Lateral Epicondylitis (Tennis Elbow) Surgery

The ECRB arises from the lateral epicondyle. It lies deep to the extensor carpi radialis longus (ECRL) and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB.[4]

Many proposed explanations for lateral epicondylitis have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and annular ligament. However, Nirschl and Pettrone defined the basic process as microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the ECRB.[5] This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of this muscle.

Concomitant intra-articular lesions (eg, loose bodies, synovitis, ulnohumeral osteophytes, chondral lesions) have been visualized during elbow arthroscopy in patients with lateral epicondylitis. However, whereas concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular one.

Any activity involving wrist extension or supination can be associated with overuse of the muscles originating at the lateral epicondyle. Tennis has been the activity most commonly associated with the disorder. The risk of overuse injury is increased two- to threefold in those who play more than 2 hours weekly and two- to fourfold in players older than 40 years.

Several risk factors have been identified, including improper technique, size of racquet handle, and racquet weight. For work-related lateral epicondylitis, a systematic review identified the following three risk factors[6] :

• Handling tools heavier than 1 kg
• Handling loads heavier than 20 kg at least 10 times per day
• Repetitive movements for more than 2 hours per day

The review also found that low job control and low social support were psychosocial factors associated with lateral epicondylitis.[6]

Lateral epicondylitis has been demonstrated to occur in as many as 50% of tennis players. However, this condition is not limited to tennis players and has been reported to be the result of overuse from many activities. Lateral epicondylitis is extremely common in today's active society.

Nonoperative management has been the mainstay of treatment.  A study by Smidt et al, which compared observation ("wait-and-see") with physical therapy and corticosteroid injection in a randomized trial, found that at 1 year, there were no significant differences among groups with regard to resolution of symptoms.[7] The majority of patients in each cohort (69-91%) had resolution of lateral epicondylitis.  

Surgical treatment of lateral epicondylitis 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. A study by Degen et al found that the most important predictor of whether ipsilateral revision surgery after failed operative treatment of lateral epicondylitis would be necessary was having three or more preoperative ipsilateral injections.[8] ​  

Patients with lateral epicondylitis present with complaints of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman in the age range of 35-55 years who either is a recreational athlete or engages in rigorous daily activities.

Upon examination, the patient has a point of maximal tenderness just (5-10 mm) distal to the lateral epicondyle in the area of the ECRB. Wrist extension or supination (but not flexion or pronation) against resistance with the elbow extended should provoke the patient's symptoms. Another helpful test is the chair raise test, in which the patient stands behind the chair and attempts to raise it by placing the hands on the top of the chair back and lifting. In patients with lateral epicondylitis, this test elicits pain over the lateral elbow.

Radiography

Radiography is the initial imaging study for chronic elbow pain. Radiographs can be helpful in ruling out other disorders or concomitant intra-articular pathology (eg, osteochondral loose body, posterior osteophytes). Calcification in the degenerative tissue of the extensor carpi radialis brevis (ECRB) origin can be seen in chronic cases.[9]  If radiographs are nondiagnostic, other modalities (eg, magnetic resonance imaging [MRI], computed tomography [CT], ultrasonography [US], and bone scanning) are considered.

Other imaging modalities

A guideline from the American College of Radiology (ACR) outlined appripriate uses of US, CT, CT arthrography, MRI, and magnetic resonance (MR) arthrography in the workup of chronic elbow pain when radiographs are normal or nonspecific, as follows[10] :

• Mechanical symptoms are present; intra-articular pathology is suspected - MR arthrography, MRI without contrast, CT arthrography, CT without contrast
• Occult stress fracture or other bone abnormality is suspected - MRI without contrast, CT without contrast, possibly three-phase bone scan
• Chronic epicondylalgia or tendon tear is suspected; empiric treatment is ineffective - US, MRI without contrast
• Collateral ligament tear is suspected - US, MR arthrography, MRI without contrast, CT arthrography, possibly radiographic stress views
• Nerve abnormality is suspected - US, MRI without contrast, possibly CT without contrast

 

If the clinical examination indicates a possible neural etiology for the patient's symptoms, electromyography (EMG) can be helpful in excluding posterior interosseous nerve compression syndrome as the diagnosis.

