Tennis Elbow

Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

 - Lateral epicondylitis

Who does it affect?

Anyone

Why does it occur?

The cause of this condition is unclear and controversial. It is most likely due to a problem with the muscles that insert onto the outer edge of the elbow. When these muscles contract they cock the wrist back.

Symptoms

Well-localised pain on the outer edge of the elbow. It is made worse by lifting objects or cocking the wrist back against resistance.

Clinical Examination

The tender point is very well localised to the outer edge of the elbow and the surgeon may ask you to cock your wrist back against resistance. If this reproduces or increases your pain it is likely you have tennis elbow.

Investigations

Classical tennis elbow presentation often requires no investigations. However an x-ray may be performed to exclude arthritis and other conditions. Occassionally an MRI may be organised. This will clearly demonstrate the abnormalitiy around the outside of the elbow.

Non-operative treatment

Physiotherapy settles the majority of cases using a variety of techniques. A tennis elbow splint can also offer benefit.

A steroid injection into the muscle tendon / bone area may improve the symptoms. Steroid injections can be repeated once. Further attempts may damage the overlying fat and skin causing a lightening of the skin and a hollow depression.

Operative treatment

The surgery is a day case procedure usually under local or general anaesthetic and takes about 15 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

The surgery can be performed open (5cm) or percutaneous (1cm). The results are about the same for both techniques, although we a performing a trial to investigate this

Open Technique

Local anaesthetic is infiltrated under the skin over the outer edge of the elbow. Once numb the skin is incised and then the underlying fat is retracted. At the base of the wound is the common extensor origin (the muscle/bone junction for the muscles that cock the wrist backwards). This area is released of the bone and the underlying bone surface is nibbled to provide a healthy bed for the tendons to stick back down. The skin is sutured and a bulky dressing is applied.

Percutaneous Technique

Local anaesthetic is infiltrated under the skin over the outer edge of the elbow. Once numb the skin is incised and the scalpel passed down to the bone and the muscles released off the bone. The skin is sutured and a bulky dressing is applied.

We do not know how the operation works and indeed there are many other types of operation for this procedure. The skin is sutured and a bulky dressing is applied.

Post-operative rehabilitation

The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers and elbow from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. Avoid forced gripping or lifting heavy objects for 2-3 weeks. The sutures are removed at about 10 days. You should notice an improvement in symptoms within a few weeks but the final result may be realised between 3-6 months.

Return to activities of daily living

It is my advice to keep the wound dry until the stitches are out at 10 days.

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probably advisable to delay returning to driving for at least 7 days or even when the stitches are removed.

Return to work:

Everyone has different work environments.
Returning to heavy manual labour should be prevented for approximately 4 to 6 weeks. Early return to heavy work may cause the tendons and nerve to scar into the released ligament. Please ask your surgeon for advice on this.

Complications

Overall, greater than 95% are happy with the result. However complications can occur.
There are complications specific to Tennis Elbow release and also general complications associated with hand surgery.

General complications:

 - Infection (Less than 1%)
 - Neuroma (Less than 1% coiled painful nerve bundle)
 - Numbness

Reflex Sympathetic Dystrophy - RSD (2% bad reaction to surgery with painful stiff hands - this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

Specific complications:

Failure to completely resolve the symptoms (approximately 1% - this may be due to failure to completely release the area). This should be rare but may be released again.