Overview

Tennis elbow, also known as lateral epicondylitis, is a common ailment where a person overuses tendons on the outside of their elbow. While conservative treatments are usually helpful, some patients develop chronic pain that demands surgery. This article discusses the causes, symptoms, and surgical treatment options for persistent tennis elbow. Read more to learn about Surgical treatment options for patients with chronic tennis elbow.

Tennis elbow

Tennis elbow is caused by inflammation, microtears, and degeneration of the extensor carpi radialis brevis (ECRB) tendon, which connects the forearm muscles to the lateral epicondyle of the humerus. Tennis elbow, despite its name, does not just afflict tennis players but also others who perform repeated wrist and arm motions.

Causes of tennis elbow

Tennis elbow is caused by repeated strain on the extensor tendons, resulting in microtears and inflammation. Common causes include:^1,2

• Repetitive motion: repeated use of the wrist and forearm, such as in racket sports, painting, or typing
• Improper technique in sports or occupational activities: may cause tendon strain
• Overuse injury: continuous stress without enough rest might cause tendon deterioration
• Individuals over the age of 40: you become more susceptible due to reduced tendon suppleness and healing capacity

Signs and symptoms 

Tennis elbow symptoms usually start gradually and worsen over time. Common signs include:

• Pain and tenderness: pain on the outside of the elbow that intensifies when holding or lifting objects
• Weak grip strength: difficulty holding objects because of weak forearm muscles
• Pain with wrist movements: activities involving wrist extension or forearm rotation may aggravate the pain
• Morning stiffness: increased soreness following periods of rest

When is surgery necessary?

Surgical surgery is recommended if symptoms continue for longer than 6-12 months after conservative treatment and/or if the following occurs:³

• Nonsurgical therapies, such as physical therapy, corticosteroid injections, and bracing, are ineffective
• The pain is intense and greatly impacts everyday activities and productivity
• Imaging (MRI or ultrasound) reveals substantial tendon deterioration or tear

Surgical treatments for chronic tennis elbow

Chronic tennis elbow, also known as lateral epicondylitis, is a disorder caused by overuse of the forearm muscles, resulting in pain and degeneration of the tendons linked to the lateral epicondyle of the humerus. When conservative treatments including physical therapy, bracing, corticosteroid injections, and extracorporeal shockwave therapy do not give enough relief, surgical intervention may be required.

To treat chronic tennis elbow, there are several surgical techniques available, each with its own set of advantages and disadvantages. This document examines the various surgical methods, including their methodologies, benefits, and potential downsides.

Open tennis elbow surgery procedure

Open surgery is the traditional method of treating persistent tennis elbow. It is usually conducted with local or general anaesthesia. To access the afflicted tendon, the surgeon makes a tiny incision on the lateral epicondyle. The diseased or deteriorated tendon tissue is identified and removed, with the remaining healthy tendon reattached to the bone. Bone spurs and excess scar tissue may also be removed to facilitate healing and relieve discomfort.

Advantages: 

• Direct visualisation enables exact tissue removal
• High success rates for long-term pain alleviation and functional improvement
• Effective for severe cases including significant tendon degeneration⁴ 

Disadvantages:

• The open aspect of the treatment results in a longer recovery time
• Risk of scarring and stiffness following surgery
• Physical therapy is necessary for optimal rehabilitation⁵

Arthroscopic tennis elbow surgery procedure

This minimally invasive procedure involves making small incisions near the elbow joint. A tiny camera called an arthroscope is placed to provide a magnified picture of the tendon and surrounding structures. The surgeon uses specialised devices to remove damaged tissue and clean the affected area.

Advantages:

• Smaller incisions reduce postoperative pain
• Reduced trauma to adjacent tissues leads to speedier recovery
• Reduced risk of consequences like infection and stiffness
• Shorter hospital stays and faster return to normal activities⁶

Disadvantages: 

• Highly technical technique necessitates specialist skills
• May not be appropriate for those with significant tendon degeneration

Percutaneous tennis elbow surgery

This treatment uses a needle or specialised surgical equipment to remove deteriorated tendon tissue without an open incision. The treatment is frequently guided by ultrasound imaging, which allows for accurate targeting of the afflicted area.

