Also known as lateral epicondylitis release
A lateral epicondylitis release is a surgery commonly used to treat tennis elbow (lateral epicondylitis). It is used when conservative treatments fail to resolve the pain and loss of grip strength caused by this overuse injury. By cutting the damaged tendon at the point where it attaches to the bone, called the lateral epicondyle, the tension in the elbow can be relieved along with accompanying symptoms.
According to the American Academy of Orthopedic Surgeons (AAOS), tennis elbow surgery is effective in around 85% to 90% of cases. However, it is not unusual to experience some loss of strength as a side effect of the procedure.
What Is Tennis Elbow Surgery?
A lateral epicondylitis involves cutting the affected tendon where it attaches to the lateral epicondyle,removing inflamed/scar tissue from around the tendon, and in some cases, reattaching the free end of the tendon to nearby soft tissues (called fascia).
The procedure can be performed with:
- Open surgery, using a scalpel and larger incision
- Arthroscopic surgery, using a narrow scope and specialized equipment to perform surgery through a tiny incision
- Percutaneous surgery, involving a small incision without a scope
None of the three approaches has proven any more or less effective than the others.
Tennis elbow surgery is typically performed as an outpatient procedure. Most take around 20 to 30 minutes to complete.
There aren’t any absolute contraindications to the procedure.
The only factors that may preempt tennis elbow surgery are those that contraindicate surgery in general, such as an active infection, untreated diabetes, or a severe bleeding disorder. These relative contraindications are considered on a case-by-case basis.
As with all surgeries, tennis elbow surgery poses certain risks. This is because the operation takes place around delicate structures that are vulnerable to injury.
Possible risk of tennis elbow surgery include:
- Post-operative infection
- Tendon rupture, manifesting with weakness when the wrist is bent backward
- Radial nerve injury, resulting in numbness, tingling, burning, or the loss of sensation in the back of the hand and forearm
- Chronic elbow dislocation
- No improvement of symptoms
With that said, the risk of complications is relatively low. According to a 2016 review of studies published in Orthopedic Clinics of North America, the rates of complications for open, arthroscopic, or percutaneous lateral epicondylitis surgery are 1.1%, 0%, and 1.2%, respectively.
Purpose of Tennis Elbow Surgery
A lateral epicondylitis release is the most common surgery used to treat tennis elbow.
While tennis elbow often affects tennis players and others who play certain sports, it can occur in anyone with a repetitive-stress injury of the extensor tendon. This, for example, includes professionals who hammer nails, carry buckets, or use pruning shears on a regular basis.
Over time, the repetitive strain can cause tendon degeneration (tendinosis) and the formation of bone spurs (osteophytes) in and around the point where the extensor tendon attaches to the lateral epicondyle on the bottom of the upper arm bone (the humerus).
Most cases of tennis elbow can be sufficiently managed with conservative treatments such as physical therapy, elbow bracing, anti-inflammatory drugs, or steroid injections. It is when these fail that a lateral epicondylitis release is considered.
According to the AAOS, a lateral epicondyle release is generally indicated when symptoms of tennis elbow do not respond to conservative treatments for a period of six months to a year. Between 3% and 11% of people with tennis elbow require surgery to treat it.
Surgery carries risks, and the success of this procedure largely relies on commitment to the rehabilitation that come after it. Before moving forward with a lateral epicondylitis release, your orthopedic surgeon will inquire as to whether you are ready for that and check to see how well you complied with treatment recommendations already given to you.
- Have you used your elbow brace as directed?
- Have you discontinued the activities that caused your condition in the first place?
- Have you explored physical therapy or newer treatments like ultrasonic tenotomy?
If it is determined that such strategies have been exhausted and that surgery may yield a desirable outcome, testing to characterize the nature of the injury and exclude all other possible causes is needed before the procedure can be scheduled.
The tests most commonly used include:
- Computed tomography (CT) scans, which can identify osteophytes and the calcification (hardening) of soft tissues
- Magnetic resonance imaging (MRI) scan, which is effective in identifying soft tissue abnormalities (such as tears in connective tissues or the formation of soft tissue masses) as well as hidden fractures
- Electromyography (EMG), which measures electrical activity in nerves and can help identify if nerve compression has occurred
How to Prepare
A lateral epicondylitis release is a relatively common orthopedic procedure but one that requires preparation on your part.
