Abstract
Background:
Extensor tendon release for tennis elbow is fraught with complications as persistence of pain because of adhesions together with weakness of wrist extension. Denervation of the epicondylar region through division of branches of posterior cutaneous nerve of the forearm (PCNF) was proposed to alleviate pain without drawbacks of tendon release.
Methods:
The first group included 19 patients treated through dividing PCNF. The second group included 23 patients treated through tendon release. Inclusion criteria included symptoms for 6 months or longer. Clinical diagnosis was based on positive resisted wrist extension and resisted forearm pronation tests. Division of branches of PCNF in the denervation group and release of extensor carpi radialis brevis tendinous origin in the release group were done.
Results:
The follow-up was 37 months. In the denervation group, 17 patients (92%) reported no pain compared with 15 patients (67%) in the release group. In the denervation group, hand grip strength had an average of 72 lb (91%) compared with 63 lb (77%) for the release group (P = 0.04). Patients of the denervation group had an average Mayo Elbow Performance Score of 95 points compared with 87 for the release group (P = 0.37).
Conclusion:
Denervation of the elbow for management of tennis elbow is a simple safe procedure.
Tennis elbow or lateral epicondylitis is not an uncommon presentation in any general orthopaedic office practice. It is a degenerative tendinopathy rather than tendinitis affecting the common extensor tendon, especially the extensor carpi radialis brevis (ECRB) tendon that is the main wrist extensor at the lateral epicondyle.1
Most patients (90%) respond well to nonsurgical treatment in the form of anti-inflammatory drugs, activity modifications, splints, and local cortisone injection. Those few patients who failed to improve with nonsurgical treatment can be treated surgically in a variety of techniques. The most commonly used surgical technique is a simple release of the common extensor origin with or without curettage of the bony lateral epicondyle.2,3 This procedure is fraught with some complications like persistence of pain because of inflammation and adhesions at the site of surgery. Also, ECRB tendon release results in its lengthening and weakness. As wrist extension is an integral part of making a closed fist with the fingers flexed, weakness of the former results in weakness of hand grip strength. As the main problem of such patients is pain, denervation of the lateral epicondylar region was suggested as a simple procedure with no adverse effects of muscle release.4,5
Surgical anatomy of the posterior cutaneous nerve of the forearm (PCNF)6 is illustrated in Figure 1.
Figure 1.
Images showing the radial nerve (yellow structure) closely related to the spiral groove of the humerus and passing between the lateral and the medial head of the triceps (A and B). Then, the nerve pierces the lateral intermuscular septum to the front of the humerus (C and D). The radial nerve is seen accompanied by posterior cutaneous nerve of the forearm (orange structure) in the spiral groove. Posterior cutaneous nerve of the forearm is seen approaching a hiatus in the deep fascia (open oval black ring) about 6 cm proximal to the lateral epicondyle to become subcutaneous (E). Then, posterior cutaneous nerve of the forearm divides into a smaller anterior and a larger posterior branches passing anterior and posterior to the lateral septum respectively (F and G). The posterior branch innervates the lateral epicondylar region (H). R = radius, U = ulna, LT = lateral triceps, MT = medial triceps
Methods
This is a single blinding (for the patients), randomized controlled study in which 42 patients with resistant tennis elbow were divided into two groups treated surgically. Randomization was computer generated and was based on the stratification technique. Selection and treatment bias were avoided as far as the author could do.
The first group (the denervation group) included 19 patients with an average age of 35 years and were treated through dividing PCNF proximal to the elbow. The second group (the release group) included 23 patients with an average age of 33 years and were treated through release of the common extensor muscle origin from the lateral epicondyle.
Inclusion criteria
Symptoms for 6 months or longer.
Failure of nonsurgical treatment.
Exclusion criteria
Patients suspected to have concomitant posterior interosseous nerve (PIN) entrapments.
Patients with previous surgery for tennis elbow.
Patients unfit for general anesthesia because of medical problems.
