Approach Considerations
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.
Medical Therapy
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]
Surgical Therapy
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.)
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.
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.)
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
Postoperative Care
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.
Complications
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.
Long-Term Monitoring
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]
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Type I lateral epicondylitis seen through the 30° arthroscope.
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Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
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Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
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Representation of the relationships in arthroscopic release for lateral epicondylitis
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Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.
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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.
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Origin of extensor carpi radialis brevis exposed.
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Lateral epicondylitis. Osteotome positioned over lateral epicondyle.
