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Tennis elbow or lateral humeral epicondylitis is considered to be an over-use phenomenon. It commonly occurs when someone over-works their arm usually with unaccustomed activity, such as excessive gardening (pruning), decorating or over-doing a lot of racquet sport. In some instances the technique or performing an activity may be the critical factor.
When the hand is resting palm down on the table, the muscles that lift the hand up at the wrist are called the extensors. They are very important muscles as they control and help position the hand in space to allow the gripping (flexor) muscles to actually do the activity. The extensors have an anchor point to the humerus, the upper arm, just above the elbow joint itself. This anchor point is more tendon-like in its nature rather than pure muscle and it is at this bone-tendon/muscle interface that the problem occurs that we call tennis elbow.
One of the theories is that repeated overuse results in minor tears occurring at that interface. If we ignore or fail to recognise the minor symptoms that appear and carry on with whatever we were doing then we run the risk of not allowing the minor tears to heal. Normally the body is pretty good at healing usually with scar tissue that over time strengthens up extremely well. For some unknown reason at the common extensor origin this process may fail to happen and only weak tissue is produced at the tears. This weak tissue is just that, it cannot take the stress of activity when loaded and the brain interprets this as pain. It was thought that this tissue was due to inflammation but this is not now thought to be the case, which is why the NSAIDS such as ibuprofen, do not work very well. Sometimes the pain is only felt when the arm is used but others can experience awful aching often at night.
Physiotherapy, using a brace and cortisone injections have been the main non-operative options, hoever a study has strongly suggested that whilst cortisone injections may give good pain relief, they do not last and that they may delay the overall resolution of the condition. This happens because the injection allows the individual to perpetuate the activity that may have been the cause of the tennis elbow in the first place. Thus it is critical for an individual who develops tennis elbow to look very carefully at their activities to see if technique is a factor. Long term recovery of the symptoms may be achieved quicker by a period of controlled use with physiotherapy and bracing. Other treatments potenially available include shock wave therapy, dry needling or platelet-rich plasma injection have been trialled but the results are equivocal. The vast majority of patients with tennis elbow can be managed non-operatively but the final solution is surgery.
The overall aim of surgery is to relieve pain and recover function, but the technical aim is to re-establish a sound anchor point for those extensor muscles. The operation is performed as a day-case either under general or regional anaesthetic (arm block). My plan is to lift off the muscle/tendon attachment to the bone, remove the area of abnormal, weak tissue and then try and make that exposed bone bleed by cutting off its outer edge (known as the cortex). This all sounds rather dramatic but when you realise that the actual diameter of bone I am going to affect is about 1.5 centimetres it doesn't seem so bad. After I have made the bone bleed I will stitch the tendon back into its normal place, suture the skin, dress the wound and splint the elbow at 90 degrees with a slab of plaster of paris or fibrecast material.
Blood is the catalyst for healing so I hope that by making the bone bleed I encourage a normal healing process to occur. I believe that it takes time for this to happen and mature so I deliberately try and slow you down for three weeks. I used to wrap the whole elbow, wrist and hand in the bandage but now I leave the wrist and hand free - this does not mean that you can find an excuse to decorate the bedroom! During that first three weeks it is absolutely critical that you avoid going into pain as if you do you may alter the attempt to heal normally. At the end of that time exercises are started ideally under the supervision of a physiotherapist.
An individual's capacity to heal and recover is obviously very dependent on that individual. In general I expect 80% of my patients to have recovered 80% of their strength and stamina by 3 months post-surgery. If you are a keen racquet sports person I recommend you plan to have that 3 months away from your sport. It may be possible to return to golf a little earlier depending on the speed of recovery.