Clinical Examination
In all patients, pain was elicited at the lateral elbow on resisted wrist dorsiflexion with the forearm pronated and the elbow fully extended (Resisted wrist extension test)7-9 (Figure 2, A). Also, pain was elicited at the elbow on resisted forearm pronation with the wrist palmarly flexed and the elbow fully extended (Resisted forearm pronation test) (Figure 2, B). In all patients, PIN entrapment was excluded. In 5% of patients with tennis elbow, tennis elbow and PIN entrapment may coexist. In PIN entrapment, tenderness is more localized over the proximal radius slightly more distal to the lateral epicondyle where tenderness is more localized in tennis elbow. Injection of local anesthetic at the lateral epicondyle alleviates pain in tennis elbow not in PIN compression. Provocative tests that are positive only in PIN compression include pain that would be elicited on resisted middle finger extension and on resisted forearm supination with the elbow fully extended in either tests (Figure 2, C and D). In severe PIN compression, active wrist extension may be associated with radial deviation because ECRB muscle (innervated from PIN) is weak so extensor carpi radialis longus (ECRL) muscle (innervated from the radial nerve itself) comes into play with the resultant radial deviation on attempted dorsiflexion (Figure 2, E). In PIN compression, resisted finger and thumb extension are noted to be weak compared with normal strength of both muscle groups in tennis elbow.
Figure 2.
Images showing provocative tests for clinical diagnosis and differential diagnosis of tennis elbow. Red arrow: patient's resistance, yellow arrow: clinician's pulling, green arrow: wrist radial deviation, blue arrow: wrist dorsiflexion.
Investigations
Diagnosis of tennis elbow was mainly a clinical one. Plain radiographs of the elbow excluded arthritis or loose bodies.10,11 Magnetic resonance imaging showed edema and thickening of the common extensor origin in all patients and partial tear in 31 patients (74%).
Surgical Technique
Under general anesthesia, X4 eye loup magnification and tourniquet control. surgery was performed.
The Denervation Group
A straight skin incision was made along the lateral midaxial line of the upper arm.12,13 The latter extended from the lateral humeral epicondyle distally to the acromial prominence proximally (Figure 3, A and B). The incision was centered around a point 6 cm proximal to the lateral humeral epicondyle. As dissection proceeded through the subcutaneous tissue and the deep fascia was incised, a longitudinal furrow was noted marking the site of the lateral intermuscular septum (dotted black line in Figure 3, C).
Figure 3.
Images showing exposure of posterior cutaneous nerve of the forearm.
The furrow was located between two muscular masses; the anterior mass encompassed the biceps muscle proximally and the brachioradialis muscle distally (white arrow in Figure 3, C) and the posterior mass was formed of the lateral head of the triceps muscle (green arrow in Figure 3, C). Dissection proximal and just anterior to the septum revealed the radial nerve as it exited through the septum crossing from the posterior to the anterior compartment (white arrow in inset of Figure 3, D). Dissection slightly distal to where the radial nerve was located and slightly behind the septum revealed the PCNF as it exited through the fascial hiatus to run superficial to the deep fascia as a cutaneous nerve compartment (green arrow in inset of Figure 3, D). Further dissection and excision of the septum allowed full exposure of PCNF with its two terminal branches: the smaller anterior and the larger posterior ones compartment (blue and yellow arrows, respectively, in inset of Figure 3, D).
PCNF was doubly ligated just proximal to its bifurcation with 3O nonabsorbable nylon suture to ensure blockage of axon regrowth and possible neuroma formation with nerve severance (inset of Figure 4, A). The nerve was sharply divided just distal to the most distal ligature so that the proximal nerve stump should carry the two ligatures (Figure 4, B). The proximal nerve stump was buried in a longitudinal slit along the fibers of the underlying lateral head of the triceps.
Figure 4.
Images showing double ligation, division, and burial of posterior cutaneous nerve of the forearm.
The slit in the triceps was closed over the nerve stump using few interrupted non absorbable stitches (inset of Figure 4, C).
