Radial tunnel syndrome: an etiology of chronic lateral elbow pain

Lateral elbow pain is common in athletic and nonathletic populations. Radial tunnel syndrome (RTS) is an infrequent condition that may produce symptoms similar to tennis elbow. However, RTS is distinguished from tennis elbow in that the symptoms are present more than six months and resistant to conservative treatment. Furthermore, three pathognomomic signs indicate RTS: 1) tenderness when palpating the radial tunnel anterior to the neck of the radius, 2) reproduction of symptoms with resisted supination, and 3) resisted extension of the middle finger. The purpose of this article is to review the literature regarding the symptomatology, pathophysiology, and treatment of RTS so clinicians can distinguish RJS from tennis elbow. Both conditions present similar symptoms; however, clinicians should be able to distinguish between them in order to achieve successful pain relief from lateral elbow pain. J Orthop Sports Phys Ther 1991;14(1):14-17.     

The posterolateral plica: a cause of refractory lateral elbow pain

Lateral epicondylitis is one of the most common upper extremity pain syndromes. We report the results of patients in whom conservative treatment was unsuccessful and who were finally treated arthroscopically for symptomatic plicae. Ten patients (mean age, 40 years [range, 18-60 years]) who were misdiagnosed as having lateral epicondylitis were included in this study. Examination revealed the site of maximal tenderness to be posterior to the lateral epicondyle and centered at the posterior radiocapitellar joint. Preoperatively, all patients received conservative treatment (physical therapy or corticosteroid injections [or both]). The mean follow-up was 25 months (range, 6-68 months). The mean score on the Disabilities of the Arm, Shoulder and Hand questionnaire was 9 (range, 0-37). Preoperatively, 7 patients had full elbow range of motion; however, in 3 patients, there was a loss of extension at the elbow ranging from 7 degrees to 20 degrees preoperatively. The range of elbow motion was full in all patients postoperatively. No patient demonstrated posterolateral pain after the operation. Synovial plicae of the elbow may be the cause of lateral elbow pain in patients with vague clinical symptoms. Arthroscopic management may provide a successful treatment option for such patients.     

The role of the musculocutaneous and radial nerves in elbow flexion and forearm supination: a biomechanical study

The intention of this prospective study was to evaluate the role of the musculocutaneous and radial nerves in elbow flexion and forearm supination. The study included 29 patients having loco-regional anaesthesia for minor hand surgery. Elbow flexion and forearm supination forces were evaluated before and after an isolated musculocutaneous nerve block in one group and an isolated radial nerve block in another group. The results showed that the biceps tendon is responsible for 47% of the forearm supination force and the combination of brachioradialis and the supinator for 64% of this force. It showed also that the musculocutaneous and radial nerves contribute by 42% and 27.5%, respectively, to the flexion force of the elbow. These results are intended to help surgeons in decision making when treating chronic biceps tendon rupture, in repair of traumatic brachial plexus neuropathy and in using tendon transfers, such as the Steindler transfer, around the elbow.     

Decompensation of a supinator syndrome in submuscular lipoma. A rare differential diagnosis of elbow pain

Important differential diagnoses to epicondylitis humeri radialis are the nerve compression syndromes of the elbow. After a long period of conservative treatment, paresis of the motor branch of nervus radialis in this case led to the diagnosis and surgical treatment showing an unknown submuscular lipoma as the cause of a supinator syndrome with paresis of the finger extensors. In cases of therapy-resistant pain of the elbow, especially resistant to the conservative therapy of an epicondylitis humeri radialis, a nontraumatic supinator syndrome should be considered as a differential diagnosis. A tumor as the cause of a compression syndrome of the motor branch of the nervus radialis is very rare.     

Compression syndromes of the radial nerve in the area of the elbow and lateral elbow pain

Preoperative, intraoperative, and postoperative findings are described and discussed with reference to 93 operations for entrapment syndromes of the radial nerve in the cubital region. Reference is also made to the importance of this pathological pattern in the context of the whole complex of "lateral elbow pain".     

