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DOI: 10.1016/S0266-7681(03)00162-1
Litigants’ EpicondylitisFrom the Claremont Hospital, Sandygate Road, Sheffield, UK Correspondence: Neville R.M. Kay, TD FRCS, 362 South Road, Sheffield, S6 3TF, UK. Tel.: +44-114-2312555; Fax: +44-0114-2314646
The speculated pathological causes of tennis elbow and the part work might play in its causation are briefly reviewed. The excellent surgical results, whatever operative technique was employed in those surgical series reported prior to the wave of work-related upper limb disorders is noted. One hundred and eight consecutive patients with tennis elbow who were also litigants (seeking compensation) were reviewed and the result of treatment and specifically surgery, analysed. Disappointing results of surgery were found in litigants and recommendations are made as to the management of litigants epicondylitis.
Key Words: epicondylitis • compensation disability
The pathology of tennis elbow (lateral epicondylitis) remains an enigma. Cyriax (1936) wrote "A condition, the symptoms and signs of which are as constant as those of tennis elbow, may well be supposed to have but one pathology and, as a corollary, but one type of treatment". Garden (1961) wrote "With such clearly defined clinical and diagnostic features – the continued obscurity of the pathology of tennis elbow is surprising". The British Orthopaedic Association’s Working Party Report (1990) addressed to the Industrial Injuries Advisory Council and subsequently reported in the British Medical Journal (Barton et al., 1992) echoed these views and stated "The cause and nature of tennis elbow are still subjects for speculation". More recently, Fairbank and Corlett (2002) observed "Lateral epicondylitis or tennis elbow is a common condition that has been widely researched but not yet fully understood. It is difficult to confidently determine the location of pathology causing pain". With uncertainty as to the precise pathology of tennis elbow, postulated causes abound. Cyriax (1936) documented some 26 different pathological causes, and concluded "the evidence is overwhelmingly in favour of a typical tennis elbow being caused primarily by a tear between the tendinous origin of the extensor carpi radialis brevis and the periosteum of the anterior surface of the lateral epicondyle", a view which received significant support from Nirschl and Pettrone (1979). All their patients had had, on average, four cortisone injections into the area prior to surgery and harvest of the histological specimen. The effects of cortisone injection into tendons are well documented and there is no histological method of distinguishing cortisone-induced degeneration of a tendon from other "natural" causes (Wiggins et al., 1995). Moreover, Verhaar et al. (1993) reporting on 63 surgical cases noted "The extensor origin was grossly normal in all but six patients" and noted vascular proliferation in 46%, mucoid degeneration in 27% and no evidence of inflammatory reaction. Amorphous white steroid deposits were identified in five patients. Wadsworth (1987) illustrates diagrammatically that cortisone is usually injected into the origin of the extensor carpi radialis brevis and Goldie (1964) believed that "with increasing age, no change as to be defined as degenerative were found in the tendinous attachment of the forearm extensors". He identified a sub-tendinous space, bounded by the epicondyle, joint capsule and aponeurosis of the extensor muscles which normally contained areolar tissue. In patients with tennis elbow, this was replaced by granulation tissue and surgical removal of the granulation tissue (which contains nerve endings of the free fibre type) allowed a rapid and complete recovery. However, Garden (1961) noted "The extensor carpi radialis brevis is the only member of the superficial extensor group which arises from the lateral ligament which in turn blends with the capsule of the elbow and is inserted into the orbicular ligament". He reinforced the view of Bosworth (1955) that pathological changes in the orbicular ligament were causative of the symptoms of tennis elbow and suggested an ingenious operation (lengthening of the extensor carpi radialis brevis at the wrist) as a surgical cure. Fairbank and Corlett (2002) identified that the muscle to the middle finger of the extensor digitorum communis is the only segment of that muscle to take origin from the lateral epicondyle and postulated that "disease within this muscle" may be the cause of symptoms in patients with a positive Maudsley’s test. A further point of interest is that prior the wave of work-related upper limb disorder claims, whatever the cause of tennis elbow might be speculated, surgical series reported an average of 90% good or excellent results (Bosworth, 1955; Garden, 1961; Goldie, 1964; Newman and Goodfellow, 1975; Jobe and Ciccotti, 1994; Verhaar et al., 1993; Nirschl and Pettrone, 1979). What is more difficult to identify is the true operative incidence. Some authors simply identify their surgical patient cohort (Garden,1961; Newman and Goodfellow, 1975; Verhaar et al., 1993) whereas Nirschl and Pettrone (1979) identified the total patient cohort which allowed a precise calculation of the operative incidence (7%). Bosworth (1955) states "Innumerable patients with this condition have been seen for the past 15 years" – and reports on 27 elbows. A "best guess" would suggest that in patients presenting to Orthopaedic/Hand clinics prior to the wave of work-related upper limb disorder claims, the operative incidence was 10% or less.