The Release Group
With the elbow flexed 90°, a chevron shaped skin incision was designed just distal to the lateral epicondyle with the obtuse angled tip (to avoid tip necrosis) pointing distally14 (Figure 5, A). This skin incision was more esthetic than a longitudinal incision and gave better exposure than a transverse one. Four muscle groups could be identified in the wound (Figure 5, B). They were followed from volar to dorsal aspects of the elbow: the brachioradialis muscle which was completely muscular covered with thin fascia (Figure 5, C); the ECRL partly muscular and partly aponeurotic (Figure 5, D); the common extensor tendon formed of extensor digitorum communis (EDC) and extensor carpi ulnaris (ECU) muscles which was completely aponeurotic and broad (Figure 5, E); and finally, the aconeus muscle which was completely muscular covered with thick fascia (Figure 5, F).
Figure 5.
Images showing exposure of the common extensor mechanism.
A longitudinal incision was made along the aponeurotic furrow between and binding the ECRL tendon volarly and the common extensor tendon (EDC and ECU) dorsally (Figure 6, A and B).
Figure 6.
Images showing release of the common extensor tendon. Black asterisk: capitellum and blue asterisk: radial head.
Retraction of ECRL tendon revealed the muscular ECRB tendon underneath (blue arrow in Figure 6, C). The ECRB tendon was yellowish and friable denoting tendinosis (blue arrow in Figure 6D). The latter tendon was sharply resected. Then, the prominent lateral epicondyle was curetted superficially to remove any attached pathologic tendon and periosteum. In all cases, the underlying capsule was opened to inspect the radiocapitellar joint for any loose bodies or synovial fringes, and in few patients, some were found and excised (Figure 6, E). The tourniquet was deflated to ensure cauterization of any bleeding points and meticulous homeostasis thus reducing the risk of postoperative hematoma formation and possible persistence or recurrence of symptoms. Good approximation of ECRL tendon to that of the common extensor (EDC and ECU) with interrupted inverted nonabsorbable suture 3O Ethibond (polyester). The arm was hung in an arm pouch sling with the elbow flexed 90°, and elbow movements were encouraged as soon as pain was tolerated.
RESULTS
The results were evaluated at the end of follow-up period which ranged between 26 and 48 months with an average of 37 months for both groups. The results were evaluated using the following parameters:
Patients of either group were examined for the following:
Pain severity
It was investigated objectively using the pain visual analog scale (PVAS).15
The latter was a two-sided folded piece of cardboard (Figure 7, A). On one side, there was a seamless transition between two colors: red and green (Figure 7, B). The red color symbolized the worst pain that could be imagined by the patient and the green color symbolized no pain at all. On the other side of the folded cardboard, pain severity was represented numerically on a scale from 0 to 10 (Figure 7, C). While 0 signified no pain at all, 10 signified the worst pain the patient could tell to have.
Figure 7.
Graph showing the pain visual analog scale.
The PVAS scale is divided into 10 points (Figure 7, D). The examiner should sneakily notice the number on the opposite side of the cardboard.
Preoperatively, patients of the denervation group got an average score of 8.5 points compared with 9 points for the release one (P = 0.12). Postoperatively, patients of the denervation group got an average score of 0.5 point compared with 3.5 points for the release one (P = 0.02). Pain severity distribution among both groups is depicted in Figure 8.
Figure 8.
Graph showing elbow pain on pain visual analog scale. Red asterisk: patient number.
Job Status
Job status was categorized into four groups. Job status varieties in both groups are outlined in Figure 9.
Figure 9.
Graph showing job status. Red asterisk: patient number.
Elbow Movements
Postoperatively, elbow extension lag showed more improvement in patients of the denervation group compared with the release one (P = 0.08). Also, pronation range showed more improvement for the denervation group compared with the release one (P = 0.04) (Figure 10).
Figure 10.
Graph showing elbow movements.
Muscle Strength Manual Testing
A hand-held digital device called Hoggan micro FET3 (Force Evaluation and Testing) dynamometer was used to measure the resistance offered by the patient against the clinician's force in pounds16,17 (Figure 11).
Figure 11.
