Surg Radiol Anat (2002) 24: 302–307
DOI 10.1007/s00276-002-0055-0
O R I GI N A L A R T IC L E
F. Duparc Æ R. Putz Æ C. Michot Æ J.-M. Muller
P. Fréger
The synovial fold of the humeroradial joint:
anatomical and histological features, and clinical
relevance in lateral epicondylalgia of the elbow
Received: 19 February 2002 / Accepted: 6 July 2002 / Published online: 12 October 2002
Ó Springer-Verlag 2002
Abstract The synovial fold of the humeroradial joint is
known, and sometimes considered as a meniscus that
could be injured by chronic repeated trauma related to
pronation and supination. The aims of this study were to
determine the gross anatomy and histological structure
of this fold, and to clarify its participation in the painful
lateral syndromes of the elbow. Fifty elbows from adult
cadavers were dissected. The capsule of the humerora-
dial part of the elbow joint was resected with the annular
ligament. The presence of a synovial fold, and its loca-
tion relative to the cranial edge of the annular ligament
divided into five sectors (ventral, ventrolateral, lateral,
laterodorsal and dorsal) were noted; morphological pa-
rameters such as thickness, width and length were
measured. The histological examination determined the
structure of the folds. Five synovial folds were resected
during surgery for epicondylalgia in five patients who
suffered from pain precisely at the level of the joint be-
tween the capitulum and the fovea radialis, and were
also examined. A fold was present in 43 cases, and in
two cases two folds were seen at the deep side of the
junction between the capsule and the annular liga-
ment. The most frequent positions were: dorsal (n=11),
The French version of this article is available in the form of elec-
tronic supplementary material and can be obtained by using the
Springer Link server located at http://dx.doi.org/10.1007/s00276-
002-0055-0
F. Duparc (&) Æ J.-M. Muller Æ P. Fréger
Laboratoire d’Anatomie, Faculté de Médecine Pharmacie
de Rouen, 22, boulevard Gambetta, 76183 Rouen cedex, France
E-mail: Fabrice.Duparc@chu-rouen.fr
Tel.: +33-2-32888007
Fax: +33-2-32888312
R. Putz
Ludwig-Maximilians-Universität, Medizinische Fakultät,
Lehrstuhl 1, Pettenkofferstrasse 11, 80336 Munich, Germany
C. Michot
Laboratoire d’Anatomie Pathologique,
Centre Hospitalier Universitaire de Rouen,
1 rue de Germont, 76031 Rouen cedex 1, France
laterodorsal and dorsal (n=6;), lateral to dorsal (n=5),
lateral (n=5), ventral (n=4) and circular (n=4). The
mean length was 21.4 mm (range from 9–51 mm). The
mean width was 2.9 mm (range 1–10 mm), and the mean
maximal thickness 1.7 mm (range 1–4 mm). The histo-
logical study showed two types of folds: a rigid struc-
ture, with oriented fibrous tissue, triangular with a
peripheral capsular base, covered on its two sides and
along the free edge by a synovial layer; and a pliable
structure, formed of two synovial layers that surrounded
a thin fatty tissue, with a villous appearance of the free
edge. No fibromyxoid structure, as in a real meniscus,
was observed. Some nerve fibers were seen in the folds.
The five folds resected in operated patients were hyper-
trophic, and showed an increased number of nerve
fibers, along the capsule but also close to the synovial
layer. Some painful syndromes of the lateral side of the
elbow are not related to tendinitis or to posterior int-
erosseous nerve compression, but have an intra-articular
origin. This study showed that the synovial fold is not a
meniscus, and may be involved in the etiology of lateral
epicondylalgia.
The French version of this article is available in the form
of electronic supplementary material and can be obtained
by using the Springer Link server located at http://
dx.doi.org/10.1007/s00276-002-0055-0.
La frange synoviale de l’articulation huméro-radiale:
aspects anatomiques et histologiques et corrélations
cliniques dans les épicondylalgies latérales du coude
Résumé La frange synoviale de l’articulation huméro-
radiale est connue et parfois considérée comme un
ménisque qui pourrait être lésé par des traumatismes
chroniques répétés en pronation et supination. Les ob-
jectifs de cette étude étaient de préciser les aspects ana-
tomiques et histologiques de cette frange et de clarifier sa
participation dans les syndromes douloureux latéraux
du coude. Cinquante coudes de cadavres adultes ont été
disséqués. La capsule de l’articulation huméro-radiale
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était réséquée avec le ligament annulaire. Nous avons

