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Lateral Epicondylitis Surgery Treatment & Management

  • Author: Brett D Owens, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Mar 04, 2015
 

Medical Therapy

Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis (tennis elbow). The goal of initial treatment is cessation of the offending activity. Rest, use of a counterforce brace, and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide relief of symptoms. In many cases, wrist splinting is necessary.[11, 12, 13, 14] Although many patients desire some sort of intervention, considerable success has been achieved with a strategy of watchful waiting.[15]

In a randomized, controlled study, Jafarian et al assessed three common orthosis types (elbow strap, elbow sleeve, or wrist splint) against a placebo orthosis to measure their effect on maximum and pain-free grip strength in 52 patients with lateral epicondylosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength; consequently, the researchers suggested that either orthosis type may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.[16]

Both corticosteroid and autologous blood injections have been shown to be effective. Corticosteroid injections at the lateral epicondyle have been shown to decrease pain scores significantly in the early postinjection period. Autologous blood injections for lateral epicondylitis were described in 2003 and showed encouraging pain relief in two thirds of patients treated.[17] Subsequent work has supported the use of platelet-rich plasma (PRP).[18, 19]

Low-level laser therapy appears to provide short-term pain relief and improvement in disability, even in cases resistant to other nonsurgical therapy. A systematic review noted, however, that success with laser therapy has been limited to studies that used direct irradiation of the tendon insertion and wavelengths of 904 nm (and possibly 632 nm), for a total dose of 0.5 to 7.2 J.[20]

When the patient is free of pain through a full range of motion, begin strengthening therapy in a very slow and progressive way. When the patient regains strength and nears resumption of activity, place the emphasis on preventing future irritation (eg, correct technique or address equipment concerns in athletes who participate in racquet sports, modify jobs or activities in patients who are not athletes).

The use of extracorporeal shockwave therapy raised initial excitement. However, two prospective, randomized, blinded trials showed no benefit of this intervention over placebo.[21, 22]

Another proposed modality is injection of botulinum toxin at the origin of the extensor carpi radialis brevis (ECRB). A large multicenter, randomized, controlled trial in Germany showed a significant decrease in pain scores in patients with lateral epicondylitis treated with botulinum toxin as compared with control patients treated with saline.[23] Most patients experienced finger extension weakness, which resolved within 4 months.

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Surgical Therapy

Numerous surgical procedures have been described for the treatment of lateral epicondylitis (tennis elbow). However, most surgical procedures involve debridement of the diseased tissue of the ECRB with decortication of the lateral epicondyle. This procedure has been performed through open, percutaneous, and arthroscopic approaches. In addition to debridement, rotation of the anconeus muscle flap has been reported to improve outcomes.[24]

Whereas the classic open approach provides excellent reproducible results, the minimally invasive approaches mentioned are reported to allow earlier rehabilitation and resumption of activities,[25, 26] as well as some improvement in outcome, as evaluated by the QuickDASH score.[27]

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Preoperative Details

Note the length of time for which the patient has been experiencing symptoms. In addition, note the conservative therapeutic course that has been implemented, including any corticosteroid injections. Consider the patient's workers' compensation status; patients with workers' compensation claims may not respond as well to intervention.[28]

A full evaluation should be performed on patients with lateral epicondylitis (tennis elbow) so that any other associated conditions can be detected. Some authors have noted a relatively high incidence of concomitant intra-articular pathology. For example, one study of 117 consecutive elbow arthroscopies in patients with lateral elbow pain resistant to conservative treatment found established degenerative changes involving articular cartilage, principally of the lateral compartment, in a substantial percentage of the patients.[29]

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Intraoperative Details

In the classic open-release procedure for lateral epicondylitis described by Nirschl, the patient is positioned supine.[6] A 3-cm longitudinal incision is made over the lateral epicondyle. An incision is made through the extensor aponeurosis. The extensor carpi radialis longus (ECRL) is retracted medially, revealing the degenerative origin of the ECRB. All pathologic tissue is excised. The lateral epicondyle is decorticated with an osteotome or by drill holes. The ECRL is sewn to the extensor aponeurosis in an attempt to repair the defect. (See the images below.)

Lateral epicondylitis. Incision for open debrideme Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.
Revision debridement for lateral epicondylitis. Th Revision debridement for lateral epicondylitis. The fascia covering the origin of the extensor carpi radialis brevis muscle and the extensor carpi radialis longus muscle is fibrotic.
Origin of extensor carpi radialis brevis exposed. Origin of extensor carpi radialis brevis exposed.
Lateral epicondylitis. Osteotome positioned over l Lateral epicondylitis. Osteotome positioned over lateral epicondyle.

