14 Tendinopathies Around the

Alan J. Johnstone and Nicola Maffulli

Introduction affect males and females equally, and most commonly involve the dominant [2]. In most patients, overuse During the last 20 years, there has been a better under- of the limb gives rise to the symptoms with the severity standing of the underlying pathology of being influenced by the overall intensity and duration of tendinopathies. This knowledge, coupled with a better the activity. Characteristically, individuals, including understanding of the exact location of the pathology, competitive athletes, who place high demands on the has enabled surgeons to rationalize the use of existing upper extremities, are prone to developing epicondy- nonsurgical and surgical management options, and to lopathy,although any task which involves repetitive activ- consider future therapeutic options. Not only has this ities may induce these conditions. Sports commonly approach improved the overall success of management, associated with these conditions include racket sports,and but it has also reduced patient morbidity. Research has sports which involve a throwing action resulting in eccen- also clarified the pathology and clinical presentation of tric loading of the muscles of the . Other less a variety of disorders involving neighboring structures common causes of epicondylopathy include a direct blow that can “mimic” symptoms commonly attributed to to the medial or lateral epicondyle. The symptoms may tendinopathies. These findings should reduce diagnostic also ensue following a sudden extreme effort or activity error and help to identify causes of refractory symptoms. resulting in injury. There also appears to be a group of However, despite the advances made, the management of patients susceptible to generalized tendinopathy: Nirschl a significant proportion of patients with tendinopathies referred to this group of patients as having a “mesenchy- around the elbow remains a clinical challenge. mal syndrome,” theorizing a possible genetic component giving rise to abnormal collagen formation [3]. These patients tend to have multiple problems that may include Tendon Injuries Around the Elbow pathology, epicondylopathy, carpal tunnel syndrome, triggering of the long finger flexor tendons, and extensor tendon pathology such as de Quervain’s disease. Confusion exists in the literature as to what constitutes Interestingly, routine rheumatological investigations tend “tennis elbow,” with some authors referring to lateral, to be normal in this population, although more recently, medial, and posterior forms. However, most surgeons Malmivaara et al have observed that a significant number reserve this term to describe involvement of the lateral of patients presenting with coexisting wrist and elbow epicondyle, referring to the similar condition involving tendinopathies have a higher incidence of rheumatoid the medial aspect of the elbow as “golfer’s elbow.” factor positivity (31%) or human leukocyte antigen-B27 tendinopathies are recognized as separate entities. positivity (38%) compared with a control group [4]. This finding suggests a possible inflammatory com- ponent in the pathogenesis of the tendinopathy in some Etiology and Epidemiology of Tennis and patients. Golfer’s Elbow Both tennis and golfer’s elbow occur in patients aged Pathology of Tennis Elbow between 35 to 50 years with a peak in the early 40s, although both conditions have been reported in teenagers Despite the possibility of an inflammatory cause in some, and in patients in their 70s and 80s [1]. These conditions in the majority of patients histology reveals a degenera-

128 14. Tendinopathies Around the Elbow 129

Table 14-1. Main ethiopathogenetic hypotheses in tennis elbow (in chronological order) Author Year Ethiopathogenetic hypothesis

Trethwan 1929 Synovial fringe inflammation Cyriax 1939 Extensor carpi radialis brevis tear Bosworth 1954 Hyaline degeneration of the annular ligament Kaplan 1968 Neuritis of the radial nerve Roles and 1972 Radial nerve entrapment Maudsley Newman and 1975 Radial head fibrillation Goodfellow Coel et al. 1993 Inflammation in the

Patients with tennis elbow rarely experience significant tenderness over the posterior aspect of the epicondyle or Figure 14-1. Calcification over the common extensor origin. condylar ridge, and if posterior tenderness is present, the clinician should consider other possible causes to explain the patient’s symptoms. The resisted wrist extension test tive process within the tendon, and the histological (Thomsen test) is useful, as is point tenderness increased appearances is remarkably similar to tendinopathy at with extension of the elbow while the wrist is held in full other sites. Generally, the abnormal or pathological flexion and the forearm is pronated. However, reliance region of the tendon can easily be identified at surgery should not be placed upon the resisted middle finger [2]. Characteristically, the abnormal region of the tendon extension test in differentiating between tennis elbow is gray compared with the surrounding normal tendon, and compression of the posterior interosseous nerve [2]. and