Tennis Elbow Surgery: Understanding Lateral Epicondyle Release, Causes, Recovery, and Prevention

What is the most common elbow surgery?

While various conditions can affect the elbow, the most common surgical procedure performed on the elbow is the surgical release of the extensor tendons for lateral epicondylitis, commonly known as "Tennis Elbow." This procedure addresses chronic pain and dysfunction resulting from degeneration of the forearm extensor muscles at their attachment point on the lateral epicondyle of the humerus.

Understanding Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis is not always an inflammatory condition, but rather a degenerative process (tendinosis) affecting the common extensor origin at the lateral epicondyle, primarily involving the extensor carpi radialis brevis (ECRB) muscle. It's an overuse injury resulting from repetitive microtrauma.

Anatomy and Biomechanics of the Elbow

The elbow joint is a complex hinge joint formed by three bones: the humerus (upper arm bone), radius, and ulna (forearm bones). On the outer side of the elbow, a bony prominence called the lateral epicondyle serves as the attachment point for several forearm extensor muscles, which are responsible for extending the wrist and fingers. The extensor carpi radialis brevis (ECRB) is particularly implicated in lateral epicondylitis due to its position and function in wrist extension and gripping activities. Repetitive motions involving wrist extension, gripping, and forearm rotation can place excessive strain on this tendinous origin, leading to microscopic tears and degenerative changes.

Causes and Risk Factors

Lateral epicondylitis is typically an overuse injury, not necessarily confined to tennis players. Common causes and risk factors include:

• Repetitive Motions: Activities involving repeated gripping, wrist extension, and forearm rotation. This includes sports like tennis (especially with poor backhand technique), squash, and golf, but also occupational tasks.
• Occupational Activities: Plumbers, carpenters, painters, butchers, dentists, and assembly line workers are at higher risk due to repetitive hand and arm movements.
• Age: Most common in individuals aged 30 to 50, though it can occur at any age.
• Poor Technique: In sports or work, improper form can significantly increase the load on the extensor tendons.
• Weakness or Imbalance: Insufficient strength in forearm muscles or imbalances between flexor and extensor groups.
• Equipment: Incorrect grip size on tools or racquets, or too tight string tension in racquets.

Symptoms of Lateral Epicondylitis

The hallmark symptom is pain on the outer side of the elbow, which may radiate into the forearm and wrist. Other symptoms include:

• Tenderness: Significant tenderness when pressing on the lateral epicondyle.
• Pain with Activity: Pain worsens with gripping, lifting, carrying objects, shaking hands, or extending the wrist.
• Weakness: Difficulty with gripping or lifting objects, sometimes leading to objects being dropped.
• Morning Stiffness: Elbow stiffness or pain that is worse in the morning.

Diagnosis

Diagnosis is primarily clinical, based on a thorough medical history and physical examination.

• Physical Examination: The physician will assess pain upon palpation of the lateral epicondyle and reproduce pain with specific movements, such as resisted wrist extension or resisted middle finger extension.
• Imaging: While not always necessary, X-rays may be used to rule out other bone-related issues, and an MRI might be considered to assess the extent of tendon degeneration or rule out nerve compression, though it's not typically required for initial diagnosis.

Non-Surgical Management (Conservative Treatment)

It's crucial to understand that surgery for lateral epicondylitis is typically a last resort, pursued only after a comprehensive course of conservative treatment has failed (usually 6-12 months). Non-surgical options include:

• Rest and Activity Modification: Avoiding activities that aggravate the pain.
• Ice Application: To reduce pain and inflammation.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Oral or topical to manage pain and inflammation.
• Physical Therapy: A cornerstone of conservative management. This includes stretching, strengthening exercises for the forearm muscles, eccentric exercises, manual therapy, and patient education on proper body mechanics.
• Counterforce Braces: Worn just below the elbow to reduce tension on the affected tendons.
• Corticosteroid Injections: Provide temporary pain relief but may not address the underlying degenerative process and can have long-term negative effects on tendon integrity if used repeatedly.
• Platelet-Rich Plasma (PRP) Injections: Injections of the patient's own concentrated platelets to promote healing. Evidence for long-term efficacy is still evolving.
• Extracorporeal Shockwave Therapy (ESWT): Uses sound waves to stimulate healing.

Surgical Procedure: Lateral Epicondyle Release

When conservative treatments fail to provide lasting relief, surgical intervention may be considered. The goal of surgery is to remove the degenerated tissue and promote healing.

• Procedure Type: The surgery can be performed using an open technique (a small incision over the lateral epicondyle) or arthroscopically (using a small camera and instruments through tiny incisions). Both approaches aim for the same outcome.
• Steps of the Procedure:
  1. Identification of Degenerated Tissue: The surgeon identifies the affected portion of the ECRB tendon, which typically appears discolored and frayed.
  2. Debridement and Release: The diseased, non-functional tissue is carefully removed (debrided). In some cases, a small portion of the ECRB tendon origin is released from the bone to reduce tension.
  3. Decortication: The underlying bone (lateral epicondyle) may be lightly roughened (decorticated) to stimulate a healing response and encourage blood flow.
  4. Repair (Optional): In some cases, if a significant portion of the tendon was detached or released, the healthy remaining tendon may be reattached to the bone.
• Anesthesia: Usually performed under regional anesthesia (nerve block) or general anesthesia.
• Duration: The surgery typically takes less than an hour.

Recovery and Rehabilitation

Recovery from lateral epicondyle release is a gradual process that requires dedication to a structured rehabilitation program.

• Immediate Post-Op: The arm is often immobilized in a splint or sling for a short period (e.g., 1-2 weeks) to protect the healing tissues.
• Early Phase (Weeks 1-6): Focus on pain control, reducing swelling, and restoring gentle, passive range of motion. Active range of motion is introduced gradually.
• Mid Phase (Weeks 6-12): Progressive strengthening exercises for the forearm and wrist are initiated. This includes isometric, then isotonic, and finally eccentric exercises.
• Late Phase (Weeks 12+): Sport-specific or work-specific activities are gradually re-introduced, focusing on proper mechanics and technique. Full return to strenuous activities may take 4-6 months, or even longer for some individuals.
• Physical Therapy: A critical component. A physical therapist guides the patient through exercises, stretches, and helps with pain management and activity modification.

Prevention

While not all cases can be prevented, several strategies can reduce the risk of lateral epicondylitis:

• Proper Technique: Learn and use correct form for sports and occupational tasks.
• Ergonomics: Adjust workstations and tools to minimize strain on the elbow and forearm.
• Strength and Flexibility: Maintain balanced strength and flexibility in the forearm, wrist, and shoulder muscles.
• Warm-up and Cool-down: Prepare muscles for activity and aid recovery.
• Gradual Progression: Increase intensity and duration of activities slowly.
• Equipment Check: Ensure sports equipment (e.g., tennis racquet grip size, string tension) is appropriate.

Conclusion

Lateral epicondylitis, or "Tennis Elbow," is a prevalent condition leading to the most common elbow surgery: the lateral epicondyle release. This procedure is typically reserved for cases unresponsive to extensive conservative management. Understanding the underlying biomechanics, adhering to a comprehensive rehabilitation program, and implementing preventive measures are key to successful recovery and long-term elbow health. If you experience persistent elbow pain, consult with a healthcare professional for an accurate diagnosis and appropriate treatment plan.