Images showing Hoggan micro FET3 hand-held digital dynamometer. The front of the device (A) carries two rectangular liquid crystal display windows; a right and left ones. The left liquid crystal display window shows high (H) (B) or low (L) (C) threshold, while the right window shows muscle strength. The back (D) of the device carries a hole where the transducer pad is to fit in.
Elbow Extensor Muscle Strength Testing
With the elbow 90° flexed and the Hoggan device applied to the distal forearm, the test began with the clinician applying force to flex the elbow, and the patient would try to resist this (Figure 12, A). Postoperatively, the average elbow extension force in the denervation group was better than that for the release group (P = 0.04) (Figure 13).
Figure 12.
Images showing manual testing of elbow extensors and wrist dorsi-flexors. Red arrow: patient's resistance, yellow arrow: clinician's pushing.
Figure 13.
Graph showing strength of elbow and hand muscles. lb = pound
Wrist Dorsiflexor Muscle Strength Testing
The patient was asked to make a closed fist and dorsiflexed the wrist. The device was applied to the dorsum of the hand. The test began with the clinician applying force to palmar-flex the patient's wrist and the patient trying to resist and maintain the wrist maximally dorsiflexed. (Figure 12, B). Postoperatively, the average wrist dorsiflexor force in the denervation group was better than that in the release group (P = 0.07) (Figure 13).
Hand Grip Strength
Hand grip strength was measured using hand jammer dynamometer18,19 (Figure 14). Postoperatively, the average hand grip strength in the denervation group was better than that in the release group (P = 0.04) (Figure 13). It can be performed even after failure of open release of extensor tendon.
Figure 14.
Images showing hand jammer dynamometer held by a patient (A and B) with its fixed (f) and mobile (m) handles (C). The device had five positions (colored arrows) varying according to the distance between the mobile (m) and fixed (f) handles. The average of hand gripping strength measured at three different positions (red arrow) representing second position in D, green arrow representing third position in (E) and the yellow one representing fifth position in (F) was determined for every patient.
Mayo Elbow Performance Score
Preoperatively, patients of the denervation group had an average score of 44 points compared with 45 for the release group.18,19 Postoperatively, the denervation group had an average score of 95 compared with 87 for the release group (P = 0.37) (Figure 15).
Figure 15.
Graph showing Mayo Elbow Performance Score.
Discussion
Some authors reported a complication rate of 3.3% after open release for resistant tennis elbow in the form of persistence of pain, weakness of hand gripping, and some limitations of elbow movements most markedly loss of full extension.20 As a result of such complications, denervation of PCNF was suggested as an alternative procedure. Denervation is a simple procedure without any reported complications as far as known to the author; no other researchers reported that the overall outcome after extensor tendon release was superior to that of denervation: the contrary is true. Also, as far as the author recalls, there is no known contraindication to perform denervation for resistant tennis elbow. It can be performed even after failure of open release of extensor tendon.21,22
Table 1 shows a comparison between outcomes of release and denervation procedures. The outcomes of the denervation procedure were superior to those of the release technique in all eight parameters.
Table 1.