may be slightly edematous [5]. It is also frequently One simple test, which can help to confirm the diagnosis friable, and may contain small flecks of calcification at the outpatient clinic, is to inject local anesthetic around (Figure 14-1). Histology is consistent with disordered the site of maximal tenderness, usually the anterior aspect healing superimposed on a degenerative process, lacking of the epicondyle or condylar ridge, or both sites depend- the classical features of acute inflammation [6]. In partic- ing upon the examination findings. A positive test will ular, a granulation type of tissue containing fibroblasts is either temporarily abolish or significantly improve a visualized and is referred to as “angiofibroblastic hyper- patient’s symptoms compared with the pre-injection find- plasia.” Adjacent to this abnormal tissue, the neighboring ings. However, it is important to use a small volume of tendon is hypercellular, containing histiocytes, lympho- local anesthetic (2 to 3mL) to reduce the risk of a false cytes, and occasional polymorphonuclear leukocytes, positive test. interspersed with small areas of localized degeneration. Differential Diagnosis of Tennis Elbow Tennis Elbow Although the majority of patients presenting with activ- Tennis elbow affects approximately 1% to 2% of the pop- ity-induced lateral elbow pain have underlying degener- ulation and is between 5 and 9 times more common than ative changes within the common extensor origin, other its medial counterpart [7]. Although any of the common causes of lateral elbow pain should be considered, espe- extensor origin tendons can be involved, the extensor cially if the clinical presentation is not typical of tennis carpi radialis brevis tendon is the most commonly in- elbow or if the patient’s symptoms are resistant to appro- volved specific site [8]. Patients most commonly present priate conservative management. Narakas and Donnard with lateral elbow pain that frequently radiates into the suggested articular and neurogenic factors for lateral extensor musculature of the proximal forearm. In most elbow pain in addition to tendinogenic causes [10]. The patients, symptoms relate to activities that stress the wrist most widely accepted differential diagnoses include bur- extensor and supinator muscles, and especially to activi- sitis, stenosis of the annular ligament, inflammation of the ties that involve forceful gripping or lifting of heavy synovium adjacent to the radial head, entrapment of the objects. Clinical examination classically localizes tender- radial or posterior interosseous nerves, chondromalacia ness to the anterior and lateral aspect of the epicondyle, or early osteoarthritis of the radial head or capitellum, and frequently over the distal part of the anterior aspect cervical nerve root entrapment, and laxity or instability of the lateral condylar ridge [9] (Table 14-1). of the lateral elbow ligament complex [2]. Generally, it is 130 A.J. Johnstone and N. Maffulli possible to exclude these differential diagnoses clinically return to their chosen activities without limitation. and, if necessary, by obtaining plain radiographs of the Secondary aims include encouraging healing of the elbow. However, a detailed clinical and anatomical study injured tendon and reducing the risk of recurrence of the documented entrapment of the posterior interosseous condition. nerve co-existing in up to 5% of patients with tennis elbow [11,12]. This finding could in part explain why a Nonsurgical Management significant proportion of patients fail to improve after Most studies document the overwhelming success of apparently adequate conservative management. Entrap- nonsurgical methods in the management of tennis elbow, ment of the posterior interosseous nerve should be con- with Nirschl reporting a personal success rate of 93% sidered if genuine weakness of the wrist extensor muscles [13]. Unfortunately, recurrences are also common, espe- can be demonstrated and if elbow pain is exacerbated by cially if patients return to their previous level of activity resisted supination of the forearm. without modification of the aggravating activity. Many different nonsurgical approaches have been Investigations used to treat patients with tennis elbow. These include It is usually possible to make the diagnosis of tennis rest, activity modification, counterforce bracing of the elbow at the outpatient clinic. However, patients whose extensor muscles of the forearm, eccentric exercise of symptoms remain resistant to treatment may require the forearm extensor muscles, cryotherapy, therapeutic further investigations to confirm the diagnosis, or, more ultrasound, extracorporeal shock wave therapy, manipu- commonly, to identify other causes of lateral elbow pain. lation of the common extensor origin under general anes- thesia, radiotherapy, acupuncture, nonsteroidal anti- Plain Radiographs inflammatory drugs, and injecting corticosteroids around the site of maximal tenderness [8]. It is unclear which of Plain radiographs may be useful to identify intra-articular these nonsurgical methods are effective in the man- pathology, although calcification