Prior to the operation, you will meet with the surgeon to review your pre-operative test results. You will also be provided a list of things you need to do and avoid before surgery. For instance, if you are hairy around the surgical site, a nurse may need to shave you the day of your procedure, but you should not do this yourself ahead of time.
Feel free to ask as many questions as you need to understand the benefits and risks of tennis elbow surgery as well as why a certain type (open vs. arthroscopic vs. percutaneous) was chosen.
Lateral epicondylitis surgery is performed in the operating room of a hospital or in a specialized outpatient orthopedic surgical center.
Depending on the type of surgery used, the operating room may be equipped with an anesthesia machine, an electrocardiogram (ECG) machine to monitor your heart rate, a pulse oximeter to monitor blood oxygen, a mechanical ventilator to deliver supplemental oxygen if needed, and a rigid arthroscope attached to a live-feed video monitor.
What to Wear
Wear something comfortable that you can get easily out of and back into. Before the procedure, you will be asked to change into a hospital gown and remove all jewelry, hairpieces, contacts, hearing aids, dentures, and lip or tongue piercings. Leave any valuables at home.
Food and Drink
Depending on the type of anesthesia used for the surgery, fasting may or may not be required. If undergoing local anesthesia, for example, there are no food or drink restrictions.
However, if a regional block or general anesthesia is being used, you will be asked to stop eating at midnight the night before the operation. Up to four hours before surgery, you may be allowed a few sips of water to take any medications your doctor has approved of. Within four hours, no liquids or food (including gum) should pass your lips.
Your doctor will advise you to stop taking nonsteroidal anti-inflammatory drugs (NSAIDs) the same class of drugs used to relieve tennis elbow pain several days before and after surgery. These drugs, which promote bleeding and slow wound healing, include:
Topical NSAIDs should also be avoided. In their place, you can take Tylenol (acetaminophen), which is not an NSAID.
What to Bring
To check in to your appointment, you will need to bring your insurance card and some form of government photo ID (such as a driver’s license). You may also need to bring an approved form of payment if upfront payment is required to cover copay or coinsurance costs.
Most importantly, you will need to bring someone to drive you home after the surgery. Even if a local anesthetic is used, your arm will be immobilized in a splint, making driving and the operation of heavy machinery difficult and unsafe.
What to Expect on the Day of Surgery
A lateral epicondylitis release is performed by your orthopedic surgeon and assisted by an operating nurse. If regional or general anesthesia is used, an anesthesiologist will also be on the surgical team. Local anesthesia does not require an anesthesiologist.
Once you are checked in and have signed the necessary consent forms, you will be led to the back to change into a hospital gown.
Before the Surgery
The nurse will record your weight, height, and vital signs (including temperature, blood pressure, and heart rate). Your weight and height may be used to calculate the anesthesia dose. If necessary, the nurse may shave the surgical site.
If regional or general anesthesia is used, an intravenous (IV) line will be inserted into a vein in your arm to deliver medications and fluids. Blood oxygen levels will also be monitored using a pulse oximeter (which clamps onto a finger), while electrode leads may be placed on your chest for connection to the ECG machine.
During the Surgery
After you have been prepped by the nurse, you are laid in a supine (upward-facing) position on the operating table with your arm placed on a slightly elevated arm table. Your arm will be bent at a 90-degree angle with the palm facing downward.
Part One: Anesthesia
Open and arthroscopic release surgeries are usually performed with general or regional anesthesia. Percutaneous surgery may only require local anesthesia.
Each type of anesthesia is delivered differently:
- Local anesthesia: A tourniquet is placed on the arm to limit the amount of drug that enters the bloodstream. The anesthesia is then injected in and around the joint using a syringe and needle.
- Regional anesthesia: A tourniquet is also used, but the anesthesia is delivered through the IV line. This type of regional anesthesia, called a peripheral block, is sometimes accompanied by monitored anesthesia care (MAC) to induce “twilight sleep.”
- General anesthesia: General anesthesia is more commonly used if extensive joint repair is being done in tandem with the release. The anesthesia is delivered through the IV line to put you completely to sleep.
Part Two: Tendon Release
The goals of a lateral epicondylitis release remain the same, irrespective of the type of surgery use. One of the main differences is the size of the incision.