Comparative Results of the Denervation and Release Groups in This Series
| Patient Data | Patient No. | Sex Male/Female | Age | Follow-Up | Return to Previous Full Time Job | |||
| Denervation group | 19 | 15/4 | 35 yr | 37 mo | 17 (92%) | P 0.24 | ||
| Release group | 23 | 18/5 | 33 yr | 15 (67%) | ||||
| Patient No. | Pain Severity | |||||||
| Preoperatively | Postoperatively | |||||||
| Sever Pain | PVAS (Points) | Sever Pain | PVAS (Points) | |||||
| Denervation group | 15 (83%) | 8.5 | P 0.12 | 17 (92%) | 0.5 | P 0.02 | ||
| Release group | 20 (89%) | 9.0 | 15 (67%) | 3.5 | ||||
| Factor | Elbow Extension Lag | Pronation | ||||||
| Preoperatively | Postoperatively | Preoperatively | Postoperatively | |||||
| Denervation group | 24° | P 0.11 | 7° | P 0.08 | 45° (56%) | P 0.28 | 68° (85%) | P 0.04 |
| Release group | 22° | 13° | 47° (59%) | 57° (71%) | ||||
| Factor | Elbow Extensor Strength | Wrist Dorsiflexor Strength | ||||||
| Preoperatively | Postoperatively | Preoperatively | Postoperatively | |||||
| Denervation group | 8 lb (30%) | P 0.18 | 19 lb (76%) | P 0.04 | 15 lb (50%) | P 0.15 | 24 lb (87%) | P 0.05 |
| Release group | 9 lb (28%) | 14 lb (58%) | 16 lb (53%) | 21 lb (70%) | ||||
| Factor | Hand Grip Strength | |||||||
| Preoperatively | Postoperatively | |||||||
| Denervation group | 43lb (54%) | P 0.15 | 72 lb (91%) | P 0.04 | ||||
| Release group | 45lb (55%) | 63 lb (77%) | ||||||
| Factor | MEPS | |||||||
| Preoperatively | Postoperatively | |||||||
| Total | Top Category | Total | Top Category | |||||
| Denervation group | 44 | Poor | 10 (83%) | 95 | P 0.37 | Excellent | 11 (92%) | |
| Release group | 45 | 8 (89%) | 87 | Good | 7 (78%) | |||
MEPS = Mayo Elbow Performance Score, PVAS = pain visual analog scale
By the end of follow-up period, pain severity was much better improved in the denervation group compared with the release group (average PVAS score of 0.5 point for the denervation group versus 3.5 points for the release one). No pain at all was experienced by 17 (92%) patients of the denervation group compared with 15 (67%) patients of the release group. Satake H et al12 reported in 2022 about the results of denervation for 15 patients with resistant tennis elbow. By the end of follow-up, complete pain relief was reported by 90% of their patients. Average scores on the PVAS and DASH questionnaire were 4.3 and 10.45 points. Sensory disturbance was noted in 90% of their patients. Torudom et al23 published in 2013 a series of 22 patients who underwent open release for tennis elbow. Their average PVAS at one month fell from 6.7 points preoperatively to 2.1 points postoperatively (in our denervation group patients, PVAS improved from an average of 8.5 points preoperatively to an average of 0.25 points postoperatively).
Regarding the patients' job after surgery, more patients of the denervation group (17 ie, 92%) than those of release group (15 ie, 67%) returned to their previous jobs on a full-time basis. In all patients, elbow extension and forearm pronation were limited because of pain on passive stretch of inflamed ECRB tendon. As far as we could find, no other authors reported about the patients' jobs before and after surgery.
As more patients of the denervation group experienced better pain relief than those of the release group, range of both elbow extension and forearm pronation showed more improvement among the former than the latter group. The pronation movement improvement was statistically significant (P = 0.04) compared with that of extension lag (P = 0.08).
The use of the digital hand held Hoggan micro FET3 device to objectively assess muscles of the elbow and the wrist was more accurate than the subjective technique of measuring the patient strength against the examiner resistance. The reason behind weakness of elbow extension strength was pain on active resistive elbow extension. So, more pain relief was associated with better strength of elbow extension. This explains that patients of the denervation group had better elbow extension strength than those of the release one (P = 0.04). Also, pain relief on resisted wrist extension was associated with improvement of wrist dorsi-flexor strength.
As more patients of the denervation group were pain free than those of the release group, wrist dorsiflexion strength showed better improvement in the former than the latter group (P = 0.07).
On making a closed fist, active wrist dorsiflexion is an integral accompanying movement. In all patients, active wrist dorsiflexion was painful; hence, the hand gripping was weak as monitored by the jammar hand dynamometer. Patients of the denervation group showed better hand grip strength than those of the release group (P = 0.04).
Jeavons et al24 reported in 2014 about 54 patients who had open release for resistant tennis elbow and follow-up of 5.5 years. Range of motion in all patients was unchanged. In our denervation group patients, elbow extension lag improved from an average of 24° preoperatively to an average of 7° postoperatively postoperatively. The average Mayo Elbow Performance Score for their patients was 90.85 points, and 75.5% of the patients were found to have an excellent score.