noté la présence d’une frange synoviale et sa position par Material and methods
rapport au bord crânial du ligament annulaire, divisée
Fifty elbows of adult embalmed cadavers, free of scars, were dis-
en 5 secteurs (ventral, ventro-latéral, latéral, latéro- sected. The capsule of the humeroradial joint was resected, from
dorsal et dorsal). L’épaisseur, la largeur et la longueur ventral to dorsal insertions, with the annular ligament (Fig. 1). The
étaient mesurées. L’étude histologique précisait la presence or the absence of a synovial fold was noted (Fig. 2). The
structure des franges. Cinq franges synoviales ont été position relative to the superior edge of the annular ligament was
réséquées au cours d’intervention pour des épicondylal- determined, categorized into one of five intervals: ventral, ventro-
lateral, lateral, dorsolateral, dorsal (Fig. 3). The shape was defined
gies chez cinq patients qui souffraient précisément au as rigid or pliable, and the morphological parameters were mea-
niveau de l’interligne huméro-radial, et ont fait l’objet de sured with a caliper: length of the fold along the superior edge of
la même étude histologique. Une frange était présente
dans 43 cas, et 2 fois deux franges étaient vues à la
jonction entre la capsule et le ligament annulaire. Les
positions les plus fréquentes étaient: dorsale (11 cas),
latéro-dorsale et dorsale (6 cas), latérale et dorsale (5
cas), latérale (5 cas), ventrale (4 cas) et circulaire (4 cas).
La longueur moyenne était 21,4 mm (9–51). La largeur
moyenne était 2,9 mm (1–10), l’épaisseur moyenne était
1,7 mm (1–4). L’étude histologique a montré deux types
de franges: une structure rigide avec du tissu fibreux
orienté, triangulaire à base capsulaire, couverte sur ses
deux faces et son bord libre par une couche synoviale;
une structure souple, faite de deux couches synoviales
qui entouraient un fin tissu adipeux, avec un aspect
villeux du bord libre. Aucune structure fibro-myxoı̈de,
comme un réel ménisque, n’a été observée. Des fibres
nerveuses ont été observées dans les franges. Les cinq
franges réséquées chez des patients opérés étaient hy-
pertrophiées et montraient une augmentation du nom-
bre de fibres nerveuses, le long de la capsule mais aussi Fig. 1 The capsule (a) of the humeroradial joint was resected
ventrally to dorsally, with the annular ligament (b) left adjacent to
au contact de la couche synoviale. Les syndromes dou- the capsule
loureux de la face latérale du coude ne sont pas toujours
en relation avec une tendinite ou une compression du
nerf interosseux postérieur, mais peuvent avoir une
origine articulaire. Cette étude a montré que la frange
synoviale n’est pas un ménisque et peut être à l’origine
de syndromes douloureux d’épicondylalgie latérale.