骨性关节炎所致慢性持续性疼痛的发病机制

在世界范围内,骨关节炎(osteoarthritis,OA)已成为引起肌肉骨骼疼痛和功能残疾的主要病因。尽管临床上已使用多种保守或介入治疗方法,但是仍不能有效控制OA所致的疼痛。各种原因引起的慢性疼痛特别是神经病理性疼痛是最具挑战的临床医疗和公众健康问题,给患者及其家庭乃至社会带来沉重的精神和经济负担。慢性疼痛治疗手段繁多但疗效却并不满意,究其原因主要是对慢性疼痛的发生发展机制认识尚不足,且已知的科研成果尚未转化为临床治疗手段。本文旨在综述OA所致慢性疼痛的潜在病理生理机制,以期探讨新的有效控制OA痛的作用靶点,对新药研发及新的治疗策略提供思路。     

颈背根节卡压与顽固性肘外侧疼痛的临床研究

目的；研究颈神经背根节卡压所致顽固性肘外侧疼痛的病理特点和诊治方法。方法；采用YabuKi对颈神经背根节的研究方法，同时对7具成人防腐标本颈背根节的位置和毗邻关系进行了观察。结果临床对35例顽固性肘外侧疼痛，因神经在颈部或同时存在肘部的卡压，所表现的不同体征，分为单卡型和双卡型，分别采取背根内侧支阻滞配合手法以及肘部痛点封闭治疗。结果：单卡型组平均治疗3次，双卡型组平均治疗5次，平均随访9个月，术后疗效优良率分别为87．5％，79．0％，总优良率为83．8％，结论：颈神经背根节卡压可能是顽固性肘外侧疼痛又一重要发病因素，神经阻滞配合手法治疗，对该类型顽固性肘外侧疼痛，具有较好的治疗效果。     

The forgotten radial nerve: A conceptual framework for treatment of lateral elbow pain

BackgroundLateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury.PurposeThe purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain.MethodsThe proposed framework - Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system.ResultsOur findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments.ConclusionFuture studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.     

Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study

The purpose of this study was to determine the relative contribution of muscle activity and the effect of forearm position on the stability of the medial collateral ligament (MCL)-deficient elbow. Simulated active and passive elbow flexion with the forearm in both supination and pronation was performed using a custom elbow testing apparatus. Testing was first performed on intact specimens, then on MCL-deficient specimens. Elbow instability was quantified using an electromagnetic tracking device by measuring internal-external rotation and varus-valgus laxity of the ulna relative to the humerus. Compared with the intact elbow, transection of the MCL, with the arm in a vertical orientation, caused a significant increase in internal-external rotation during passive elbow flexion with the forearm in pronation, but forearm supination reduced this instability. Overall, following MCL transection the elbow was more stable with the forearm in supination than pronation during passive flexion. In the pronated forearm position simulated active flexion also reduced the instability detected during passive flexion, with the arm in a varus and valgus gravity-loaded orientation. The maximum varus-valgus laxity was significantly increased with MCL transection regardless of forearm position during passive flexion. We concluded that active mobilization of the elbow with the arm in vertical orientation during rehabilitation is safe in the setting of an MCL-deficient elbow with the forearm in a fully supinated and pronated position. Splinting and passive mobilization of the MCL-deficient elbow with the forearm in supination should minimize instability and valgus elbow stresses should be avoided throughout the rehabilitation period.     

旋后肌在肘外侧软组织损害中的重要作用(附197例诊治分析)

目的：明确旋后肌在肘外侧软组织损害中形成中的重要作用，以提高治愈率、缩短病程。方法：对197例患者（244肘）开始均施以痛点注射（244肘）无效者用银质针治疗（67肘），对15肘非手术治疗无效而压痛广泛者行手术松解治疗。结果：197例患者（244肘）得到了半年以上的随访，总有效率97．1％，治愈率87．7％。结论：旋后肌损害与本病的发生密切相关，只有明确了病变范围后采取针对性的治疗是提高疗效的关键。     

Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability

Purpose

In recalcitrant epicondylitis innumerable operative techniques have been published, nevertheless a certain percentage of patients remains symptomatic after operative treatment. We developed an individual, systematic diagnostic pathway including arthroscopic assessment of elbow stability to identify the optimal and respectively less invasive therapy.

Methods

We so far included 40 patients with recalcitrant lateral epicondylitis (mean age 46 ± 11). 5 patients had previous surgery. In all patients, we did an elbow arthroscopy and a systematic arthroscopic stability testing. 25 patients were treated exclusively arthroscopically once instability was excluded. In 13 patients with slight instability, we did an open debridement of the lateral tendon complex and local refixation. Two patients with severe instability were treated with open debridement and additional stabilization of the LUCL with a trizeps graft. With a minimum follow-up of 1 year, we assessed the DASH score and subjective patient satisfaction.