Relationship of epicondylitis to work Cyriax (1936) acknowledged that "work or play which entails repetitive pronation supination movements with the elbow almost fully extended, is essential for the development of tennis elbow" and recognized a "chronic occupational variety" in which the tendency to spontaneous cure is less certain than in the acute type. Nirschl and Pettrone (1979) reporting on 88 surgical elbows noted the association in tennis and golf (in the non-dominant arm) with symptoms, but also pointed out that tennis elbow occurs in non-tennis players. Verhaar et al.’s (1993) cohort of patients were primarily workers (72%) covered by compensation schemes and their men were engaged in strenuous occupations (construction workers, mechanics, etc). In a study which included investigation of epicondylitis in a meat processing factory, Kurppa et al. (1991) noted "epicondylitis of similar clinical severity may mean total vocational handicap to a meat cutter, but little discomfort to a foreman". The British Orthopaedic Association’s Report (1990) acknowledged that "when it (tennis elbow) does occur, symptoms are more likely to be troublesome in those doing manual work and reoccurrence, which is quite common, is likely to occur when manual activities are resumed". There is, however, no validated evidence to suggest that tennis elbow is caused by manual work. It is equally common in non-manual workers (Dimberg, 1987) but there should be little difficulty in understanding that in patients engaged in manual work who have tennis elbow, use of the arm will provoke symptoms, as indeed would be the case in patients with any painful elbow condition.
Disability associated with tennis elbow Kurppa et al. (1991) observed that "The meat cutter must seek medical attention whilst the foreman may just wait for the symptoms to disappear. It is very possible that most of the afflictions in workers in non-strenuous jobs remain unknown to medical personnel". In their cohort of 211 patients, some of whom had epicondylitis, only three had to change their occupation due to work-related upper limb disorders and the authors concluded "These facts support our general impression that the diseases under study (tenosynovitis, peritendinitis and epicondylitis) generally followed a mild course". Cyriax (1936) noted "The condition usually clears up in 8 to 12 months without any treatment" but observed that cases lasting much longer are observed and noted that the "chronic occupational type" were less likely to resolve but were associated with less pain and disability than the acute type. Nirschl and Pettrone (1979) noted the peak incidence of epicondylitis in the fourth decade. Although they gave little mention to the natural history of the condition they did observe "It cannot be emphasised that a thorough analysis of the patient’s emotional outlook and stability is essential prior to undertaking surgical intervention for any pain syndrome". Their cohort of patients were highly motivated sportsmen who did well following surgery. Though there is a plethora of papers on the pathology and conservative and surgical management of tennis elbow, little "hard evidence" exists as to its natural history. Hay et al. (1999) in a randomized multi-centre trial of different treatments for tennis elbow suggested that steroid injections produced a good initial response and that few patients would relapse, but are silent on their cohort of patient’s symptoms and disability after 12 months. Hamilton (1986) also reported on a primary care cohort of patients and observed "No relationship between the incidence and socio-economic class could be found to demonstrate an excess of patients in manual occupation. He noted that epicondylitis was a relapsing condition and identified that 17 of 77 patients (13%) had one or more relapses of pain in up to 18 months, despite treatment. He gives no further information beyond that 18 month follow-up period. Interestingly, O’Driscoll SW (2002), reviewing and commenting on a paper that reported the effects of various treatments for tennis elbow, observed that "Whilst most Surgeons have had tennis elbow at some point, only a tiny minority have sought intervention". This uncertainty as to the true natural history of epicondylitis, particularly with regard to the level of pain and disability it causes is not surprising, as the pathological basis of the condition is an unknown variable. Patients whose tennis elbow represents the first flare of osteoarthritis of the elbow (Stanley, 1992) are unlikely to recover, whereas the young tennis player who sustains a minor forearm muscle tear due to an ill-judged racket shot can be expected to rapidly recover, whatever the treatment. A common experience is that "chronic" epicondylitis takes 6 to 12 months to become asymptomatic (Bowland and Deeland, 1993) and there may be "occasional" incapacitating epicondylitis that requires surgical intervention. Nirschl (1993) in tennis players noted an average duration of symptoms of 6 months in half his patients, but the other half had major symptoms which persisted for about 2.5 years. It is therefore difficult, if not impossible, to give a true representation of what is "the natural history" of tennis elbow (lateral epicondylitis). However, most surgeons with a "mixed patient population" would appear to support the view that, in broad terms, 90% of their patients with epicondylitis settle down with conservative treatment and less than 10% require surgical intervention.
