Understanding "Tennis Elbow": A Guide for Patients

1. What is "Tennis Elbow"?

"Tennis elbow" is the common name for a painful condition that causes burning and soreness on the outer side of your elbow. Despite its name, this problem is actually a misunderstanding—most people who get it do not play tennis at all! It is incredibly common in middle-aged adults, affecting both men and women equally. It frequently happens to people with office jobs, housewives, and manual laborers alike. The pain can be highly stubborn, lasting for weeks, months, or even over a year if the root cause isn't addressed.

2. The Main Symptoms

If you are suffering from tennis elbow, you will likely experience:

• A persistent pain or burning sensation on the outside of your elbow.

• Pain that travels down your forearm and into your wrist.

• A noticeably weak grip. In severe cases, the pain can make everyday tasks frustratingly difficult—even turning a doorknob, wringing a cloth, or lifting a light object can feel intolerable.

3. How Doctors Diagnose It

A doctor can easily diagnose this condition through a quick physical exam and your medical history. The classic sign is that the outer bone of your elbow is highly tender to the touch, but your elbow joint can still bend and straighten completely freely without stiffness. Specialized medical imaging, like X-rays or ultrasounds, is rarely ever needed unless your doctor wants to make absolutely sure that your pain isn't being caused by a rare, hidden issue.

4. The Hidden Cause: How You Sleep

Many traditional treatments—like physical therapy, stretching exercises, painkillers, or steroid injections—only offer temporary relief because they don't fix the underlying cause.

A closer look at patient habits reveals a fascinating clue: patients almost always sleep very soundly at night without any pain, but the moment they wake up in the morning, their arm is stiff, painful, and difficult to use.

When asked, most patients admit they have a habit of sleeping on their side and tucking their forearm directly under their head to use it as a pillow. Even if you don't realize you are doing this, family members or sleep partners almost always confirm it.

Here is exactly why this posture causes so much damage:

1. When you rest the full weight of your head on your forearm for hours at a time, it locks your wrist and forearm into a twisted, palm-down position.

2. This heavy, continuous downward pressure forces the small bones in your elbow joint slightly out of their natural alignment.

3. This structural shift stretches and severely strains a vital, ring-shaped ligament in your elbow (called the annular ligament).

Because the real problem is a stretched and strained ligament caused by the pressure of your head, a much more accurate name for this condition would be a "Strained elbow ligament" rather than tennis elbow.

5. A Simple, No-Cost Treatment Plan

Because this painful condition is caused by a simple sleeping posture, the cure is equally simple. In fact, the rapid relief you feel once you stop sleeping on your arm is the ultimate proof that the posture was causing the problem.

• Change Your Posture: The single most important step is to immediately stop using your arm as a pillow. Use a supportive bed pillow instead.

• The Elbow Wrap Trick: It can be very difficult to control how your body moves while you are fast asleep. If you find yourself automatically curling your arm under your head during the night, tie a towel or a large napkin snugly around your elbow before going to bed. This prevents your elbow from bending tightly, making it physically impossible for your body to slip back into that painful posture while you sleep.

• Temporary Pain Relief: To help your body heal during the first week, your doctor may suggest simple, over-the-counter painkillers, warm pain-relief ointments to apply to the skin, and standard daily vitamins to support tissue repair.

Tennis Elbow: Re-evaluating Lateral Epicondylar Pain as a Postural Annular Ligament Strain

 

1. Introduction & Epidemiology

Lateral epicondylar pain of elbow, traditionally labelled as "tennis elbow" or lateral epicondylitis, is a highly prevalent condition affecting the elbow joint. Clinical data indicates the condition is most common in middle-aged adults of both sexes. Despite its common name, it frequently presents in sedentary workers and individuals who do not participate in racquet sports, making the term "tennis elbow" a clinical misnomer.

The condition affects a highly diverse demographic, presenting equally in males and females, and across varied occupational demands—from individuals engaged in sedentary office desk work and domestic activities to those performing heavy manual labour.

2. Clinical Presentation & Traditional Aetiology

The standard clinical presentation involves persistent pain and a burning sensation localized over the lateral epicondyle. This pain frequently radiates down the forearm and wrist, resulting in a significantly weakened grip strength. In advanced presentations, functional impairment is severe; basic mechanical actions involving forearm rotation and gripping—such as turning a doorknob or lifting minor objects—become intolerable for the patient. Symptoms are notably chronic, frequently persisting for weeks, months, up to 10 to 12 months or more. Traditional orthopedic literature attributes this pathology to repetitive microtrauma and straining of the common extensor tendon originating from the lateral epicondyle, alongside localized ligamentous strain due to muscular overuse.