Berry et al25 reported in 2011 about a comparative study between denervation and epicondylectomy for management of resistant tennis elbow. Their study included 31 patients divided into three groups: 17 patients were treated with epicondylectomy alone, seven patients were treated with lateral epicondylectomy plus neurectomy, and seven patients were treated with lateral denervation alone. Denervation alone gave statistically significantly greater improvement in pain relief and faster return to work than did epicondylectomy alone.
The study included a relatively small number of patients because of the rarity of the disease and the fact that most patients respond very well to nonsurgical measures.
Conclusions
Denervation procedure addresses the main problem in patients with tennis elbow which is disabling pain on routine hand and elbow daily activities. It avoids the side effects of extensor tendon release which are postoperative adhesions and weakness of wrist dorsiflexion and hand gripping.
Acknowledgements
The author owes a lot to all scrubbing nurses who assisted him during surgery and the residents who helped him following patients postoperatively.
Footnotes
The results of this study were presented at ASSH Meeting in Chicago, 2008. The author presented poster at ASSH Meeting in San Francisco, 2009. The results of this study were presented at ASSH Meeting in Boston, 2010. The results of this study were presented at BSSH Meeting in London, UK, autumn meeting 2010. The results of this study were presented at BSSH Meeting in London, UK, autumn meeting 2011. The results of this study were presented at EFORT Meeting in Berlin, Germany, autumn meeting 2012. The results of this study were presented at BSSH Meeting in London, UK, autumn meeting 2013. The results of this study were presented at EFORT Meeting in Istanbul, Turkey, autumn meeting 2013. The results of this study were presented at EFORT Meeting in Prague Chec Republic, Turkey, autumn meeting 2013. The results of this study were presented at EFORT Meeting in Geneva Switzerland, Turkey, 2016. The results of this study were presented at AAOS Meeting in Orlando, Florida, 2016. The results of this study were presented at AAOS Meeting in San Diego, California, 2017. The results of this study were presented at FESSH Meeting in Copenhagen, Denmark, 2018. The results of this study were presented at AAOS Meeting in Las Vegas, Nevada, 2019.
Neither Dr. Quolquela nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.
The single author analyzed and interpreted the patient data, performed surgery and wrote the final manuscript.
The research was approved by the research ethics committee of the faculty of medicine. Fedral Wide Assurance (FWA) A00022834, IRB0010038. Approval Code: 36242/12/22. Tanta University, Tanta, Egypt.
All patients involved in this study have signed consent that their data would be used in this research.
The data sets generated and/or analyzed during this study are available in the Tanta University hospital repository. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. All data generated or analyzed during this study are included in this published article.
The author had fellowships in two institutes in USA. Fellowship at Hand Surgery Department, New Mexico University, Albuquerque, NM, USA with Moheb S. Moneim from January to April 2000. Fellowship at Hand Surgery Department, Thomas Jefferson University, Philadelphia, PA, USA with Lee Osterman, Lawerace H. Shneidr, Jhon Taras, Randal Culp and David Zealouve from May 2000 to January 2002.
