbow can be cured by the two procedures described. If the lesion seems refractory or if it frequently recurs, less usual measures can be used.

Infiltration with a sclerosant solution

The intention is no longer to reduce inflammation of the scar but to provoke the formation of dense adhesive scarring, which engulfs the original scar, using the irritant effect of hypertonic dextrose. The beneficial result may also stem from the powerful destructive effect of phenol on the small unmyelinated pain fibres.¹¹²

After-pain is considerable and may last several days, after which the condition gradually improves. The effect may only be expected after 2–3 weeks. Symptoms should disappear after one infiltration; if not, a second is unlikely to help.

Recent studies have demonstrated that 1–2 injections with a sclerosant solution effectively decreased elbow pain and improved strength testing in subjects with refractory tennis elbow compared to control injections.113,114

Tenotomy

If all other means have been tried without lasting effect, percutaneous tenotomy under local anaesthesia is worth consideration. This is a very simple operation, performed on an ambulant patient. The extensor carpi radialis brevis tendon at the anterior aspect of the lateral epicondyle is divided across its whole width. It is immediately followed by Mills’s manipulation to ensure complete separation of the two cut ends. This treatment again imitates the mechanism of spontaneous cure. A study by Daubinet of 18 tennis elbow patients who did not respond to conservative treatment showed the effectiveness of insertion–tenotomy of the extensor carpi radialis brevis.¹¹⁵ A prospective long-term follow-up study by Verhaar et al claims gratifying results and a low rate of complications with lateral extensor release as a simple outpatient procedure. They consider it to be the operation of choice for the treatment of long-standing tennis elbow.¹¹⁶ Dunkow et al conducted a prospective randomized controlled trial of 47 patients with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. They concluded that the percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results.¹¹⁷ Other authors also claim good to excellent results with percutaneous release of the common extensor origin for long-standing symptoms.^118–122

If tenotomy fails, one unexpected outcome is that treatment can be started again from the very beginning. The lesion, which hitherto showed no lasting response to infiltration with triamcinolone, may become amenable and will be helped with one or two further infiltrations.

Technique: tenotomy ¹²³

The exact spot is palpated. Using the same infiltration technique as for treatment with steroids, the whole tender area is infiltrated with 1 mL of a 2% xylocaine solution. Some of the fluid is reserved to inject subcutaneously in order to render the skin anaesthetic. After a minute, resisted extension of the wrist is retested. If the correct spot has been chosen, this movement should be completely painless.

A small, thin, double-edged tenotome is then thrust through the skin into the dense tendinous tissue in the same way the needle was introduced – vertically. The tenotome is moved further down until it touches bone (Fig. 19.19). By moving the tip of the tenotome up and down along the bone of the epicondyle in a perpendicular way, the tendon of the extensor carpi radialis brevis is divided transversely across its entire width. The small lancet is then removed and the bleeding, if present, stopped by pressure.

Fig 19.19 Tenotomy.

Mills’s manipulation is then carried out to ensure complete separation of the two cut ends. No further treatment is needed. Suture is not necessary as the opening in the skin is only a few millimetres long.

The patient should be warned of serious after-pain, which may last for a few days. The elbow should not be exerted for a week and follow-up is after 2 weeks. Most of the traumatic arthritis, which sometimes results after a tenotomy, will have disappeared by then. If this is not the case, an intra-articular injection with 20 mg of triamcinolone acetonide should be given.

If the operation is not successful and resisted extension of the wrist remains painful after, say, a month, a further infiltration with 10 mg of triamcinolone acetonide should be given at the tender spot, which is usually localized at both cut ends.

Extracorporeal shock wave therapy

Attempts are made with extracorporeal shock wave therapy (ESWT) to treat resistant cases. The patient receives 500–3000 shock waves of 0.08–0.12 mJ/mm² three times at weekly intervals. Some authors consider this a useful conservative alternative in the treatment of tennis elbow.124–126 However, more recent randomized clinical studies comparing different extracorporeal shock wave regimens with placebo did not show strong statistical evidence in favour of ESWT.^127–129

Bracing and taping

Through the years, tape and braces have been used to treat injuries suffered by athletes. In the early stages of the use of external support systems, physicians and certified athletic trainers used mostly trial and error and intuition to provide support for the injured area. Nowadays, interest in this aspect of preventive sports medicine has increased, and sound scientific principles have been used to improve the design and effectiveness of external support systems.130,131

