Injury to the extensor tendons at the elbow often can be attributed to repetitive trauma or overuse, leading to mechanical fatigue or biomechanical overload. Some literature reports the possibility of exostosis in the area of the extensor tendons or a degenerative process that causes pain at the lateral epicondyle.2 Symptoms may be described as an ache at the elbow with sharp pain that infrequently radiates to the dorsal forearm and occasionally to the middle and ring fingers with attendant loss of grip.³

The most frequently involved tendon is that originating from the extensor carpi radialis brevis (ECRB). It is responsible for static and dynamic wrist extension required for certain tasks and stabilizes the wrist while grasping. Lesions can occur at the extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, and supinator tendon. According to the current literature, microtraumatic ECRB tendon tears may propagate to include the common extensors.¹ Plancher and associates¹ report that gross tendon rupture is noted in a large number of patients at the time of surgical intervention.

Microtears can result from repeated sprains, repetitive forceful wrist extension and gripping, and suboptimal mechanics in hitting. Inadequate racquet size or improper tool grip size also can predispose to injury. Other factors that may influence the onset of symptoms are inadequate strength, endurance, and flexibility of the forearm musculature; changes in regular activity; increasing age; and hormonal imbalance in women.³ The incidence is equal in men and women during the fourth and fifth decades, with 75% of all cases involving the dominant arm.¹ Among the older population, the insult can possibly be work-related, in contrast to the sports-related injuries seen in the younger population.

Lateral epicondylitis can be successfully managed nonsurgically in 90% of patients with a combination of activity modification, nonsteroidal antiinflammatory medication, functional and counterforce bracing, various therapeutic modalities, and injection therapy. A small percentage of patients with persistent and disabling symptoms require surgical intervention.⁴ Lesions caused by overuse during job-related activities are more likely to require surgical intervention secondary to an inability to stop the aggravating activity.

Indications for surgery are individualized according to patient demands and activity level. The period of disability and previous conservative management must be considered before surgical management is chosen. There are no absolute indications for surgical intervention to treat lateral epicondylitis, and the clinician must exercise caution in cases in which secondary gain may be important.

The most important factors in considering surgical intervention are the intensity, frequency, and duration of disability caused by pain. The Nirschl classification system indicating the severity phase of pain, its relation to activity and exercise, and symptom resolution following these activities may have some impact on the therapeutic intervention (Table 8-1). Constant and unrelenting focal lateral elbow discomfort is not tolerated well by active individuals and pain that accompanies exercise and activity (phase 4) may indicate pathologic tendon architectural alteration. Most patients treated surgically have symptoms for 1 year, but special consideration may be given to patients in whom other therapies have failed after 6 months of compliance with a well-tailored therapeutic regimen. Calcification around the lateral aspect of the elbow may portend a less favorable outcome to conservative measures. When symptoms are present for more than 12 months, they will rarely respond to further therapeutic management. Although cortisone injections have been the historical standard for acute pain relief in significant cases of tennis elbow, the high recurrence rate has prompted autologous whole blood, platelet rich plasma, sclerosing agents, botulinum toxin, and periarticular hyaluronate injections to provide more long-lasting results. At this time, despite some compelling reports, no consensus exists regarding the ideal injection for a given patient in a particular phase of their lateral epicondylosis malady.

Similarly, less invasive surgical interventions are being investigated by some authors for a quicker return to activity and exercise. Arthroscopic treatment when compared with open management may provide athletes a shorter time period to functional recovery. In contrast to percutaneous release, arthroscopic release appears to achieve outcomes more quickly and provide a clearer visualization of the pathology. Nonetheless, the benchmark procedure for this condition is an open release for which various modifications have been proposed. Regardless of the open method chosen, these procedures are technically simple and provide predictable and long-lasting results and rely on readily available instrumentation. No single technique has been or will be adopted by all surgeons.

According to Nirschl,5,6 85% of patients were able to return to all previous activities without pain. Pain that occurred during aggressive activities was noted in 12% of the cases observed, and no improvement was apparent in 3% of the cases. When both medial and lateral releases are performed, a high level of patient satisfaction was achieved in a group of 53 patients followed an average of 11.7 years, and 96% of patients returned to their sports activity. Reasons for failure include misdiagnosis or the concomitant diagnosis of entrapment of the posterior interosseous nerve, intraarticular disorders, or lateral elbow instability. Poor prognostic factors include poor initial response to cortisone injections, numerous previous cortisone injections, bilateral lateral epicondylitis, other concomitant associated disorders, and smoking.

GOALS: Achieve full range of motion (ROM) of adjacent joints, promote wound healing, control edema and pain, and increase active range of motion (AROM) of the elbow (Table 8-2)

After surgery, the therapist instructs the patient concerning the need to elevate the site to avoid edema and initiates gentle AROM exercises for the hand and shoulder. The patient is to remain immobilized in the postoperative splint with the elbow positioned at 90°. On the fifth day after surgery, the postsurgical dressing and splint are removed and therapy is initiated to the elbow.

The initial postoperative examination is conducted by a physical or occupational therapist. Upon removal of the postsurgical dressing, the examination conducted should measure and address ROM, edema, pain, functional ability, and wound healing. ROM of the hand, wrist, elbow, and shoulder along with girth measurements of the hand, forearm, elbow, and upper arm are taken. Pain levels can be monitored using a 0 to 10 VAS (Visual Analog Scale). It is recommended to have patients use this during therapy sessions and with the home exercise program for optimum accuracy. Functional ability can be monitored using the DASH (disabilities of the arm, shoulder, and hand) or PRTEE (patient-rated tennis elbow evaluation) questionnaire. The above recorded data should be taken at subsequent visits for comparison and assessment of the patient’s progress.

In this phase the patient’s wounds are kept clean and dry until the sutures are removed 10 to 14 days after surgery. After the operative site has been exposed, other forms of edema control can be used, including ice, pneumatic intermittent compression (performed at a 3 : 1 on/off ratio at a pressure of 50 mm Hg), and high-voltage galvanic stimulation (HVGS). The recommended settings for the use of HVGS to prevent edema are negative polarity with continuous modulation at 100 intrapulse microseconds and intensity to the sensory level.⁷