Results

Mean follow-up was 24 ± 12 months, mean duration of symptoms before surgery was 19 ± 18 months. The mean DASH score at follow-up was 22 ± 19.36 patients reported symptoms improvement, 34 patients would repeat surgery given the same situation; in 30 cases, patients expectations had been fulfilled. We did not observe any intraoperative complications or infections. One patient developed joint stiffness requiring reoperation.

Conclusion

Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate.

Level of evidence

Level III.     

脊髓Cav3.2型钙通道在大鼠慢性神经病理性痛形成中的作用

目的探讨Cav3.2型钙通道在大鼠慢性神经病理性痛形成中的作用。方法健康雄性SD大鼠,制备大鼠背根神经节慢性压迫（CCD）模型,选取鞘内置管成功的32只大鼠,随机分为4组（n=8）：假手术组（S组）、CCD模型组（CCD组）、CCD＋Cav3.2反义寡聚核苷酸组（CCD＋Cav3.2-AS组）和CCD＋Cav3.2错义寡聚核苷酸组（CCD＋Cav3.2-MM组）。S组和CCD组于CCD后1～4d每天早晚鞘内注射生理盐水10μl;CCD＋Cav3.2-AS组和CCD＋Cav3.2-MM组于CCD后1～4d每天早晚鞘内注射Cav3.2反义寡聚核苷酸或Cav3.2错义寡聚核苷酸12.5μg（10μl）。各组于CCD前2d和CCD后1～5d测定大鼠机械刺激缩足反应阈值（MWT）和热刺激缩足潜伏期（TWL）。于CCD后5d处死大鼠,取L4,5脊髓节段采用免疫组化法测定脊髓背角神经型一氧化氮合酶（nNOS）的表达。结果与CCD前2d比较,CCD组、CCD＋Cav3.2-AS组和CCD＋Cav3.2.MM组CCD后1～5d MWT和TWL均降低（P〈0.05或0.01）。与S组比较,其余3组CCD后1～5d MWT、CCD后2～5d TWL降低（P〈0.01）。与CCD组比较,CCD＋Cav3.2-AS组术后3～5d MWT和TWL升高（P〈0.01）,CCD＋Cav3.2- MM组差异无统计学意义（P〉0.05）。与S组比较,其余3组脊髓nNOS表达上调（P〈0.01）;与CCD组比较,CCD＋Cav3.2-AS组nNOS表达下调（P〈0.01）,CD＋Cav3.2-MM组差异无统计学意义（P〉0.05）。结论Cav3.2型钙通道参与了大鼠慢性神经病理性痛的形成,其机制与抑制脊髓背角nNOS的表达上调有关。     

The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading

BACKGROUND: The current treatment of coronoid process fractures of the ulna is based on the classification system of Regan and Morrey. We found no biomechanical studies that specifically addressed the role of the coronoid process in elbow stability. In the present investigation, the elbows of cadavera were tested before and after fracture of the coronoid process to assess the stabilizing contribution of the coronoid process under axial loading. METHODS: Six fresh-frozen cadaveric elbows were tested mechanically. All soft tissue surrounding the elbow, including the skin, was left intact. An axial load compressing the elbow joint was applied along the shaft of the forearm in the sagittal plane. A displacement of fifteen millimeters per minute was applied until a load of 100 newtons was attained. Each elbow was tested in 15, 30, 45, 60, 75, 90, 105, and 120 degrees of flexion. Next, less than 25 percent, 25 to 50 percent, or more than 50 percent of the coronoid process was fractured with an osteotome under radiographic guidance, and the testing was repeated. Each elbow served as its own control, and one elbow was used for two tests; therefore, a total of seven situations were investigated. The difference in displacements between the intact and osteotomized elbows was measured. RESULTS: There was no significant difference, at any flexion position, in posterior axial displacement between the intact elbows and the elbows in which 50 percent or less of the coronoid process was fractured (type I and type II) (p = 0.43). There were significant differences, across all flexion positions, in posterior axial displacement between the intact elbows and the elbows in which more than 50 percent of the coronoid process was fractured (type III) (p = 0.006). Specimens with a type-III fracture also showed a significant increase in displacement compared with specimens with a type-I or type-II fracture (p = 0.012). Specifically, from 60 to 105 degrees of flexion, a significant increase in posterior translation of up to 2.4 millimeters was found (p<0.05). CONCLUSIONS: In response to axial load, elbows with a fracture involving more than 50 percent of the coronoid process displace more readily than elbows with a fracture involving 50 percent or less of the coronoid process, especially when the elbow is flexed 60 degrees and beyond.