At the elbow, a constricting band can be applied to the proximal part of the forearm (Fig. 19.20). It acts as a counterforce brace, constraining full muscular expansion and therefore decreasing intrinsic muscular force to the sensitive area in the forearm extensors. The intent is to cause the extensor mechanism on the lateral side of the elbow to work at the point where the band is attached, rather than at its point of origin on the lateral condyle. We consider the use of a counterbrace to be a valuable method for preventing recurrence because it causes improvement in wrist extension and grip strength with positive biomechanical effects.^132–135

Fig 19.20 Counterforce brace for tennis elbow.

Special circumstances

There are two rare types of lateral elbow pain that are worth considering here.

Tenoperiosteal lesion of the extensor carpi radialis brevis with limitation of movement

This is encountered from time to time. If the limitation is in the capsular pattern, involvement of the capsule is suggested. This possibility will have been confirmed recently by arthroscopic examination.¹³⁶ If this is the case, the capsule should be treated first. If the limitation follows a non-capsular pattern, it may be caused either by a loose body limiting mostly extension, or by a cyst. The loose body can be manipulated. A cyst gives rise to a few degrees’ limitation of passive extension of the elbow. The end-feel is softish, sometimes even a bit springy. Palpation usually reveals a cystic swelling under the origin of the tendon.

This type of tennis elbow has been shown to be refractory to any of the treatments described above. When a thick needle is thrust in, cystic fluid can be aspirated. Immediately afterwards, passive extension becomes full-range. A triamcinolone solution is now infiltrated, 1 mL at the origin of the tendon and 1 mL at a deeper site where the cyst has been detected. The patient is seen again after 2 weeks and, if necessary, treatment is repeated.

Radial tunnel syndrome

Some authors consider the so-called radial tunnel syndrome to be a type of tennis elbow (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

Treatment procedure for type II tennis elbow

There are three therapeutic options for a type II tennis elbow (Fig. 19.21):

Fig 19.21 Treatment procedure for type II tennis elbow.

1. Waiting for spontaneous cure. Tennis elbow is a self-limiting disorder that is usually spontaneously cured in 1–2 years. Therefore, in a mild case of lateral epicondylitis that is present for several months, it is worthwhile waiting before giving active treatment, and advising the patient to wear a counterbrace during activities.¹³⁷

2. Treatment with triamcinolone infiltrations. Immediate relief is always obtained, provided the diagnosis and the applied technique are correct. However, this does not mean that all cured patients with type II tennis elbow remain well. The recurrence rate is high if the procedure (repeated reassessment and treatment), together with good secondary prophylaxis, is not properly followed. With a good infiltration technique and consequent procedure, complete and lasting cure is obtained in more than 70% of cases. If the condition recurs a few months after complete cure, triamcinolone infiltrations can be applied again. If relapses are very frequent, the case must be regarded as refractory and another treatment form should be considered: sclerosing injections or tenotomy.

3. Mills’s manipulation. This form of treatment has a success rate of about 50%. However, there are no recurrences after complete cure. Mills’s manipulation and triamcinolone infiltrations are interchangeable but are never applied at the same time.

Treatment of type III (tendinous) tennis elbow

Deep transverse friction is the better treatment in this case and should be successful in six sessions, performed 2–3 times a week.

Technique: deep friction

The patient sits at the couch with the arm resting on it. The elbow is held in 135° extension and in nearly full pronation by the ipsilateral hand. The tendon of extensor carpi radialis brevis now overlies the head of the radius.

The therapist takes hold of the patient’s elbow with the contralateral hand. Counterpressure is applied at the medial aspect of the elbow with the fingers. With the flexed thumb, palpation is carried out at the tender spot. The therapist starts with the thumb at the medial aspect of the tendon and the friction is applied by pulling the thumb towards him, so that it slips over the tendon (Fig. 19.22). The thumb is then relaxed and the same movement started again.

Fig 19.22 Deep friction in tendinous tennis elbow: (a) starting position; (b) end position.

The therapist must make sure that the amplitude of the friction movement is not diminished or stopped by the hand coming in contact with the couch. The patient’s forearm is therefore best supported with a cushion, which leaves the elbow free.