Open tennis elbow surgery requires a 3- to 7-centimeter incision (roughly 1 to 3 inches) along the elbow, while arthroscopic and percutaneous surgeries involve incisions of less than 3 centimeters. Moreover, arthroscopic surgery requires two to three incisions (one for the arthroscope and one or two for the surgical tools), while the others only require one incision.
The surgery, regardless of the approach used, follows the same general steps from here:
- An incision is made over the lateral epicondyle.
- Soft tissue is gently moved aside to reveal the extensor tendon underneath.
- The extensor tendon is cut at the lateral epicondyle to release it.
- The tendon is then split to expose underlying tissues and bone.
- Osteophytes are debrided (removed) with cutting or scraping tools, and the area is cleaned.
- The split tendon is stitched back together with dissolving sutures.
- Some surgeons stitch the loose end of the tendon to adjacent tissue to limit its retraction.
- The external incision is then closed with sutures and covered with a sterile bandage.
Upon completion of the surgery, your arm in a placed in a removable splint that keeps your elbow bent at a 90-degree angle.
After the Surgery
After the surgery is complete, you are monitored in the recovery room until the anesthesia has fully worn off. The doctor will want to see if you can wiggle your fingers and ensure that you aren’t experiencing any adverse reactions to the anesthesia.
It is not uncommon to feel pain around the wound. The doctor may provide you with an oral analgesic like Tylenol and anti-nausea medications, if needed. If the surgery was extensive, you may be provided stronger opioid drugs like Vicodin (hydrocodone and acetaminophen) to help control pain for the first few days.
Once you are steady enough to change into your clothes and your vital signs have normalized, you will be released in the care of someone who can drive you home.
Recovery from tennis elbow surgery takes a relatively long time. Upon arriving home, you will need to keep your arm in the sling for seven to 10 days to allow your wound to properly heal. While sitting or resting, you should keep the arm elevated and bolstered with pillows to help ease pain. Ice therapy can also help.
You will also need to change your bandages as directed by your doctor to keep the wound clean. You may need to bathe rather than shower to avoid getting the wound wet.
After seven to 10 days, you will visit the surgeon to ensure the wound is healing properly. Stitches will be removed, and you may be given a smaller splint that you will need to wear for up to two more weeks.
During this initial recovery phase, you may need someone to help with tasks that require two hands. If needed, your doctor can refer you to an occupational therapist who can offer aids to assist with these tasks or advice on how to “work around” daily challenges.
Coping With Recovery
Once the splint is no longer needed, you will find that your elbow is extremely stiff and that you have lost a lot of range of motion in the joint. At this stage, extensive rehabilitation is needed, ideally under the direction of a physical therapist.
Even before the splint is removed, you will need to start passive rehabilitation exercises, including arm and shoulder stretches and the flexing and bending of the fingers and wrists. Starting early can make the more active phases of rehabilitation easier to cope with.
After the splint is removed, the range, duration, and intensity of exercises will gradually increase. You will move from passive exercises to gentle resistance training to build muscle and flexibility in the major muscle groups of the arm.
As your strength and range of motion improve usually within six to eight weeks additional exercises and therapies may be added, including:
- Hand-squeezing exercises with putty or sponges
- Static arm cycles (using a bicycle-like device for the arms)
- Upper-limb mobility exercises, like wrist extensions and flexion and shoulder rotations
- Eccentric and concentric training with light dumbbells or wrist weights
With sustained rehabilitation efforts, most people are able to return to normal activities by week 12. Even so, you may need to wait for another four to 10 weeks before you can return to sports or lift heavy objects safely.
The majority of people who undergo a lateral epicondylitis release will never need surgery for tennis elbow again. According to a 2018 review in the journal Hand, 95% of people who had an open surgery stated that they were “very satisfied” or “satisfied” with the results. Those who underwent arthroscopic or percutaneous surgery had similar rates of satisfaction: 93% and 95%, respectively.
However, if pain persists after the completion of rehabilitation, you may need to work with your doctor to investigate other possible causes of your elbow pain. It is not uncommon, for example, for tennis elbow to occur in people with an underlying rotator cuff injury.
At other times, tennis elbow can co-occur with golfer’s elbow (medial epicondylitis), requiring an entirely different approach to treatment.
Article originally published in Very Well Health: Jonathan Cluett, MD
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