within the common agement of tennis elbow, with studies from different extensor origin is seen in 22% of patients presenting with centres providing conflicting evidence about the benefits tennis elbow13. Soft tissue calcification frequently exists of ultrasound [17], and the use of nonsteroidal anti- despite spontaneous resolution of elbow symptoms. inflammatory drugs [18]. Injected corticosteroids remain a mainstay in the management of tennis elbow, and are Thermography consistently helpful, although research has failed to This technique is rarely used clinically, although research confirm which corticosteroid preparation and dosage are has demonstrated that thermographic images correlate most effective [8]. Similarly, the literature is unclear as to with clinical severity of symptoms, and may be of prog- how many corticosteroid injections can be administered nostic use [14]. and to the timing of injections in view of the recognized complications of skin and subcutaneous fat atrophy com- High-Resolution Real-Time Ultrasonography bined with the potentially more serious complication of aggravating degeneration of the tendon. The mechanism In experienced , ultrasonography can confirm the of action of corticosteroids is also far from clear, since, in clinical diagnosis of tennis elbow, and provides additional most patients, tennis elbow results from a degenerative information about the neighboring soft tissues and elbow process rather than from an inflammatory condition. Cor- joint [15]. ticosteroids have a wide variety of effects on cells, and presumably their ability to limit intracellular activity by Magnetic Resonance Imaging reducing the nuclear-cytoplasmic communication path- The extent of tendon degeneration seen with magnetic ways influences the degenerative and reparative compo- resonance imaging correlates well with surgical and his- nents of this condition. Irrespective of the nonsurgical tological findings, and may have a place in the investiga- method employed, modified rest is a fundamental part tion of patients whose symptoms fail to resolve following of the management that cannot be overemphasized. apparently adequate management [16]. Despite this, mag- Similarly, modification of the aggravating activity is also netic resonance imaging is expensive, and is difficult to of importance if the rate of symptomatic recurrence is to justify when one considers the high accuracy of clinical be reduced. diagnosis. Surgical Management Management of Tennis Elbow Identifying which patients should be offered surgery The primary aim of management is to reduce or elimi- is frequently difficult although, according to Nirschl, nate elbow pain that, in turn, will permit the patient to patients whose symptoms have continued for more than 14. Tendinopathies Around the Elbow 131

Table 14-2. A chronological synopsis of some of the surgical postoperative elbow weakness, and approximation of the procedures advocated in the management of resistant tennis common extensor origin over the bone may limit this. elbow (in chronological order) Some surgeons divide the lateral collateral ligament as a Franke (1910): Epicondylar osteotomy routine part of their operation for the management of Fisher (1923): Excision of the subcutaneous tissue tennis elbow. However, this seems illogical due to the Hohmann (1927): Incision of the ECRB potential for causing elbow instability, which can itself Tavernier (1946): Partial lateral denervation give rise to significant symptoms. Bosworth (1955): Partial resection of the annular ligament Kaplan (1959): Partial ventral denervation Other operations have been described for the man- Garden (1961): Distal lengthening of the extensor carpi radialis brevis agement of tennis elbow, but are less frequently Wilhelm and Giesler (1962): Complete denervation employed. The procedure described by Bosworth is an Goldie (1964): Excision of subcutaneous pathological tissue extensive procedure, which addresses possible intra- Capener (1966): Decompression of the posterior interosseous nerve articular pathology [19].This technique involves the exci- (supinator arcade) Roles and Maudsley (1972): Decompression of the radial nerve sion of part of the annular ligament in addition to releas- Boyd and McLeod (1973): Epicondylectomy and distal annular ing the common extensor origin. Such procedures still ligament excision have their place provided the indications are strictly Wilhelm (1977): Radial nerve decompression (Hiatus of the radial adhered to, but they have a higher morbidity than the less nerve) invasive procedures. Posch (1978): Extensor fasciotomy Narakas (1987): Proximal lengthening of ECRB and PIN decompression Postoperative Rehabilitation Wilhelm (1989): Denervation and decompression of the posterior interosseous nerve Postoperative regimes vary significantly, but they all share certain common features, namely a period of rest followed by a period of gentle passive and active exer- cises during which time the patient is advised to avoid lifting heavy objects, forceful gripping of objects, and one year despite receiving a quality nonsurgical manage- resisted dorsiflexion of the wrist and extension of the ment regime should be considered for surgery [2]. He fingers. Most surgeons advocate a 6-week rehabilitation also suggests other criteria which indicate the severity of period for the majority of their patients. symptoms, such as radiographically visualized calcifica- tion within the soft tissues adjacent to the lateral epi- Chronic Refractory Tennis Elbow condyle suggesting a refractory process; the need for Following Surgery multiple corticosteroid injections to control the level of symptoms; and the presence of constant pain without Some patients do not follow the prescribed postoperative activity (Table 14-2). regime and are left with residual symptoms, although A variety of operative procedures have been in the majority of case, the severity of the residual described, but perhaps the most important step has been symptoms does not warrant further surgery. However, the general agreement between surgeons that most cases difficulties arise when a patient continues to have severe of tennis elbow originate within the substance of the symptoms despite undergoing apparently adequate common extensor origin, with the extensor carpi radialis surgery. Usually the first thing to consider is the time brevis being the most common specific site [8]. Open and scale of their symptoms following surgery. Most patients percutaneous techniques have been described to release should be treated nonsurgically for at least 6 to 9 months the common extensor origin (“extensor slide”) and, before any decision is taken to reoperate, unless it is regardless of the technique employed, they succeed in obvious that another previously undiagnosed problem eradicating or significantly reducing symptoms in up to exists. 90% of patients [8]. Open techniques also permit addi- A detailed assessment of patients with refractory tional stages to be added to the release of the common symptoms must be performed, taking into consideration extensor origin and include elevation of the extensor any possible motives that they may have. Morrey carpi radialis brevis muscle from the anterior aspect of describes two groups of patients; those whose symptoms the lateral condylar ridge, excision of the abnormal are identical to their preoperative symptoms (Type I region of degenerative tendon, decortication of the failure), and those patients who have different symptoms lateral epicondyle and lateral condylar ridge to encour- following surgery (Type II failure) [20]. He subclassifies age revascularisation of the region, and selective dener- the former group as follows: improper patient selection, vation of the lateral epicondyle. However, there is incomplete or improper diagnosis, and inadequate or concern about overzealous release of the common exten- incomplete procedure. Correctly identifying patients who sor tendon, as one may inadvertently release the exten- genuinely have symptoms and signs consistent with the sor carpi radialis longus tendon, resulting in some diagnosis of tennis elbow and who are willing to comply 132 A.J. Johnstone and N. Maffulli with the postoperative regimes is fundamental if tion to localizing the site of maximal tenderness, the clin- the desired result is to be achieved following surgery. ical diagnosis can also be aided by provocation tests Therefore, the clinician must also assess a patient’s that stress the muscle groups involved, such as resisted motivation, and the possibility of secondary gain prior to forearm pronation, and resisting wrist flexion. Increased offering surgery. Incomplete or improper diagnosis is point tenderness while extending the elbow with the self-explanatory. The most common cause for continuing forearm supinated and the wrist extended is also a useful symptoms is an undiagnosed entrapment of the posterior clinical sign in my experience. Ulnar nerve entrapment is interosseous nerve that may be either the sole cause of a commonly associated with golfer’s elbow, and it is there- patient’s symptoms, or coexisting with them, in approxi- fore essential to palpate the course of the ulnar nerve mately 5% of patients with tennis elbow [11,12]. Finally, from its emergence through the medial intermuscular patients may continue to experience symptoms if the septum, behind the medial epicondyle, and distally surgical procedure performed did not fully address the between the heads of flexor carpi ulnaris to identify local- underlying pathology. Type II failure is iatrogenic, and ized tenderness. In addition, it is essential to assess the may result from overzealous surgery to treat tennis patient’s and forearm for signs of sensory abnor- elbow. In particular, the surgeon should consider elbow malities, and more importantly for wasting and for weak- instability, capsular pathology such as a capsular fistula or ness of the intrinsic innervated by synovial herniation, and bursae as possible sources of the ulnar nerve. These signs are frequently subtle. symptoms. Arthrography is useful to identify capsular Tinel’s sign may also be useful in making the diagno- pathology, and some surgeons use arthroscopy to identify sis of ulnar nerve entrapment when compared with the mild to moderate forms of ligamentous insufficiency, asymptomatic side. In approximately 10% to 15% of indi- assuming that the pivot shift test and stress radiographs viduals, the ulnar nerve subluxes anteriorly with elbow are negative. flexion, and may “exaggerate” or even mimic the symp- Overall, potentially up to 85% of patients with contin- toms of golfer’s elbow assuming that ulnar nerve pathol- uing symptoms (types I and II) will improve, if a careful ogy exists, or may even trick the clinician into assuming assessment of the presenting symptoms and signs, that the individual does not have coexisting ulnar nerve coupled with any necessary investigations are under- pathology due to the absence of tenderness posterior to taken, so that the most appropriate secondary operation the medial epicondyle [22]. Other diagnostic tests, such as is performed [20]. the injection of a small volume of rapidly acting local anesthetic, are also useful in helping to confirm the diag- Golfer’s Elbow nosis. Causes of medial elbow pain other than golfer’s elbow are similar to those described for tennis elbow. Golfer’s elbow is, rather confusingly, referred to by some However, instability of the ulnar collateral ligament surgeons as medial tennis elbow. In most patients, it complex is a particularly significant problem [2]. Typi- results from overuse of the forearm wrist and finger cally, this happens to individuals who undertake activities flexor muscles, and in particular of the pronator teres and that repetitively stress the ligament complex, such as flexor carpi radialis muscles [7]. Occasionally, symptoms throwing the javelin. These individuals should be investi- develop as a result of a direct injury to the medial epi- gated with stress radiographs, and possibly with arthro- condyle. In other patients, the causative factors may scopic assessment of elbow instability prior to surgical be difficult to identify, and this latter group of patients stabilisation. may fall into the “mesenchymal syndrome” category of patients. In most patients, the pathological changes Investigations observed within the common flexor origin mirror those seen with tennis elbow both macroscopically and micro- The diagnosis of golfer’s elbow is essentially clinical scopically. Essentially, the clinical examination findings although, on occasions, the investigations described for are also very similar with localized tenderness being most tennis elbow may be of use in assessing individuals with evident over the anterior and medial aspects of the golfer’s elbow. Nerve conduction studies assessing ulnar medial epicondyle and medial condylar ridge.Tenderness nerve damage may be of use to the clinician, especially if is frequently noted over the posterior aspect of the the surgeon anticipates that surgical decompression of medial epicondyle and condylar ridge, and probably the nerve is unlikely to significantly improve nerve func- relates to the coexistence of ulnar nerve pathology which tion, and wishes to have the preoperative severity of can be expected in up to 50% of cases [21]. The history nerve damage documented. This is particularly relevant provided by the patient is opposite to that of tennis when one considers that the long-term prognosis follow- elbow, with medial elbow discomfort being exaggerated ing release of the common flexor origin combined with by activities that involve active contraction of the wrist decompression of the ulnar nerve strongly correlates with and finger flexors, and pronation of the forearm. In addi- long-term ulnar nerve function8. 14. Tendinopathies Around the Elbow 133

Management of Golfer’s Elbow Triceps Tendon Injuries Approximately 90% of patients with symptoms and Triceps Tendinopathy clinical findings suggestive of golfer’s elbow without co- This condition is observed almost exclusively in males existing entrapment of the ulnar nerve can be treated suc- undertaking regular heavy manual work and in throwing cessfully using the nonsurgical modalities described for athletes7. It results from repetitive resistance of elbow tennis elbow [23]. The main significant complications extension resulting in a traction injury through the reported following the injection of corticosteroids are the tendon’s insertion into the olecranon. Clinical examina- accidental intraneural injection of the ulnar nerve, and tion is usually sufficient to differentiate this condition the injection of corticosteroid into the ulnar collateral lig- from the considerably more common condition of ole- ament which may result in its rupture and elbow insta- cranon bursitis, with the typical features of the former bility.To avoid accidentally injecting the ulnar nerve with condition being direct tenderness of the olecranon and steroid, corticosteroid injections should administered discomfort on attempting to extend the elbow against with the elbow in extension [22]. This precaution takes resistance. Although unnecessary, radiographs of the into account those patients (approximately 15% of the elbow usually demonstrate an olecranon traction spur population) who have naturally occurring anterior sub- (Figure 14-2). Management consists of avoidance of luxation of the ulnar nerve. elbow extension activities for up to 6 months, and, in Surgery is reserved for those patients whose symptoms refractory cases, excision of the olecranon spur combined fail to improve following an adequate nonsurgical with repair of the triceps mechanism to the olecranon. regime and for those with ulnar nerve symptoms and signs. Release of the common flexor origin is performed Rupture of the Triceps Tendon in a similar way to surgical decompression of the lateral aspect of the elbow. In many cases, abnormal degenera- Ruptures or avulsion injuries of the triceps tendon are tive changes are found within the common flexor rare, and occur in both men and women. Most injuries origin, situated most commonly between the origins of result from a fall on to the outstretched arm, combined the pronator teres and the flexor carpi radialis muscles. with excessive contraction of the triceps in an attempt to During this procedure care must be taken not to break the fall. In 80% of cases, a small fragment of bone accidentally divide the ulnar collateral ligament which is avulsed from the tip of the olecranon and can be seen gives rise to considerable postoperative symptoms and frequently requires surgical reconstruction of the liga- ment complex. In view of the common association between ulnar nerve entrapment and golfer’s elbow, decompression of the ulnar nerve is recommended while releasing the common flexor origin. For many surgeons, clinical findings or nerve conduction study evidence con- sistent with ulnar nerve entrapment is an indication for proceeding directly to surgical release of the common flexor origin combined with decompression of the ulnar nerve. However, opinions differ as to whether simple decompression of the ulnar nerve is sufficient, or whether this should be combined with anterior transpo- sition. Kurvers and Vehaar suggest that anterior transpo- sition provides better long term results compared with decompression of the ulnar nerve within the [24]. However, one must consider the risk of dam- aging the neural vascular plexus by extensively mobiliz- ing the ulnar nerve with its subsequent long-term problems [2]. Formal transposition of the ulnar nerve is unneces- sary unless it naturally transposes with flexion of the elbow. Otherwise, wide decompression of the ulnar nerve proximally, distally, and at the level of the elbow is usually sufficient to reduce the tension on the nerve. Figure 14-2. An olecranon traction spur. 134 A.J. Johnstone and N. Maffulli readily on radiographs [25]. Physical examination may the radial tuberosity, a palpable defect in the line of the reveal a palpable defect depending on the extent of tendon is frequently felt, although the presence of triceps retraction. Partial injuries are more difficult to an intact lacertus fibrosis can make the clinical diagnosis identify, and may require to be confirmed using ultra- slightly harder. sonography or magnetic resonance imaging. Investigations to confirm the diagnosis are rarely The triceps squeeze test is useful in distinguishing required, except on rare occasions when the distal biceps partial tears from complete tears, and has features that tendon is partially torn, or in preoperative assessment of resemble Simmonds test for assessing the integrity of chronic ruptures where magnetic resonance imaging has Achilles tendon ruptures [26]. The arm is held in approx- been used to identify the level of the proximal end of the imately 90 degrees of flexion, and the triceps muscle belly biceps tendon within the arm [28]. Plain radiographs, is squeezed. Extension of the elbow indicates a partial although not essential for making the diagnosis, some- rupture of the triceps mechanism. Surgery is the man- times reveal hypertrophy of the radial tuberosity indica- agement of choice for complete ruptures, permitting tive of an ongoing degenerative process prior to rupture the tendon to be reattached to the olecranon via tran- of the distal biceps tendon, but add little to the diagnosis sosseous sutures. Some surgeons advocate the use of a or to planning management. flap of forearm to augment the repair [25]. Post- Partial ruptures of the distal biceps tendon do occur, operatively, the arm is immobilized at approximately 90 but are much less common than complete ruptures. degrees of elbow flexion for 3 weeks and gently mobi- Although these injuries have been categorized according lized thereafter. Although few surgeons have extensive to the anatomical site of the lesion, most of partial biceps experience with these injuries, early repair appears to tendon injuries occur at the point of insertion into the have a good outcome with excellent restoration of triceps radial tuberosity, and, when diagnosed, should be treated function. Failure to repair the triceps tendon is associated in a similar manner to the far more common complete with an inordinately high loss of elbow extension biceps tendon rupture, assuming that most partial rup- strength. tures herald an impending complete rupture. The other Spontaneous rupture of the triceps tendon, or rupture sites for partial injury of