Advantages:

• Reduced invasiveness and faster healing times
• Reduced postoperative pain and scarring
• Suitable for those who prefer to forgo standard surgery⁷

Disadvantages: 

• Limited effectiveness for significant tendon damage
• If symptoms continue, the surgery may need to be repeated
• The procedure is less prevalent than open or arthroscopic surgery

Tendon release surgery (lateral epicondylitis release)

The surgery involves releasing the afflicted tendon from its attachment to the lateral epicondyle. Any scar or aberrant tendon tissue is removed, and the healthy tendon is restored and reattached to the bone. This can be done using either open or arthroscopic procedures.

Advantages:

• Helps relieve chronic pain and improve function
• Can be modified based on the severity of the tendon damage
• In circumstances where conservative treatment is ineffective, this approach may provide long-term relief⁸

Disadvantages:

• Surgery may cause diminished grip strength
• Requires organised rehabilitation to regain strength and mobility
• Some people may endure ongoing discomfort or stiffness

Platelet-rich plasma (PRP) augmented surgery

This new treatment uses platelet-rich plasma (PRP) during surgery to improve tendon repair. PRP is produced from the patient's own blood and contains growth factors that stimulate tissue regeneration. PRP is injected into the surgical site to speed up recovery.

Advantages

• Promotes faster healing and better tissue restoration
• Minimally invasive and promotes long-term tendon health
• Can be used in conjunction with other surgical methods⁹

Disadvantages

• Effectiveness is currently being investigated through large-scale investigations
• Not all patients respond equally to PRP therapy
• Additional expenses may not be reimbursed by insurance

Radiofrequency microtenotomy

This technique uses radiofrequency energy to tear down and remove deteriorated tendon tissue. The energy boosts the tendon's natural healing response, which promotes tissue regeneration without requiring substantial surgical intervention.

Advantages: 

• Minimally invasive surgery includes faster recovery time compared to traditional open surgery
• Can be done in an outpatient setting
• Useful alternative for patients who do not want standard surgery¹⁰

Disadvantages: 

• May not be appropriate for severe situations with extensive tendon damage
• Effectiveness varies by individual: some may require additional treatment

Recovery and rehabilitation

The recovery period after surgery for chronic tennis elbow varies depending on the type of technique used, the severity of the condition, and the patient's overall health. 

General rehabilitation guidelines include:

1. Immobilisation: A splint or brace can be used for 1-2 weeks after surgery to preserve the surgical site and encourage healing
2. Physical therapy: Stretching and strengthening exercises improve function and avoid stiffness
3. Therapy aims to restore grip strength, range of motion, and general forearm endurance
4. Pain management: Ice therapy and NSAIDs are typically used to alleviate swelling and discomfort
5. Prescription pain medications may be required during the first few days after surgery
6. Return to activity: Light activities can usually resume 6-8 weeks after surgery
7. Full healing and return to sports or strenuous labour may take 3-6 months, depending on the treatment and rehabilitation progress³

FAQs

How long does it take to recuperate after tennis elbow surgery?

Recovery time varies based on the surgical procedure employed, however most patients can resume mild activities in 6-8 weeks and complete recovery in 3-6 months.³

What are the risks of having tennis elbow surgery?

Infection, nerve injury, stiffness, long-term pain, and partial symptom alleviation are all possible risks.⁴

Will I regain full strength following surgery?

Following proper therapy, most patients achieve significant improvement in strength and function but complete recovery is dependent on individual healing.⁵

Can a tennis elbow recover after surgery?

Recurrence is uncommon but possible if suitable post-surgical rehabilitation and activity reductions are not followed.⁸

Is physical therapy necessary following surgery? 

Yes, physical treatment is essential for restoring strength and flexibility while avoiding future injuries.⁹

Can I avoid surgery to treat chronic tennis elbow?

Alternative treatments, such as PRP injections, physical therapy, and lifestyle changes, may help control symptoms without requiring surgery.⁶

Summary

When conservative therapy fails to offer relief, surgical treatment options for chronic tennis elbow can be successful. Open surgery is still the gold standard for severe cases, but arthroscopic and percutaneous methods provide less intrusive options with faster recovery times. Adjunct treatments, such as PRP augmentation and radiofrequency microtenotomy, show potential in improving healing but require further investigation. Postoperative rehabilitation is crucial to ensuring a positive outcome, emphasising the importance of systematic therapy and a gradual return to activity. Understanding the many surgical alternatives available allows patients and healthcare providers to make informed decisions and obtain the best treatment outcomes.