3. Diagnostic Criteria

Diagnosis is primarily clinical, established through comprehensive medical history and physical assessment. Pathognomonic signs include:

• Localized pain and exquisite tenderness directly over the lateral epicondyle.

• Completely preserved, pain-free passive range of motion of the elbow joint.

• Subjective exacerbation of pain and weakness during active, resisted functional use of the hand and wrist.

Advanced diagnostic imaging, such as musculoskeletal ultrasound or radiography, is rarely indicated and are reserved primarily to rule out rare differential diagnoses or co-existing intra-articular pathologies.

4. The Postural Pathomechanics: A New Aetiological Model

While standard conservative management—encompassing physical therapy, targeted eccentric exercises, systemic analgesics, and localized corticosteroid injections—is widely utilized, these interventions frequently yield inconsistent or non-definitive long-term outcomes.

A detailed review of patient history reveals a critical, overlooked chronological pattern: patients consistently report sound, rarely interrupted sleep during movement of the limb, yet experience severe, immediate pain and restricted functional mobility upon waking. Focused questioning reveals a highly prevalent behaviour pattern: these patients often sleep in lateral decubitus on the affected side, inadvertently using their ipsilateral forearm as a pillow under their head. These patients rarely connect this sleep posture to their daytime symptoms, some of them even deny use of this sleep posture, although accompanying relatives or cohabitants consistently confirm this positioning.

The pathomechanics of this posture can be explained through clear anatomical relationships:

1. The weight of the cranium resting continuously over the distal third of the forearm stabilizes the distal radioulnar (RU) joint in a position of semi-pronation.

2. This sustained gravitational load forces the radial head to adjust its articulation within the radial notch of the ulna and against the capitulum of the humerus. This mechanical adjustment places continuous severe microvascular and mechanical strain on the surrounding stabilizing ligaments and musculature.

3.This model is further supported during physical examination: deep palpation frequently elicits localized tenderness over the anterior or posterior bony attachments of the annular ligament when the forearm is placed in extreme supination or pronation. Consequently, a more anatomically precise diagnostic term for this condition is "Strained annular ligament of the radial head."

5. Therapeutic Intervention Plan

Given the primary postural aetiology, successful resolution relies heavily on mechanical behaviour modification rather than purely pharmacological or modalities-based therapy. The clinical efficacy of eliminating this posture serves as diagnostic confirmation of the underlying cause.

Behavioral Modification (Primary)

Strict instruction to immediately cease utilizing the forearm as a pillow during sleep or rest.

Nocturnal Mechanical Restraint

For patients unable to consciously break the habit during deep sleep, instruct them to tie a napkin, towel, or supportive wrap around the elbow joint. This physically restricts inadvertent, tight elbow flexion, making the pathomechanical posture impossible to adopt.

Short-Term Pharmacotherapy

Prescription of simple systemic analgesics and topical anti-inflammatory liniments for a duration of 7 days to manage residual neurochemical inflammation, supplemented with routine vitamins to support tissue recovery.

Orthopaedic Surgery: Fixation of atypical IT # neck femur with Jewett nail plate :-

Patient under spinal anaesthesia is laid on his side keeping the fracture side up with the hip extended and thigh supported on a thick pillow. After proper preparation  and draping, a 6" long incision is made starting fron the tip of greater trochanter distally. Same incision is extended proximally for 3" curving posteriorly towards PSIS. Deep fascia (fascia lata) is cut inline with the incision exposing posterior border of the gluteus medius muscle, greater trochanter and proximal part of vastus lateralis. The vastus lateralis muscle is elevated extra periosteally to expose the lateral surface of proximal part of the femoral shaft. At this point the fracture ends of the proximal and distal fragment are identified. Generally the proximal fragment that is the femur neck is in flexion, adduction & internal rotation. To align the fracture fragments it is necessary to manipulate the proximal fragment in alignment. For this fracture fragments are disengaged by lifting the proximal end of the femut while applying longitudinal traction to the the leg. The reduction is then checked in anteroposterior projection with C-arm image intensifier. In case the reduction is unsatisfactory it should be repeated. A stable anatomic reduction is usually acheived in case there is no comminution of the calcar. This reduction is stabilized with two K-wires; the first one of 3 mm diameter is passed through the base of greater trochantor into the superior part of head and neck of the femur and the second one a 2 mm diameter guide wire is passed through a drill hole in the lateral surface of femur shaft 4 cms distal to the base of greater trochantor passing through the central axis of neck up to the sub-articular bone of the femoral head. At this stage it is necessary to confirm the position of guide wire with image intensifier  in both AP and frog-lateral projection of femoral neck.
In case the position of guide wire is satisfactory a right size Jewett nail-plate device having proper nail length and matching nail-plate angle is selected. To facilitate passage of the Jewett nail through the femur-neck, an 8 mm diameter bone-hole is made using a cannulated triple reamer over the guide wire through the lateral cortex of the femur up-to the center of the femoral head. The hole in the lateral cortex is further enlarged to 14 mm diameter to avoid its breakage while hammering to insert the Jewett-nail. The nail is now hammered in in the femoral neck till the plate part of the Jewett device sits well over the lateral surface of the femur shaft. It is then fixed with adequate number of screws. Finally confirm the position of fracture alignment and position of Jewett nail plate with C-arm. Satisfied with the fracture alignment and fixation wound is lavaged thoroughly and closed in layers.
Post operatively patient is given antibiotics and necessary analgesics and kept on bed rest with a POP boot and derotation bar for 6 weeks. After which patient is mobilised non weight bearing on crutches. Full weight bearing is allowed after bony union that is nearly 3 months.

