Arthroscopic Treatment of Lateral Epicondylitis

Christian Veillette, M.D., FRCSC
Toronto, ON

Since the original description of lateral epicondylitis by Runge in 18731, there has been controversy regarding the etiology, pathoanatomy and most appropriate methods of nonoperative and operative management. Although, commonly referred to as ‘tennis elbow' because of an initial association with lawn tennis, it can be caused by minor trauma or overuse with repetitive motion of the wrist while the arm is extended. The accepted theory of the pathogenesis of lateral epicondylitis is that overuse leads to microscopic tears in the origin of the ECRB with subsequent tendon replacement by immature reparative tissue consisting of disorganized collagen, fibroblasts and vascular elements (angiofibroblastic tendinosis)2-4.


The vast majority of patients respond to nonoperative management such as activity modification, bracing and steroid injections5. Low-cost counterforce braces may transfer force from the ECRB and its origin and distribute it more evenly, allowing the tendon to heal. Steroid injections may enhance early recovery but can cause calcium deposits and recent studies have not shown consistent long-term benefits. Between 4-11% of patients fail nonoperative management and require operative treatment for disabling, recalcitrant symptoms2, 5-7. Traditionally, the standard procedure for lateral epicondylitis has been an open release as described by Nirschl3; however, arthroscopic techniques have shown as reliable outcomes but with several advantages8-16.
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Figure 1. Anatomic landmarks for arthroscopic lateral release. 1 - Medial epicondyle, 2 - Ulnar nerve, 3 - Proximal anteromedial portal, 4 - Radiocapitellar joint.

Surgical Indications
Surgery is indicated for patients who fail a comprehensive course of nonoperative treatment and have continued pain that interferes with daily activities. Most physicians accept a six-month course of nonoperative treatment. Before surgery, it is important to assess compliance and motivation, which may explain why a patient failed to respond to nonoperative treatment.

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Figure 2. Needle localization of radiocapitellar joint and creation of anterolateral portal using outside-in technique.

Technique
The patient is positioned in the lateral decubitus position with the arm over an elbow holder. A proximal anteromedial portal is created approximately two centimetres proximal to the medial epicondyle and one centimetre anterior to the medial intermuscular septum (Figure 1). A 4.0 mm 30 degree arthroscope is inserted over a switching stick and from the proximal anteromedial portal, the radiocapitellar articulation and adjacent joint capsule are examined. Pronation and supination of the forearm allow for full examination of the radial head. An 18 gauge needle is used to localize the anterolateral portal using an outside-in technique and a 15 blade is used to create the portal and release the majority of the ECRB tendon off the lateral epicondyle under direct visualization (Figure 2 and Figure 3). A 4.0 mm shaver is inserted and the capsule surrounding the portal is debrided and removed (Figure 4). The diseased ECRB tendon lies between the capsule and the overlying extensor digitorum communis. An Arthrocare bipolar probe can be used to release the remainder of the ECRB from the lateral epicondyle (Figure 5). The release is carried distally making certain to remain above the equator of the radial head to prevent injury to the lateral collateral ligament. Debridement of the ECRB is considered complete when all visibly abnormal tissue has been removed (Figure 6). Portals are closed with a 3-0 prolene suture.

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Figure 3. Creation of anterolateral portal and release of ECRB under direct visualization.

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Figure 4. Debridement of capsule and pathologic ECRB tendon origin with shaver.

Advantages of Arthroscopic Over Open Lateral Release

  1. Smaller incisions, minimal morbidity to the soft tissues and thus less postoperative pain. Although anecdotal, for surgeons who have performed both open and arthroscopic lateral releases, the improved pain levels in the day surgery unit and subsequent follow-up is easily noticed with arthroscopic techniques.
  2. Ability to address coexistent intra-articular pathology (synovitis, plica). Several authors using arthroscopic techniques have noted associated intra-articular lesions present in 19% to 44% of patients11,14,16. Baker et al reported a higher incidence of intra-articular lesions. In their early experience, they routinely looked into the posterior compartment of the elbow which they no longer do8. Nirschl and Pettrone noted an 11% incidence of associated intra-articular disorders using an open approach2. Failure to address associated intra-articular lesions may be a reason for persistent symptoms despite adequate open release.
  3. Only the tendon affected by tennis elbow (ECRB) is released in the arthroscopic method, as this tendon is the closest extensor tendon to the elbow joint. With the open procedure, other extensor tendons are split or released leading to increased soft tissue morbidity and weak grip strength postop. Several cadaveric studies have demonstrated the efficacy of arthroscopic techniques in removing 100% of the ECRB origin without violating the lateral ulnar collateral ligament or injury to adjacent neurovascular structures17,18. Cummins recently assessed the effectiveness of the arthroscopic debridement. After an initial arthroscopic debridement, a traditional open exposure was performed with gross and histological analysis done. The results suggest that after an initial learning curve, arthroscopic debridement can effectively remove all of the gross pathologic tissue seen during a traditional open exposure10.
  4. Accelerated rehabilitation and earlier return to sports and work and no loss of grip strength. Baker et al reported a mean return-to-work interval of 2.2 weeks8. Owens et al14 reported a mean return to work of six days in their military population while Jerosch et al11 showed that their patients who were primarily tradesmen and office workers returned to work at a mean of 3.2 weeks. Although open procedures achieve a high level of satisfactory results, they typically have a longer recovery period. In the study by Nirschl and Pettrone3, patients with good to excellent results took a mean of 2.6 months to be symptom free. Verhaar et al19 reported that only eight of 44 patients returned to work by six weeks after open release and at 12 weeks, 13 patients were still unable to return to work.