Treatment of type IV (muscular) tennis elbow

The treatment of choice is infiltration with 10 mL of a local anaesthetic in the upper part of the belly of the extensor carpi radialis muscles. Two to four weekly infiltrations usually give lasting relief (Fig. 19.23).

Fig 19.23 Infiltration of the extensor carpi radialis muscle bellies.

Deep transverse friction is an alternative treatment; it is difficult, painful and not always curative. It is performed with a pinching grip (Fig. 19.24).

Fig 19.24 Deep friction to the extensor carpi radialis muscle bellies.

Technique: infiltration of the extensor carpi radialis muscle belly

The patient sits with the elbow resting on the couch. The elbow is flexed at a right angle and supinated. A 10 mL syringe is filled with 0.5% procaine and a 5 cm, thin needle is fitted. The tender spot is held pinched up by the therapist’s thumb and index finger. The needle is inserted obliquely through the belly of the brachioradialis muscle until the point strikes the radius. It is then slightly withdrawn to lie between the fingertips (see Fig. 19.23). The solution is now infiltrated fanwise with different withdrawals and reinsertions so that the entire lesion is covered.

After 5 minutes, resisted extension of the wrist is retested. This movement should no longer hurt; if it does, the lesion was not entirely reached. Infiltration should be repeated at the patient’s next appointment and concentrated on the areas that were missed.

The patient must be warned that a temporary weakness of hand extension is possible because infiltration of a local anaesthetic may paralyse the deep branches of the posterior interosseous nerve.

Lesion of the extensor carpi ulnaris muscle

Occasionally, resisted extension and resisted ulnar deviation of the wrist are painful at the outer aspect of the elbow. This indicates a lesion of the extensor carpi ulnaris muscle, usually at its tenoperiosteal origin at the posterior aspect of the lateral epicondyle of the humerus (Fig. 19.25) or, more rarely, at the olecranon. Palpation will, of course, disclose the exact site of the lesion.

Fig 19.25 The extensor carpi ulnaris muscle.

Treatment consists of either infiltration with triamcinolone suspension or deep transverse friction.

Lesion of an extensor digitorum muscle

Lesions of the extensors of the fingers do occur but are quite uncommon. The diagnosis is made too often and is probably the result of a misinterpretation of the clinical examination – resisted extension of the fingers, and especially of the middle finger, is often found to be positive in tennis elbow and apparently is a consequence of the close relationship of the extensors of wrist and fingers in the region of the elbow. When a lesion of the extensor digitorum does occur, resisted extension of the wrist with the fingers held actively flexed should be negative.

Treatment consists of either infiltration with triamcinolone (origin) or deep transverse friction.

Resisted flexion of the wrist (with the elbow held in extension) causing pain at the medial aspect of the elbow indicates a lesion of the common flexor tendon, which originates mainly from the medial epicondyle. The lesion is known as medial epicondylitis or golfer’s elbow. The disorder is diagnosed 7–10 times less often than lateral epicondylitis.¹³⁸ Although golfer’s elbow may affect patients from 12 to 80 years of age, it is most commonly seen in the 40–50-year age group.⁷⁸ The condition has been attributed to repetitive forearm pronation and wrist flexion.^139,140 As in tennis elbow, it follows a series of repeated (often occupational) strains,¹⁴¹ rather than a single injury. Histological analysis shows pathological changes in the common flexor tendon: micro-tearing with disruption of the collagen bundles, vascular and fibroblast proliferation, focal hyaline degeneration and an incomplete reparative process. As in tennis elbow, these changes have been called ‘angiofibroblastic hyperplasia’ and, as there is no evidence of any inflammatory process, the term ‘tendinosis’ is preferred over ‘tendinitis’.¹⁴²

The patient, aged between 40 and 60 years, describes pain at the medial aspect of the elbow that may radiate down the upper part of the forearm at the ulnar side. The pain is provoked by palmar flexion of wrist and/or fingers. Resisted pronation of the elbow is often positive as well, because the pronator teres muscle partly originates from the common flexor tendon. Rarely, pain is only evoked by resisted pronation and/or resisted flexion of one or two fingers. This may occur in very localized lesions and depends on which part of common flexor tendon is affected.

Palpation of the medial epicondyle is necessary to find the exact spot, which is usually very localized. There are two possible sites (Fig. 19.26):