Anesthetic injections into the origin of the ECRB can help confirm the diagnosis; patients should experience symptomatic relief with such injections.

Despite the implication of the term lateral epicondylitis, the histology of the lesions shows neither acute nor chronic inflammatory cell infiltrate; thus, the term is actually a misnomer. The lesions are characterized by fibroblastic invasion with neovascularization. One study noted mesenchymal cell proliferation indicative of a healing process. However, most other studies indicate degenerative changes.[11]

Nirschl defined the following progressive stages of lateral epicondylitis:

• Stage 1 - Inflammatory changes that are reversible
• Stage 2 - Nonreversible pathologic changes to the origin of the ECRB
• Stage 3 - Rupture of the origin of the ECRB
• Stage 4 - Secondary changes, such as fibrosis or calcification

Approximately 90-95% of patients with lateral epicondylitis (tennis elbow) respond to conservative measures and do not require surgical intervention. Patients whose condition is unresponsive to 3-6 months of conservative therapy (eg, corticosteroid injections, splinting, and occupational therapy) are candidates for surgical treatment. No absolute contraindications for surgical treatment of lateral epicondylitis exist. Relative contraindications include any comorbidities that would place the patient at a higher level of surgical risk.

Controversy about the pathology of lateral epicondylitis notwithstanding, the surgical treatment options described below have all yielded excellent results. Although some less invasive approaches have been proposed and have shown excellent results,[12]  large prospective studies have not been performed to provide conclusive evidence of any significant benefit of one particular procedure over another.

Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis. 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.[13, 14, 15, 16] Although many patients desire some sort of intervention, considerable success has been achieved with a strategy of watchful waiting.[17]

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.[18]

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.[19] Subsequent work supported the use of platelet-rich plasma (PRP).[20, 21, 22, 23]

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.[24]

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.[25, 26]

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.[27] Most patients experienced finger extension weakness, which resolved within 4 months. A subsequent study from Taiwan found botulinum toxin and steroid injections to have comparable efficacy.[28]

Numerous surgical procedures have been described for the treatment of lateral epicondylitis. Most, however, 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.[29]

Whereas the classic open approach provides excellent reproducible results, the minimally invasive approaches mentioned are reported to allow earlier rehabilitation and resumption of activities,[30, 31] as well as some improvement in outcome, as evaluated by the QuickDASH score.[32]  A study comparing the Nirschl procedure with arthroscopic ECRB débridement for lateral epicondylitis found the two techniques to be comparable, with both being highly effective for treating chronic recalcitrant lateral elbow tendinopathy.[33]

A minimally invasive approach of potential interest is ultrasound-guided percutaneous tenotomy. In this technique, the extensor tendon origin is repetitively perforated under ultrasonographic (US) guidance with a small microresection device that includes a needle tip and suction. Seng et al presented a 3-year follow-up on a cohort of 20 patients treated with US-guided percutaneous tenotomy and noted that all 20 reported relief of pain and return of function, with pain Visual Analog Scores of 0 (standard deviation, 0.9; range, 0-3).[34]

Preparation for surgery

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.[35]

A full evaluation should be performed on patients with lateral epicondylitis 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.[36]

Operative details

Open approach

In the classic open-release procedure for lateral epicondylitis described by Nirschl, the patient is positioned supine.[5]  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 via drill holes. The ECRL is sewn to the extensor aponeurosis in an attempt to repair the defect. (See the images below.)

Arthroscopic approach

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.[37]

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.)

Surgical treatment of lateral epicondylitis is an outpatient procedure. If the open approach is used, the elbow is usually protected initially with a splint or brace at 90° for 7-10 days. A process of slow progressive mobilization is then followed, with limited lifting for 4 weeks.

One of the most concerning complications of aggressive surgical debridement for lateral epicondylitis is lateral elbow instability. The proximity of the lateral collateral ligaments and the anular 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.

Early motion in a brace may be initiated at 3-5 days after surgical treatment of lateral epicondylitis, 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.[38, 39, 40]