References
- 1.Sanders TL, Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF: The epidemiology and health care burden of tennis elbow: A population-based study. Am J Sports Med 2015;43:1066-1071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Meunier M: Lateral epicondylitis/extensor tendon injury. Clin Sports Med 2020;39:657-660. [DOI] [PubMed] [Google Scholar]
- 3.Tosti R, Jennings J, Sewards JM: Lateral epicondylitis of the elbow. Am J Med 2013;126:357.e1-357.e6. [DOI] [PubMed] [Google Scholar]
- 4.Wilhelm A: Partial joint denervation: Wrist, shoulder, and elbow. Plast Reconstr Surg 2010;126:345-347. [DOI] [PubMed] [Google Scholar]
- 5.Brummel J, Baker CL, III, Hopkins R, Baker CL, Jr: Epicondylitis: Lateral. Sports Med Arthrosc Rev 2014;22:e1-e6. [DOI] [PubMed] [Google Scholar]
- 6.Starr BW, Lee DS, Stern PJ: Anatomy of the posterior antebrachial cutaneous nerve, revisited. J Hand Surg Am 2020;45:360.e1-360.e4. [DOI] [PubMed] [Google Scholar]
- 7.Cutts S, Gangoo S, Modi N, Pasapula C: Tennis elbow: A clinical review article. J Orthop 2020;17:203-207. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lenoir H, Mares O, Carlier Y: Management of lateral epicondylitis. Orthop Traumatol Surg Res 2019;105:S241-S246. [DOI] [PubMed] [Google Scholar]
- 9.Karanasios S, Korakakis V, Moutzouri M, et al. : Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)—A systematic review. J Hand Ther 2022;35:541-551. [DOI] [PubMed] [Google Scholar]
- 10.Wenzke DR: MR imaging of the elbow in the injured athlete. Radiol Clin North Am 2013;51:195-213. [DOI] [PubMed] [Google Scholar]
- 11.Frick MA, Murthy NS: Imaging of the elbow: Muscle and tendon injuries. Semin Musculoskelet Radiol 2010;14:430-437. [DOI] [PubMed] [Google Scholar]
- 12.Satake H, Honma R, Naganuma Y, Shibuya J, Takagi M: Strategy for the treatment of lateral epicondylitis of the elbow using denervation surgery. JSES Int 2020;4:21-24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rose NE, Forman SK, Dellon AL: Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis. J Hand Surg Am 2013;38:344-349. [DOI] [PubMed] [Google Scholar]
- 14.Buchbinder R. Green SE Struijs P. Tennis elbow. BMJ Clin Evid 2008;2008:1117. [PMC free article] [PubMed] [Google Scholar]
- 15.Shafshak TS, Elnemr R: The visual analogue scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain. J Clin Rheumatol 2021;27:282-285. [DOI] [PubMed] [Google Scholar]
- 16.Kotte SHP, Viveen J, Koenraadt KLM, The B, Eygendaal D: Normative values of isometric elbow strength in healthy adults: A systematic review. Shoulder Elbow 2018;10:207-215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Bohannon RW: Manual muscle testing: Does it meet the standards of an adequate screening test?. Clin Rehabil 2005;19:662-667. [DOI] [PubMed] [Google Scholar]
- 18.Cusick MC, Bonnaig NS, Azar FM, Mauck BM, Smith RA, Throckmorton TW: Accuracy and reliability of the Mayo Elbow Performance Score. J Hand Surg Am 2014;39:1146-1150. [DOI] [PubMed] [Google Scholar]
- 19.Pomerantz ML: Complications of lateral epicondylar release. Orthop Clin North Am 2016;47:445-469. [DOI] [PubMed] [Google Scholar]
- 20.Celik D: Psychometric properties of the Mayo Elbow Performance Score. Rheumatol Int 2015;35:1015-1020. [DOI] [PubMed] [Google Scholar]
- 21.Cha SM, Shin HD, Kim KC, Park JW: Comparison of grip strength among 6 grip methods. J Hand Surg Am 2014;39:2277-2284. [DOI] [PubMed] [Google Scholar]
- 22.Beumer A, Lindau TR: Grip strength ratio: A grip strength measurement that correlates well with DASH score in different hand/wrist conditions. BMC Musculoskelet Disord 2014;15:336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Torudom Y, Thepchatri A: Open tennis elbow release surgery (in chronic case). J Med Assoc Thai 2013;96(suppl 1):S101-S103. [PubMed] [Google Scholar]
- 24.Jeavons R, Berg AJ, Richards I, Bayliss N: The Boyd-McLeod procedure for tennis elbow: Mid- to long-term results. Shoulder Elbow 2014;6:276-282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Berry N, Neumeister MW, Russell RC, Dellon AL: Epicondylectomy versus denervation for lateral humeral epicondylitis. Hand (NY) 2011;6:174-178. [DOI] [PMC free article] [PubMed] [Google Scholar]