We have been using somewhat modified Jewett nail plate with core of trifin nail 8 mm with 12 mm overall nail diameter and plate part now has locking screw facilities of 5 mm diameter.

Orthopaedc Surgeries:- Fractures of humerus condyles:

 Fractures of humerus condyles:
Posterior transolecranon exposure: -  6"-7" long longitudinal incision is made on posterior aspect of elbow curving laterally around olecranon. Sides of the olecranon is cleared of its muscle attachments. Narrow part of the olecranon is identified for osteotomy. Before osteotomizing the olecranon, a drill hole (3.5mm) is made through the olecranon starting at its tip upto the coronoid process anteriorly and tap it with a 4.5 mm tap for fixing it back in position at the end of surgery. The osteotomized olecranon with the attached triceps muscle is lifted proximally to expose the posterior surface of distal 4" of the humerus extraperiosteally and the condylar fragments with their articular surface.  At this point it is necssary to give a good saline lavage to clear haematoma and visualize the fracture anatomy and displacement of the fragments. Muscles and soft tissues attached to posterior surface of condylar fagments and the distal 2" of the shaft are cleared extraperosteally. On medial side the ulnar nerve is mobilized carefully along with mucle mass from the medial epicondyle medial side of the ulna. No attempt is made to isolate it from other soft tissues.
   The fractured lower end of humerus usually has three major fragments, the shaft proximally, and the lateral and medial condyle fragments with their articular surface distally. One of the condylar fragment is usually larger less fragmented than the other. There are usually a few smaller fragments with or without any soft tissue attachments.
 To start with it is easier to align larger fragment with the shaft and stabilize it with a 5-6 hole recon. plate and a screw (3.5mm) holding each fragment. Thereafter the other condylar fragment's  articular surface is aligned to the articular surface of the former condylar fragment in such a way that ita other frature end gets aligned to the shaft.and the same is then stabilized with another recon. plate and/or a K-wire. In case there are more fragments, they are aligned like jig-saw puzzle while fixing the other condyle. A proper size lag screw is then used for intercondylar stabilty to align  the articular surface of trochlea and capitulum fragments under compression. Other smaller fragment are used as fillers if possible or discarded. Once the anatomy of the distal end of the humerus is restored, fracture stabilty recon plates is augmented with additional screws. Wherever possible, these fixations are done extraperiosteally all along to preseve viability of the fragments. At the end of the procedure, the olecranon is fixed with a proper size lag screw and a k-wire to avoid any rotatory displacemnt. The muscles and soft tissues in the sides are suturedback without anteriorly transposing the ulnar nerve,
Postop AE POP slab applied for 6 weeks in 90 degree flexion of the elbow for 4 weeks; and then active mobilization of the extremity started. It takes around 3 to 6 months to get almost free elbow movemnts

Orthopaedic Surgery: IM screw fixation of # clavicle M/3

Procedure:

A 4'" long transverse incision is made along the inferior border of clavicle and superficial & deep fascia is divided in the same line. The Superficial surface of the clavicle is viewed by retracting the skin proximally..The fracture-ends of medial & lateral fragments are exposed and mobilized by clearing muscle and fascial attachments extraperiosteally.

A trial reduction of the fracture fragments is made to check the straightness of the middle third of the clavicle. Using non elastic 3.5 mm K-wire, an intra medullary straight pathway is drilled through fracture-ends in both the fragments of the clavicle piercing anterior cortex of the medial fragment and posterior cortex of the distal fragment; and the pathways in both the fragments are tapped from medial to lateral direction with a 4.5 mm tap. The combined length of tapped medullary canal of both the fragments is measured and the fracture after reduction is fixed from medial to lateral fragment with a cortical screw of proper length. Bone grafting is done in old ununited fractures.

 Post op.a cuff & collar is given for 3 weeks for pain to subside. It takes almost 3 months for the fracture to consolidate.