Wilhelm Denervation: Pain Treatment for the Wrist and Tennis Elbow

Chronic pain in the wrist or elbow can severely restrict quality of life. When conservative measures have been exhausted, Wilhelm denervation offers a way of interrupting the transmission of pain without sacrificing joint mobility. This article explains the principle, indications, technique and current evidence.

History and principle

Rüdinger published the first studies on the nerve supply of the wrist as early as 1857. In his 1958 habilitation thesis, Albrecht Wilhelm specified the territories of the individual nerve branches and was the first to describe denervation of the wrist as a treatment for chronic pain; he published the first results in 1966. He pointed out early on that the joint capsule is supplied by a network of different nerves whose course varies from person to person. At some sites he therefore preferred a “blind” denervation, in which the skin and subcutaneous tissue are bluntly detached from the underlying tissue, instead of exposing individual nerves.

The aim of the procedure is not to eliminate the cause of the pain – such as osteoarthritis – but to interrupt the transmission of pain signals from the joint capsule. Wilhelm observed that pain relief was often less pronounced in very advanced cartilage loss with exposed bone. He suspected additional pain conduction via the bone itself.

Part 1: denervation of the wrist

Indications

• chronic wrist pain in osteoarthritis, for example after scaphoid non-union (SNAC wrist) or ligament injury (SLAC wrist),
• lunatomalacia (Kienböck’s disease),
• pain after injuries when a joint-preserving approach is desired,
• patients for whom fusion or a prosthesis is not (yet) an option.

A prerequisite is a positive test block. A distinction is made between total denervation according to Wilhelm, with several skin incisions, and partial denervation, in which only the posterior and anterior interosseous nerves are divided. The partial variant is often also performed in addition to other wrist procedures.

The test block

Before surgery, the nerve branches supplying the joint are blocked with a local anaesthetic. If the typical pain then decreases significantly, this suggests that the procedure will be successful. A lack of effect from the block is regarded as an indication that denervation will bring little benefit.

Wilhelm’s ten denervation points

Point	Nerve branch	Origin	Procedure (summary)	Test block
1	Posterior interosseous nerve	Radial nerve	transverse incision dorsally in the midline approx. 3 cm proximal to the carpus, open the fascia, expose and divide the nerve	1 ml dorsally in the midline down to the radius
2	Articular branch of the first interosseous space	Radial nerve	longitudinal incision approx. 2 cm over the 1st intermetacarpal space, divide the fine articular branch and perforating branches	0.5 ml between the bases of metacarpals I and II
3	Articular branches of the lateral antebrachial cutaneous nerve	Musculocutaneous nerve	via a curved incision over the distal radius (points 3–5), divide the tissue around the radial artery	1 ml perivascularly around the radial artery
4	Superficial branch of the radial nerve (articular branches)	Radial nerve	epifascial detachment of the skin–subcutaneous envelope, especially in the area of the anatomical snuffbox	3–4 ml subcutaneously in a transverse line, approx. 3 cm proximally
5	Palmar branch of the median nerve	Median nerve	incision between the radial artery and the tendon of flexor carpi radialis, divide the soft tissue down to the volar carpal ligament	1–2 ml subcutaneously proximal to the scaphoid tubercle
6	Anterior interosseous nerve	Median nerve	approach at the distal border of pronator quadratus, coagulate the tissue on the radius	1 ml approx. 3 cm proximal to the flexion crease
7	Perforating branches II	Ulnar nerve	transverse incision over intermetacarpal joint II	1 ml
8	Perforating branches III	Ulnar nerve	transverse incision over intermetacarpal joint III	1 ml
9	Dorsal branch of the ulnar nerve (articular branches)	Ulnar nerve	detachment of a skin–subcutaneous flap around the ulnar styloid process	2 ml around the ulnar styloid process
10	Posterior antebrachial cutaneous nerve (articular branches)	Radial nerve	epifascial detachment in the area of the ulnar styloid process	2 ml subcutaneously in a transverse line up to the radioulnar joint

Note: in the literature the points are sometimes numbered differently, for example by Rudigier, who combines points 7 and 8.

Results and evidence

Many case series report significant pain relief in a large proportion of patients, with mobility preserved. However, in some patients the effect wears off over time, and some later require partial or total fusion after all. A recent review in Hand Clinics (2026) concludes that the evidence for isolated division of the posterior interosseous nerve, combined division of both interosseous nerves and total denervation is limited by inconsistent outcome reporting and a lack of controlled trials. The authors call for standardised data collection.

Risks

• incomplete or diminishing pain relief,
• painful nerve nodules (neuromas) at the division sites,
• altered skin sensation in the operated area,
• wound healing problems; rarely, complex regional pain syndrome (CRPS).

Part 2: denervation of the elbow in tennis elbow

In tennis elbow (lateral epicondylopathy), the origin of the wrist and finger extensors at the lateral epicondyle of the humerus is painfully irritated, especially the extensor carpi radialis brevis. In Wilhelm denervation, the fine sensory nerve branches that run to the periosteum of the epicondyle are divided. It is frequently combined with other procedures, such as the Hohmann operation.

When surgery may be considered

The German S2k guideline “Epicondylopathia radialis humeri” of the professional societies (AWMF 033-019, 2019) emphasises that symptoms improve within a year in more than 80 per cent of those affected. Corticosteroid injections relieve pain only in the short term and do not perform better than other measures in the long term; repeated injections are associated with relapses. Surgery should only be considered after at least six months of consistent conservative treatment, if there are corresponding findings on imaging.

Surgical procedures

• Hohmann: release of the extensor origin and removal of the altered tissue,
• Wilhelm: denervation of the epicondyle, often combined with Hohmann,
• Nirschl: removal of the altered tendon tissue without releasing the extensors,
• arthroscopic and percutaneous procedures.

The guideline does not recommend any one procedure over another. Overall, 80 to 95 per cent of patients who undergo surgery are satisfied, and 60 to 70 per cent become pain-free. In 5 to 20 per cent, a good result is not achieved.

Aftercare

• early functional treatment and regular wound checks,
• return to sport usually after eight to ten weeks,
• in individual cases, recovery can take several months to more than a year.

Frequently asked questions

Does the hand lose sensation after denervation?

Mainly branches that supply the joint capsule are divided. Small areas of altered skin sensation are possible, but the sense of touch in the fingers is preserved.

Can the wrist still be fused after denervation?

Yes. Denervation does not rule out later procedures. This is one of its advantages.

Note: This article is for general and professional information only and does not replace a medical examination and advice. Last updated: October 2026.

Sources

• DGOOC u. a.: S2k-Leitlinie Epicondylopathia radialis humeri, AWMF-Register 033-019 (2019)
• Tee R, Ek ET: Wrist Denervation – Total vs Partial. Hand Clinics 2026;42(2):129–144
• Wilhelm A: Die Gelenkdenervation und ihre anatomischen Grundlagen. Hefte zur Unfallheilkunde 1966
• Rudigier J: Kurzgefasste Handchirurgie. Thieme