Keywords Elbow Æ Humeroradial joint Æ

Synovial fold Æ Epicondylalgia Æ Pain

Introduction

The etiology of painful syndromes of the lateral side of

the elbow may be tendinous (epicondylitis), nervous
(compression of the posterior interosseous nerve), or
articular. Some authors [1, 2, 4, 5, 13] have hypothesized
a chronic injury of the synovial fold that is located in the
joint line between the capitulum and the fovea radialis.
This classically described synovial fold is sometimes
called a ‘‘meniscus’’, but the surgical findings show nu-
merous variations in location, shape, and structure of
this fold.
The aim of this study was to answer three questions:
(1) What is the gross anatomical appearance of this fold? Fig. 2 Frontal scan of the humeroradial joint. When it is present,
the synovial fold (c) could be regarded as a ‘‘pseudo-meniscus’’,
(2) Is it histologically a real meniscus? (3) What is its placed between the capitulum (a) and the edge of the fovea radialis,
possible role in the pathogenesis of lateral pain of the fixed to the capsule (b), above the superior edge of the annular
elbow? ligament (d). e, low capsule of the humeroradial joint; f, radial head
304
Fig. 3 The location of the fold was related to the superior edge of
the annular ligament, which we divided into five parts: 1, ventral;
2, ventrolateral; 3, lateral; 4, laterodorsal; 5, dorsal
the annular ligament, height as the maximal thickness, width as the
distance measured between the attachment at the deep side of the
capsule and the free margin (Fig. 4).
The synovial folds were then fixed and stained (hematoxylin-
eosin-safran), sectioned (10 lm) (Fig. 5), and examined histologi-
cally. Immunohistochemical testing was performed using anti-S100
protein (dilution 1/1500, DAKO). The sections were incubated with
primary antibody, followed by staining with a streptavidin-per-
oxidase kit (LSAB2, DAKO).
Five recently removed synovial folds, resected during surgery
for painful humeroradial joint and showing an increased thickness
and an inflammatory appearance, underwent a histological exam-
ination, including study of the nerve fibers.
Results
A synovial fold was found in 43 elbows (86%). In seven
cases (14%), none was observed. It appeared as a rigid
structure in 30 cases, and as a pliable structure in 13. In
14 cadavers examined bilaterally, the fold was bilateral
Fig. 4 The length (1), the height (2) (maximal thickness) and the
width (3) of the fold were measured
Fig. 5 Position of the synovial folds to be sectioned (10 lm) for
the histological examination
in 24 elbows of 12 cadavers, absent in both right and left
joints in one, and present in only one elbow in one case.
Only two of the 14 cadavers examined bilaterally
showed a symmetrical appearance between the right and
left sides. The position along the superior edge of the
annular ligament was: circular in four cases, dorsal in 11,
laterodorsal and dorsal in six, lateral to dorsal in five,
anterolateral to dorsal in four, lateral in five, antero-
lateral in two, lateral and laterodorsal in two, and lat-
erodorsal in two. In two elbows, two separate folds were
seen, one ventral and the second one dorsal or latero-
dorsal (Fig. 6). When a fat pad was present in the pos-
terior aspect of the humeroulnar joint, either the
Fig. 6 The main shapes observed (n = number of cases) of the
humeroradial synovial folds: a, laterodorsal and dorsal (n=6); b,
dorsal (n=11); c, lateral to dorsal (n=5); d, lateral (n=5); e,
ventrolateral (n=2); f, ventrolateral to dorsal (n=4); g, circular
(n=4); h, double (n=2); i, lateral and laterodorsal (n=2); j,
laterodorsal (n=2)
 305

synovial fold was posterior or posterolateral, or the

synovial lining was in continuity. No intra-articular
septum was found. Osteoarthritis of the capitulum and
the fovea radialis was seen in six elbows, without a
specific appearance of the synovial folds, which were
present in only five cases.
The histological examination showed two main fea-
tures: (1) a double-layered synovial pliable structure,
with a thin fibrous axis (Fig. 7); (2) a rigid structure,
with a thicker fibrous axis, presenting a slightly orien-
tated pattern, with fatty tissue (adipocytes) along the
attachment on the capsule and developed in the fibrous
tissue (Fig. 8). The synovial layer was often thicker than
in the folds with a pliable structure. The synovial layer
was thin and regular or slightly villous or plicate. No
fibrochondroid tissue was found. Nerve fibers were ob-
served in the deep part of the synovial fold, along the
collagen orientated fibers of the capsule, above the an- Fig. 9 Nerve fibers (a and b), labelled black, were found in the
nular ligament, and mainly placed close to small arteries deep part of the synovial fold, close to the capsule
(Fig. 9).
In the five folds resected during the peroperative
study, the thickness of the folds was increased in com-
parison with the observed thickness of the cadaveric
folds.
Adipocytes were seen in greater numbers in the re-
sected folds compared with the cadaveric folds. The fi-
brous axis remained slightly orientated, parallel to the
axis of the fold, and the synovial layer was thicker than
in the cadavers. The nerve fibers were numerous, and
located close to the synovial layer (Fig. 10).

Discussion

Incidence
Fig. 7 Histology. The pliable type: a thin fibrous axis (a) is
surrounded on two sides by the synovial layer The presence of a synovial fold in the humeroradial joint
was inconstant in our study: 86% of the joints showed

