Lateral epicondylitis, commonly known as tennis elbow, involves the degeneration of the wrist extensor tendons where they attach to the bony prominence on the outside of the elbow. This injury is typically caused by the repetitive strain or eccentric overload of the common extensor tendon, particularly the extensor carpi radialis brevis (ECRB) tendon. The resulting pain can be debilitating, often limiting simple daily actions like gripping or lifting objects. While most cases of tennis elbow improve with non-operative management, surgical intervention is generally considered a treatment of last resort when conservative therapies have failed over a prolonged period.
Determining the Need for Surgery
The decision to move forward with surgery relies on strict criteria, as conservative treatments successfully resolve symptoms for the majority of patients. A primary requirement is persistent, debilitating pain that has lasted for a minimum of six to twelve months despite dedicated non-operative care. This pain must significantly interfere with a person’s quality of life, work, or athletic activities to warrant the risks of an operation.
Surgical candidacy is established by documenting the failure of multiple types of non-operative treatments, including physical therapy, bracing, and pharmacologic management with non-steroidal anti-inflammatory drugs (NSAIDs). Patients are usually expected to have failed at least two or three injection-based treatments, such as corticosteroid injections or orthobiologic options like platelet-rich plasma (PRP) therapy.
Imaging studies, such as magnetic resonance imaging (MRI) or ultrasound, are also needed to confirm the pathology. These scans must show evidence of significant tendon damage, chronic degeneration, or tearing within the common extensor tendon origin. The presence of structural damage, combined with a lack of response to a prolonged non-surgical protocol, guides the final decision for surgical intervention.
Types of Surgical Procedures
When surgery is determined to be the appropriate next step, the operation focuses on removing the diseased tissue and stimulating a healing response in the remaining healthy tendon. There are two primary techniques used to achieve this goal. The open technique is the traditional method, requiring a small incision of approximately two to four centimeters over the outside of the elbow.
Through this incision, the surgeon gains direct visualization of the degenerate ECRB tendon, excising the damaged tissue and preparing the bone underneath. The healthy tendon is then reattached, often incorporating a process of bone scraping (decortication) to encourage new blood flow and healing. The open procedure is well-established, offers excellent visualization, and can often be performed with local anesthesia.
The second primary approach is the arthroscopic technique, which is a minimally invasive procedure. This method uses two or three tiny incisions, typically only five millimeters long, to insert a camera and specialized instruments into the joint. The surgeon removes the diseased tendon tissue by viewing the operation on a monitor, which allows for the simultaneous treatment of any co-existing issues inside the elbow joint.
The Post-Surgical Rehabilitation Process
The commitment to post-surgical rehabilitation is a major factor in determining the overall success of the operation. The recovery process is lengthy and structured, beginning immediately after the procedure to protect the surgical repair. The initial phase, lasting approximately one to two weeks, focuses on immobilization in a splint or sling, managing pain, and starting gentle, pain-free movements of the wrist and hand.
The second phase, typically spanning weeks two through six, centers on regaining motion. During this time, the patient begins gentle active and active-assisted range of motion exercises for the elbow and forearm to prevent stiffness. The goal is often to achieve near-full elbow and forearm motion by the end of this phase, with all activities remaining within a comfortable, pain-free range.
Formal strengthening begins in the third phase, usually from six to twelve weeks post-operation. This involves progressive resistance training, including both concentric and eccentric exercises, to rebuild strength in the forearm muscles. The physical therapist guides the patient to gradually increase the load, which is essential for maximizing the function of the healed tendon.
The final phase, which can extend from three to six months and beyond, involves a gradual return to full activity, heavy work, or sports-specific movements.
Expected Outcomes and Risks
For patients who meet the strict criteria for surgery, success rates for significant pain relief and improved function range between 80% and 95%. This high satisfaction rate indicates that for the small percentage of patients whose symptoms are resistant to all other treatments, surgery provides a reliable pathway to recovery. Achieving the maximum benefit is a slow process, often taking six to twelve months post-operation for the tendon to fully remodel and strength to return completely.
The procedure carries risks. Nerve irritation or damage is a potential complication, particularly to the radial or ulnar nerves, which can result in temporary or persistent numbness, tingling, or weakness in the forearm and hand. Infection at the surgical site is a risk with any operation, though it is rare in elbow procedures.
A common concern is stiffness or a loss of full range of motion in the elbow, which is why adherence to the early motion phase of rehabilitation is so important. In a small number of cases, symptoms may not improve or may recur, potentially requiring additional intervention. Tennis elbow surgery offers a high potential reward for those with recalcitrant pain but requires dedicated recovery and carries inherent risks.