What is tennis elbow (lateral epicondylitis)?
Tennis elbow is a common condition caused by degeneration at the attachment of the muscles to the outer side of the elbow joint.
Patients typically between 40 and 60 years old usually start by having some discomfort on the outer side (lateral aspect) of the elbow, particularly with lifting their wrist into extension, i.e. tipping back. A common example would be lifting a kettle. Initially this may be mild but may gradually increase with time. It may become very severe such that they hardly use that elbow, wrist or hand at all. There may be some localised swelling, although this is uncommon.
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at their elbows, wrists and hands and in particular stressing the affected area. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful.
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
In tennis elbow the diagnosis is usually obvious after listening to and examining a patient. If not the commonest test is an X-ray performed on the day of consultation. In more difficult cases an MRI scan may be performed This is performed at a later date. An MRI scanner is usually a short tunnel which the patient’s arms and top half of the body go into. Usually the arms are stretched out in a “superman” pose which is a little uncomfortable but generally well tolerated. Once in the tunnel a loud magnet is spun around and images of the bones and soft tissues created. Some people find the tunnel rather claustrophobic. If any patient doubts whether they would tolerate the scan they are best advised to visit the scanner department in advance. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.
The other common possible causes of the symptoms are problems in the elbow such as arthritis particularly around the near end of the radius bone (head of the radius).
What are the non-operative treatments?
Treatment should start with non-operative options. Patients are advised to reduce those activities that cause the pain and many of them will already have done that. Anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be helpful. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. Tennis elbow splints can be of value. These can be purchased from sports shops. By gripping the muscles a little below the elbow they reduce some of the stress from the muscle attachment at the lateral epicondyle. Some people will find wrist splints helpful although they tend to be more cumbersome. If these modalities fail then a steroid injection would usually be recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb. The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site. Success cannot be guaranteed but in 70-80% of patients there is some significant benefit. How long this lasts is unpredictable. Some people only have a few weeks or months of benefit. Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms. If one injection provides only short term benefit then it may well be repeated. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable). By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely the third injection will be successful and most surgeons would recommend an alternative approach. If, however, injections are only required infrequently, perhaps once every 2-3 years, then having a fourth or fifth injection would, in themselves, be a lot safer than having an operation, and if they give benefit this is reasonable. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic. In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years. The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked. This is more common with this injection than some other injections. If it does occur then that is a relative contra-indication to further injections, i.e. the patient’s surgeon would probably decide not to go ahead with further injections because of the risks of further local damage.
What does the operation involve?
The operation is called a tennis elbow release or lateral epicondylitis surgery.
If non-operative measures have failed to give adequate relief then surgery would be recommended. This is by no means essential and many patients cope long term with mild symptoms, particularly if it does not affect their day to day activities too much. Surgery is reasonably but by no means 100% reliable.
The operation is almost performed either under a general anaesthetic or, increasingly, under local anaesthetic,. A band, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 15-20 mins or so that it is inflated (this happens just before the surgeons starts the operation). Before that the arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection.
A 3-4cm incision is made on the outer aspect of the elbow. The abnormal tissue in the muscle is found and excised and may be sent to the Laboratory for analysis. The attachment of the muscle to the bone is released to take some of the strain off the muscle and prevent recurrent pain. The deep tissues are closed and the skin is closed normally with an absorbable suture. Either a soft dressing or a plaster cast is applied, depending on clinical findings and surgeon preference.
The total time in hospital is usually 3-4 hours.
What are the results of the operation?
Most patients have good results and in our experience a good 85-90% of patients are very satisfied, i.e.they have minimal or no pain, full movement in the elbow and a return to most if not all of their previous activities. Of the remaining 10-15% most of these have some benefit although probably have a little more continuing discomfort and restriction of activities. 1-2% of patients will be dissatisfied, either with almost no relief of their pain and rarely an increase in pain. The latter has never occurred with us over 10 years of experience but is a recognised complication of this operation.
Are there any risks?
All interventions in medicine have risks. In general the larger the operation the greater the risks. For tennis elbow surgery the risks include
- The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
- Aching at the operation site for 3-6 months.
- Grip strength can also take some months to return to normal.
- Stiffness may occur in particular in the elbow. This is usually short-term and only infrequently requires physiotherapy.
- Numbness can occur around the scar but this rarely causes any functional problems.
- Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
- Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery.