Dear Tennis Elbow Group,

I was a G.P. for a long period in a logging area in Washington State. I had lots of patients, through the years (ret. after 30 years of it) who had tennis elbow, but it seemed that most treatments were plus minus and many useless.

Eventually, I decided that the tendon attached to the lateral epicondyle was a joint tendon for the "extensor muscles of the fingers and wrist". Those muscles do not do much work, do not stress its tendons much. The medial epicondyle, however, it the attach point for a tendon that develops from the individual tendons of the "flexor muscles" of the forearm that do become physically stressed when people grasp things: but people only rarely have medial epicondylitis. I never saw a case, really.

So, what is causing the pain in the lateral elbow area. Get rid of the dogma first: get rid of the name: lateral epicondylitis. Think of tennis elbow. Tennis players, the good ones, put top-spin on their balls so they curve down over the net. To do that, a player has to rotate the forearm at the elbow. When that happens, the radius rotates, but the ulna does not rotate since the hand is attached to the distal radius (and the racket is grasped by the hand). I thought, the head of the radius is attached to the ulna by the annular ligament and a synovial (slippery) sheath extends between the annular ligament and the radius to provide for its lubrication while the radial neck is rotating within the ligament.

I then palpated (fancy word for press the finger on!) the radial head on the anterior side of the forearm and low and behold it was tender too. This location is quite distant from the lateral epicondyle.

When people grasp something usually tennis elbow hurts more. How could that take place with extensor tendonitis? I learned that when people grasp things, the flexor tendons flex the fingers, but they also pull the hand slightly proximally (towards the shoulder) and that displaces the radius neck in the annular ligament and causes more pain.

Treatment: I would find a place lateral-anterior above the radial neck. Then I would "numb-up" the skin with lidocain, 1 cc. Then I would inject half a cc of lidocain and half a cc of marcain and 40 mg of Triamcinolone, together, into the area around the radial neck. The lidocain and marcain would "numb that area up" and patients tennis elboe pain would dissapate in seconds: so we both knew we were at the problematic location and then the triamcinolone, a potent anti-inflammatory would decrease the inflammation, swelling, etc. and the mechanical relationship of the radial neck and the annular ligament would normalize. I was a minor hero...after so many people had various treatments most of which didn't do much.

I think when people have surgery the "disabling of the arm" for a number of weeks provides the excessive rest that lets the radial neck/annular ligament get back to normal, not the surgery proper...most of the time.

A question is: do you have red palms? Redness means inflammation and grasping things causes the blood vessel inflammation to become worse: red palms. There are shades of red and more or less red, so I am talking about meaningful reddened or ruddy palms. The blood vessels in the synovial membrane around the radial head acts the same way as it is used repetitiously by people's hand motions.

Yours,

Nosk10