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Figure 5. Completion of debridement with Arthrocare ablation.

There are no prospective, randomized studies in the literature comparing arthroscopic debridement of the ECRB origin with open release. There are only a couple retrospective, nonrandomized studies comparing arthroscopic release with other operative treatments. Szabo et al16 compared patients that underwent a lateral release done percutaneously, arthroscopically or open with a mean follow-up of 48 months. There were no significant differences with respect to complications, failures, pain scores or outcome scores. Peart et al15 reported on 46 patients with open releases compared to 29 patients with arthroscopic releases. Patients treated with arthroscopic release returned to work sooner and required less postoperative therapy. Baker et al20 compared 15 open Nirschl procedures with 15 arthroscopic releases in a nonrandomized trial and found a significant difference in the return-to-work and sports rate with a mean 66 days in the open group and 35 days in the arthroscopic group.

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Figure 6. Debridement of the ECRB is considered complete when all visibly abnormal tissue has been removed.

Several authors have published successful results at short-term follow-up using similar arthroscopic techniques with minor modifications11, 14-16. Baker et al9 have shown that these short-term results are maintained in the long-term. They retrospectively reviewed 30 patients who had undergone arthroscopic lateral release with a mean follow-up of 11 years. The average pain score at rest was 0; with activities of daily living, 1.0; and with work or sports, 1.9. The mean functional score was 11.7 out of a possible 12 points. No patient required further surgery or repeat injections after surgery. One patient continued to wear a counterforce brace with heavy activities. Twenty-three patients (77%) stated they were "much better," six patients (20%) stated they were "better," and one patient (3%) stated he was the same. Twenty-six patients (87%) were satisfied, and 28 patients (93%) stated they would have the surgery again if needed.

Conclusions
High rates of good to excellent results have been reported regardless of the type of surgical technique used for the operative treatment of lateral epicondylitis. There is a lack of controlled trials to support one technique over another. However, the current literature suggests that arthroscopic lateral release results in less soft tissue morbidity, improved ability to address co-existent pathology, and accelerated rehabilitation with earlier return to sports and work as compared with open techniques. In addition, short and long-term outcomes are equivalent or better and there is no increased rate of complications.

References

  1. Runge F. Zur genese und behandlung des schreibekrampfes. Berl Klin Wochenschr 1873;10:245-248.
  2. Nirschl R.P. Elbow tendinosis/tennis elbow. Clin Sports Med 1992 Oct;11(4):851-70. 
  3. Nirschl R.P., Pettrone F.A. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979 Sep;61(6A):832-9.
  4. Lo M.Y., Safran M.R. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res 2007 Oct;463:98-106.
  5. Bowen R.E., Dorey F.J., Shapiro M.S. Efficacy of nonoperative treatment for lateral epicondylitis. Am J Orthop 2001 Aug;30(8):642-6.
  6. Boyd H.B., McLeod A.C.,Jr. Tennis elbow. J Bone Joint Surg Am 1973 Sep;55(6):1183-7.
  7. Coonrad R.W., Hooper W.R. Tennis elbow: its course, natural history, conservative and surgical management. J Bone Joint Surg Am 1973 Sep;55(6):1177-82.
  8. Baker CL,Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg 2000 Nov-Dec;9(6):475-82.
  9. Baker C.L.,Jr, Baker C.L.,3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med 2008 Feb;36(2):254-60.
  10. Cummins C.A. Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes. Am J Sports Med 2006 Sep;34(9):1486-91.
  11. Jerosch J., Schunck J. Arthroscopic treatment of lateral epicondylitis: indication, technique and early results. Knee Surg Sports Traumatol Arthrosc 2006 Apr;14(4):379-82.
  12. Kuklo T.R., Taylor K.F., Murphy K.P., Islinger R.B., Heekin R.D., Baker C.L.,Jr. Arthroscopic release for lateral epicondylitis: a cadaveric model. Arthroscopy 1999 Apr;15(3):259-64.
  13. Mullett H., Sprague M., Brown G., Hausman M. Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clin Orthop Relat Res 2005 Oct;439:123-8.
  14. Owens B.D., Murphy K.P., Kuklo T.R. Arthroscopic release for lateral epicondylitis. Arthroscopy 2001 Jul;17(6):582-7.
  15. Peart R.E., Strickler S.S., Schweitzer K.M.,Jr. Lateral epicondylitis: a comparative study of open and arthroscopic lateral release. Am J Orthop 2004 Nov;33(11):565-7.
  16. Szabo S.J., Savoie F.H.,3rd, Field L.D., Ramsey J.R., Hosemann C.D. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg 2006 Nov-Dec;15(6):721-7.
  17. Cohen M.S., Romeo A.A., Hennigan S.P., Gordon M. Lateral epicondylitis: Anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. J Shoulder Elbow Surg 2008 Jul 9.
  18. Smith A.M., Castle J.A., Ruch D.S. Arthroscopic resection of the common extensor origin: anatomic considerations. J Shoulder Elbow Surg 2003 Jul-Aug;12(4):375-9.
  19. Verhaar J., Walenkamp G., Kester A., van Mameren H., van der Linden T. Lateral extensor release for tennis elbow. A prospective long-term follow-up study. J Bone Joint Surg Am 1993 Jul;75(7):1034-43.
  20. Baker C.L.,Jr. Arthroscopic versus open techniques for extensor tendinosis
    of the elbow.
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