the distal biceps include the mus- following minimal trauma has been observed in patients culotendinous junction, which is very rare, and a tear of who have systemic disorders such as renal osteodystro- the biceps tendon in continuity, which is also uncommon. phy,secondary hyperparathyroidism, Marfan’s syndrome, Due to the rarity of the latter two types of partial rupture, and osteogenesis imperfecta tarda. Surgical repair is the the literature is far from clear as to how they should be management of choice, and augmentation of the repair treated, although some advocate augmenting the site of with a strip of forearm fascia is indicated in most cases injury with a tendon autograft or allograft, or by using a [26]. ligament augmentation device at the time of surgical repair. Distal Biceps Tendon Injuries Management of Distal Biceps Tendon Ruptures Unlike ruptures of the long head of the biceps in associ- ation with rotator cuff pathology, ruptures involving As mentioned, the most common site for injury of the the distal biceps tendon are relatively uncommon and distal biceps tendon is at its insertion into the radial account for 3% to 10% of all biceps tendon injuries [27]. tuberosity. Complete ruptures at this site are consider- By far the most common site for injury to the distal ably more common than partial ruptures, and the litera- tendon is at its point of insertion into the radial tuberos- ture strongly suggests that both injuries should be treated ity. Characteristically, this injury occurs predominantly surgically if reasonable long-term function is to be in males (greater than 95%) and usually occurs during restored [26]. Nonsurgical management of these injuries the fourth through to the sixth decades of life [7]. Not results in up to 40% to 50% loss of elbow flexion strength uncommonly, younger patients with distal biceps tendon and forearm supination strength7. In addition, it is advis- ruptures present after using anabolic steroids as part of able to proceed with surgery within two weeks of sus- a bodybuilding regime [8]. This injury results from an taining the injury to obtain the best results, before the eccentric contraction of the biceps while lifting heavy tendon retracts proximally. Two surgical exposures have loads, and is often accompanied by a popping sensation been well described: the anterior Henry approach to the in the anterior aspect of the elbow in addition to severe elbow and proximal forearm, and the two incision tech- pain. Profound weakness of elbow flexion and supination nique popularized by Boyd and Anderson [29]. of the forearm, combined with pain while performing The main advantage of the procedure undertaken these activities against resistance, are in keeping with the using the anterior Henry approach is that only one inci- clinical diagnosis. In addition to identifying localized ten- sion is required, and may be extended as necessary to derness over the anterior aspect of the elbow and over improve the access to the radial tuberosity. However, this 14. Tendinopathies Around the Elbow 135 approach is technically more demanding than the two- grafts, sometimes strengthened with a ligament augmen- incision approach, and there is greater risk of damaging tation device, have been used successfully [8]. Another the posterior interosseous nerve. The two incision tech- alternative is to attach the stump of the biceps tendon to nique is easier to perform and uses two limited incisions, the which improves elbow flexion to first identify the distal end of the biceps tendon, and, strength, but has no effect on supination strength. through a simple muscle-splitting incision placed over the radial tuberosity with the forearm held in full pronation, obtain access to it. Surgeons undertaking the two incision References technique should be aware of the dangers of inducing 1. Nirschl RP,Sobel J. (1981) Conservative treatment of tennis ectopic bone formation between the proximal radius and elbow. Phys Sports Med. 9:42. ulna by accidentally exposing the radial side of the ulna. 2. Nirschl RP. (1993) Muscle and Tendon trauma: Tennis To avoid this complication, which in some patients has elbow. In: Morrey BF, ed. The Elbow and its Disorders. resulted in synostosis, it is important to maintain the Philadelphia: W.B. Saunders; 537–552. plane of muscle dissection adjacent to the radius, while 3. Nirschl RP. (1969) Mesenchymal syndrome. Virginia Med passing the tendon around to the posterior aspect of the Mon. 96:659. forearm, which in turn will prevent inadvertent stripping 4. Malmivaara A, Viikari-Juntura E, Huuskonen M, et al. (1995) Rheumatoid factor and HLA antigens in wrist of the anconeus muscle from the radial aspect of the ulna tenosynovitis and humeral epicondylitis. Scand J Rheuma- [26]. Irrespective of the surgical approach employed, the tol. 24:154–156. biceps tendon is attached to the radial tuberosity after 5. Nirschl RP, Pettrone F. (1979) Tennis elbow: The surgical hollowing out the tuberosity to accommodate the tendon, treatment of lateral epicondylitis. J Bone Joint Surg. 61A: using burrs or a curette. The tendon can be attached with 832. transosseous sutures placed at the lip of the tuberosity, 6. Sarkar K, Uhthoff HK. (1980) Ultrastructure of the or, more recently, with suture anchors. Postoperatively, common extensor tendon in tennis elbow. Virchows Arch the patient’s elbow should be splinted at 90 degrees of Pathol Anat Histol. 