With elbow arthroscopy, the lateral capsule and the undersurface of the ECRB tendon are easily visualized and evaluated through the proximal medial portal. Advancing the 30° arthroscope past the radial head brings the camera directly in front of the ECRB tendon, which can then be followed to its origin on the lateral epicondyle. Associated synovitis may be noted at this location.

The capsule is adherent to the undersurface of the ECRB tendon. Often, the capsule is torn with the ECRB tendon or is thin and translucent. A 4.5-mm synovial resector then is introduced through the proximal lateral portal. If the capsule is present, it is debrided to reveal the undersurface of the ECRB muscle.

The release of the ECRB tendon is begun at the site of pathology and is continued back to its origin on the lateral epicondyle. After release of the visible ECRB origin, a 4.5-mm round burr is used to decorticate the lateral epicondyle and distal portion of the lateral condylar ridge in the area of the ECRB muscle origin. A cadaveric study showed that this release removed an average of 23 mm of ECRB tendon and 22 mm of lateral epicondyle.[30]

Although a more aggressive resection may be possible with the 70° arthroscope, this has the potential to injure the lateral collateral ligament complex. Resection to the limit of the visualization provided by the 30° arthroscope produces adequate release while protecting the lateral collateral ligaments. (See the images below.)

Type I lateral epicondylitis seen through the 30° Type I lateral epicondylitis seen through the 30° arthroscope.
Type 2 lateral epicondylitis showing a linear tear Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
Type 3 lateral epicondylitis showing a large tear Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
Representation of the relationships in arthroscopi Representation of the relationships in arthroscopic release for lateral epicondylitis
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Postoperative Details

Surgical treatment of lateral epicondylitis (tennis elbow) is an outpatient surgical procedure. If the open approach is used, the elbow is usually protected initially with a splint or brace at 90°.

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Follow-up

Early motion in a brace may be initiated at 3-5 days after surgical treatment of lateral epicondylitis (tennis elbow), with strengthening exercises usually started by 3 weeks, depending on the patient's symptoms. Return to racquet sports can be expected by 4-6 months. Depending on the specific job requirements, patients can return to work in 6-12 weeks, though job modification or persistent use of a counterforce brace during work activities may be necessary.[31, 32, 33]

For patient education resources, see Tennis Elbow.

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Complications

One of the most concerning complications of aggressive surgical debridement for lateral epicondylitis (tennis elbow) is lateral elbow instability. The proximity of the lateral collateral ligaments and the annular ligament renders these structures susceptible to injury. In addition, when the arthroscopic technique is used, the radial nerve is at risk.

Other complications include recurrence or incomplete relief of pain.

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Outcome and Prognosis

Surgical treatment of lateral epicondylitis (tennis elbow) has yielded predictably favorable results, with approximately 85% of patients reporting complete pain relief. Some patients may have persistent symptoms despite surgical treatment, and these patients may benefit from a more aggressive debridement.

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Future and Controversies

Whereas much of the controversy regarding the pathology of lateral epicondylitis (tennis elbow) has been discussed, the surgical treatment options described have all yielded excellent results. Although some less invasive approaches have been proposed and have shown excellent results,[34] large prospective studies have not been performed to provide conclusive evidence of any significant benefit of one particular procedure over another.

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Contributor Information and Disclosures
Author

Brett D Owens, MD Professor of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of Health Sciences; Assistant Professor of Orthopedic Surgery, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Chief of Orthopedic Surgery, Keller Army Hospital

Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons

Disclosure: Received consulting fee from Musculoskeletal Transplant Foundation for consulting; Received consulting fee from Johnson & Johnson (MITEK) for consulting; Received royalty from SLACK Publishing for other; Received salary from American Journal of Sports Medicine for employment.

Coauthor(s)

Jennifer Moriatis Wolf, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut Health Center

Jennifer Moriatis Wolf, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Mark D Lazarus, MD Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Timothy R Kuklo, MD, JD Associate Professor, Department of Surgery, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.

Kevin P Murphy, MD Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Director, Sports Medicine, Department of Orthopedic Surgery and Rehabilitation, Walter Reed Army Medical Center

Kevin P Murphy, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

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Type I lateral epicondylitis seen through the 30° arthroscope.
Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
Representation of the relationships in arthroscopic release for lateral epicondylitis
Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.
Revision debridement for lateral epicondylitis. The fascia covering the origin of the extensor carpi radialis brevis muscle and the extensor carpi radialis longus muscle is fibrotic.
Origin of extensor carpi radialis brevis exposed.
Lateral epicondylitis. Osteotome positioned over lateral epicondyle.
 
 
 
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