Fig. 8 Histology. The rigid type showed a thick fibrous axis (a).
Adipocytes were seen along the attachment to the joint capsule, Fig. 10 Nerve fibers were numerous (a and b), and were located
and in the fibrous tissue closely to the synovial layer
306
one. In the classical description of the elbow joint in the
textbooks of anatomy, it was either consistently found
[9, 12], or not described [11]. Poirier [9] described this
structure as a meniscus-like shape called a ‘‘bourrelet
falciforme’’, in comparison with a scythe-shaped la-
brum. Paturet [8] considered that the fold was a synovial
fold raised by a fold of the capsule, and Testut [12] called
it a ‘‘bourrelet huméro-radial’’, which could be trans-
lated as ‘‘humeroradialis labrum’’. Isogai et al. [6] found
a synovial fold attached to the annular ligament–joint
capsule angle in all the 179 specimens and 40 embryos
they studied.
Shape
The shapes we described – a pliable fold, soft and fine, or
a rigid fold, hard and thicker – correspond to the dif-
ferent shapes characterized by Isogai et al. [6] as semil-
unar, belt-like, petal-like or tongue-like. This illustrates
the various appearances encountered as regards the size
and thickness of the folds.
Anatomical position
Isogai et al. [6] distinguished anterior and posterior
positions of the fold relative to the superior edge of the
annular ligament. These authors found four completely
circular folds among 179 folds in adults (2.2%), and six
among 40 folds in embryos (15%). In our sample, only
four circular folds were seen among 43 (7%). Posterior
folds were generally longer and extended more laterally
than the anterior synovial folds; they also appeared
wider and more deeply interposed in the humeroradial
joint than were the anterior folds. Paturet [8] described
the fold in an anterior and lateral position.
The morphological parameters were similar to the
data presented by Isogai et al. [6]: circumference (length)
25 mm (range 8.2-40.8 mm), thickness (height) 1.7 mm
(range 0.2–4.3 mm).
Functional role
Rouvière and Delmas [10] and Paturet [8] explained that
the fold could occur in the joint and fill the humeroradial
space during extension of the elbow, when the fovea
radialis is no longer in close contact with the capitulum.
The role during pronation and supination may be con-
sidered as a protective one, but in fact the fold is not
directly compressed between the capitulum and the fo-
vea radialis. The mechanical concept of dispersion of
loading forces, as in a meniscus of the knee, is not so
true because the stresses are mainly transmitted from the
central part of the capitulum to the center of the fovea
radialis, and from the capitulotrochlear notch to
the medial crest of the ulnar edge of the radial head.
Murata et al. [7] have shown that the development of
degenerative lesions of the cartilage of the humeroradial
joint extended from the crest to the ulnar part of the
fovea radialis and lastly to the fovea radialis. The
synovial fold does not cover these loading areas.
Embryology
The origin of the synovial fold of the humeroradial joint
is thought to be the remaining part of the initial intra-
articular septum, which covers a larger part of the radial
head in embryos than in adults, and would have par-
tially disappeared [3, 6]). No elbow in our 50 cases
showed any septum.
Meniscus or not?
Our study may answer the question of whether the fold
is a meniscus or a meniscus-like structure: the absence of
a fibrochondroid structure means this anatomical
structure cannot be called a meniscus. The presence of a
synovial layer on the two sides of the fold is not in favor
of the role of a real meniscus placed between two ar-
ticular surfaces in order to increase the congruence.
Innervation
The innervation has not been studied previously. The
presence of nerve fibers close to the attachment on the
capsule provides an explanation for a painful fold.
Furthermore, the presence of thicker nerve fibers in a
superficial position in the folds resected in symptomatic
elbows may suggest participation of the fold in epi-
condylalgia.
Clinical relevance
The participation of the synovial fold in the origin of
pain in the elbow joint is advocated by Isogai et al. [6],
and especially in the elderly as a result of degenerative
changes induced by aging, repeated injuries and in-
flammation.
Intra-articular surgery must be considered for pa-
tients with incomplete pain relief after a test injection of
local anesthetic at the sore spot on the epicondyle [13].
This author performed an intra-articular procedure in 27
of 86 patients, and found degeneration of the orbicular
ligament or a redundant synovial fold in 77% of cases.
The intra-articular lesions were tears or lamination, or
could only have affected the synovial layer, which was
separated by Isogai et al. [6] into three types according
to its microscopic appearance: villous, fringed, and pli-
cate.
Akagi and Nakamura [1] published the case of a 27-
year-old man presenting a snapping elbow because of
chondroid metaplasia of the synovial fold, mimicking a

meniscus with ‘‘chondrocyte-like’’ cells in dense orien-
tated collagen bundles. These authors underlined the
role of mechanical stresses. This outcome could suggest
chronic inflammatory synovitis of a plica synovialis [5],
and indicate the resection of the synovial fold if its
pathological participation in the pain syndrome is as-
sessed [4].
These pathological features may support the hy-
pothesis of a role of the synovial fold in the pathogenesis
of some painful lateral syndromes of the elbow joint,
and may justify performing an arthrotomy when doing
surgery for epicondylitis, or an arthroscopic investiga-
tion as a diagnostic tool as well as a therapeutic tool for
a patient with pain in the lateral aspect of the elbow with
a snapping sensation during motion, resistant to usual
conservative treatment.
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