386:317 flexion for 3 to 4 weeks. Some surgeons advocate a period 7. Gabel GT. (1999) Acute and chronic tendinopathies at the of dynamic splintage for 4 to 6 weeks thereafter, which elbow. Curr Opinion Rheumatol. 11:138–143. permits active extension. Alternatively, patients are 8. Morrey BF. (1997) Tendon injuries and tendinopathies about the elbow. In: Norris TR, ed. Orthopaedic Knowledge permitted to actively extend the elbow while passively Update: and Elbow. Rosemont, IL: American flexing the joint. Thereafter the patient is encouraged to Academy of Orthopaedic Surgeons;337–344. actively flex and extend the elbow in addition to actively 9. Rompe JD, Hopf C, Kullmer K, Heine J, Burger R. (1996) rotating the forearm. It is not recommended that patients Analgesic effect of extracorporeal shock-wave therapy on be permitted to return to full activity for 6 months chronic tennis elbow. J Bone Joint Surg. 78B:233–237. after surgery. From the literature, normal strength is not 10. Narakas AO, Donnard CH. (1993) Epicondyalgia: conserv- achieved following surgical repair in a considerable ative and surgical treatment. In: Tubiana R, ed. The Hand. number of patients, with poorer results being more Philadelphia: W.B. Saunders;833–857. common following surgery to the non-dominant arm [8]. 11. Werner CO. (1979) Lateral elbow pain and posterior In addition, a considerable proportion of patients lack a interosseous nerve entrapment. Acta Orthop Scand. 114 full range of flexion and forearm supination, although (Suppl):174. 12. Yerger B,Turner T. (1985) Percutaneous extensor tenotomy patients’ satisfaction is generally high. However, the for chronic tennis elbow: an office procedure. Orthopedics. results of patients treated surgically compare very favor- 8:126. ably with patients treated nonsurgically. 13. Nirschl RP. (1992) Elbow tendinosis/tennis elbow. Clin Sports Med. 11:851–870. Delayed Surgical Management of Distal Biceps 14. Binder A, Parr GP,Thomas PP, Hazleman B. (1983) A clin- Tendon Ruptures ical and thermographic study of lateral epicondylitis. Br J Rheumatol. 22:77–81. In some instances, the diagnosis of biceps tendon rupture 15. Maffulli N, Regine R, Carrillo F, Capasso G, Minelli S. is either made late or the decision to operate is deferred (1990) Tennis elbow: an ultrasonographic study in tennis for other reasons. The ideal time to undertake surgical players. Br J Sports Med. 24:151–155. repair is within 2 weeks of the injury, during which time 16. Potter HG, Hannafin JA, Morwessel RM, Dicarlo EF, O’Brien SJ, Altchek DW. (1995) Lateral epicondylitis: cor- the biceps tendon can be easily retrieved and mobilized, relation of MR imaging, surgical, and histiopathologic find- although there have been reports of successful tendon ings. Radiology. 196:43–46. retrieval being undertaken up to 3 months following 17. Stratford PW, Levy DR, Gavaldie S, Miseferi D, Levy K. injury. Where excessive scarring is present, it may prove (1989) The evaluation of phonophoresis and friction impossible to mobilize the tendon sufficiently to permit massage as treatment for extensor carpi radialis tendinitis: direct repair to the radial tuberosity, and tendon auto- a randomized controlled trial. Physiother Can. 41:93–99. 136 A.J. Johnstone and N. Maffulli

18. Labelle H, Guibert R. (1997) Efficacy of diclofenac in 24. Kurvers H, Verharr J. (1995) The results of operative treat- lateral epicondylitis of the elbow also treated with immo- ment of medial epicondylitis. J Bone Joint Surg. 77A:1374– bilization. Arch Fam Med. 6:257–262. 1379. 19. Bosworth DH. (1955) The role of the orbicular ligament in 25. Farrar EL, Lippert FG. (1981) Avulsion of the triceps tennis elbow. J Bone Joint Surg. 37A:527. tendon. Clin Orthop. 161:242. 20. Morrey BF. (2000) Surgical failure of the tennis elbow. In: 26. Morrey BF. Tendon injuries about the elbow. In: Morrey Morrey BF, ed. The Elbow and its Disorders. Philadelphia: BF, ed. The Elbow and its Disorders. Philadelphia: W.B. W.B. Saunders;553–559. Saunders;492–504. 21. Gabel GT, Morrey BF. (1995) Operative treatment of 27. Hempel K, Schwenke K. (1974) Uber abrisse der distalen medial epicondylitis. influence of concomitant ulnar neu- Bizepssehne. Arch Orthop Unfallchirurg. 79:313. ropathy at the elbow. J Bone Joint Surg. 77A:1065– 28. Le Huec JC, Moinard M, Liquois F, Zipoli B, Chauveaux D, 1069. Le Rebeller A. (1996) Distal rupture of the tendon of biceps 22. Stahl S, Kaufman T. (1997) Ulnar nerve injury at the elbow brachii. Evaluation by MRI and the results of repair. J Bone after steroid injection for medial epicondylitis. J Hand Surg. Joint Surg. 78B:767–770. 22B:69–70. 29. Boyd HB, Anderson MD. (1961) A method for reinsertion 23. Vangsness CT, Jobe FW. (1991) Surgical management of of the distal biceps brachii tendon. J Bone Joint Surg. 43A: medial epicondylitis. J Bone Joint Surg. 73B:409–411. 1041.