One hundred and eight consecutive patients presenting to the Court with tennis elbow/epicondylitis were seen and examined by the author. One hundred and six patients were seen for the Defense and two on behalf of the Plaintiff. All had support for the diagnosis by the other side’s medical expert and in all but six patients, full access to the General Practitioner’s notes, hospital notes and the other expert’s opinion was allowed. Tennis elbow/epicondylitis is commonly reported as a condition primarily affecting patients in the fourth and fifth decade of life (Coonrad and Hooper, 1973; Nirschl and Pettrone 1979, p. 20; Verhaar et al., 1993). In this series, the age group varied from 23 to 70 years with an average of 50 years (Fig 1). There were 44 men (41%) and 64 women (59%) which contrasts with most series which have an approximately even balance between men and women (Kurppa et al., 1991; Coonrad and Hooper, 1983) and others (Verhaar et al., 1993) which report series of patients who are predominantly male.
Work category Eleven per cent were office workers, 76% were manual workers of varying types and 13% were in heavy manual labour. Most were engaged in full-time employment (81%), but some 14% worked part-time and 5% had mixed employment records (some working full-time with part-time jobs as well) or no precise clarification of the work engaged upon was available.
Persistence of symptoms
Surgery In this series, a very high operative incidence was noted, with 42 of the 108 patients (39%) submitted to surgery. Of these operative patients, a further nine had a second operation. No patient in this series identified a surgical cure but 26% volunteered some improvement following surgery. The remaining 74% were not aware of any improvement whatsoever.
Employment status In the non-operative patients, 35% were unemployed, 8% retired, 36% were in other forms of employment and only 21% remained in their original employment.
Amidst the continuing speculation as to the precise pathology of tennis elbow and uncertainty as to the natural history of the condition, clinicians are faced with the problem of managing such patients. As well as the medical uncertainty relating to the pathology and the true level of symptoms and disability, there are further uncertainties relating to causation and compensation. An analysis of this cohort of patients who all have epicondylitis and are litigants, reveals several interesting features. Firstly, this series is predominantly female, in contrast to most other reported series (Coonrad and Hooper 1973; Kurppa et al., 1991; Verhaar et al., 1993). Secondly, this series of litigants with epicondylitis had greater severity and persistence of the condition than normally reported. Prior to the wave of work-related upper limb disorder claims, most series identify limited symptomatology and disability in the vast majority of patients (Bowland et al. 1993; Dimberg, 1987; Nirschl, 1993), though Cyriax (1936) acknowledged that chronic occupational types may occur and Kurppa (1991) noted that epicondylitis may mean total vocational incapacity to a meat cutter. In this series, however, whatever the "employment status", the effects of epicondylitis appeared to be grossly disabling and persistent. Fifty per cent of patients submitted to surgery ceased employment, 35% of the non-operative patients were unemployed and some 17% retired due to their epicondylitis. Taken at "face value," such figures would suggest that contrary to all other reported series, epicondylitis in litigants is a severe persistent disabling condition. Whilst it might be suggested that this cohort of patients represents "the tip of the iceberg" and only those workers with severe and disabling epicondylitis, such a view would be incorrect for this cohort of patients is consecutive and unselected and the only common feature to all these patients is their belief that they have been "injured" at work and are seeking compensation through the Courts on that basis. A legitimate question is to inquire what factor is it that has changed a relatively minor condition into a major socio-economic problem despite best medical and surgical efforts. The one factor common to this cohort and different to all other series is litigation. It is difficult to escape the conclusion that litigation powerfully affects the patient’s perception of pain and disability in tennis elbow. The results of surgery in this cohort of patients can only be described as "disappointing". It is worth noting that though the operation notes have been reviewed in most of these cases, no real knowledge can be gained as to the precise surgical procedures. All too often the record simply states "lateral release of epicondyle". On one occasion, this was a percutaneous procedure utilising a tenotome! No complications of surgery, that is to say instability of the elbow, neuroma, sinus, fistula or persistent weakness of finger extension were identified and persistent pain was the only indication for re-operation. Nonetheless, whatever the operative procedure employed, some 20% went on to re-operation and only 12% returned to their previous employment. The rest either ceased work, formally retired or changed jobs which contrasts markedly with all other surgical series (Bosworth, 1955; Garden, 1961; Goldie, 1964; Nirschl and Pettrone, 1979) all of which report excellent or good surgical results. It would appear therefore, that the "social dimension" of causation and compensation have profoundly affected this series of litigants with epicondylitis. There can be little doubt that if a worker develops a painful elbow and work involves the use of the elbow, then such use will initiate the symptoms of pain, as indeed it would if there was a boil (furuncle) on the outer surface of the elbow. However, there does not appear to be any validated scientific evidence that use of the elbow can "cause" the pathology of epicondylitis and there does not appear to be any strong evidence that the persistent use of the elbow with tolerant symptoms will significantly alter the natural history of epicondylitis. What is clear from this series is that surgeons, when presented with apparent chronic severe disabling epicondylitis must inquire about the "social dimensions" of their patients. Thus, should litigation and compensation form part of this "social dimension" then a surgical cure is unlikely and the ethics of submitting such patients to surgery, which is unlikely to be successful, must be questioned.
Received for publication June 20, 2002. Accepted for publication April 16, 2003.
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Abstract
INTRODUCTION
