Patients › Elbow
Tennis Elbow Release
Tennis elbow release surgery — for persistent pain despite physiotherapy and other conservative treatments.
Why this operation has been suggested¶
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Tennis elbow is wear-and-tear of the tendon on the outer side of your elbow. Most people improve without surgery. About 90% of people with untreated tennis elbow achieve symptom resolution at 1 year, and symptoms often settle within 12 to 18 months. So we usually try non-operative care first: activity change, physiotherapy or hand therapy, splinting, and injections. Surgery is considered when that has not given enough improvement.
Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your elbow, and arrange imaging where needed. Tennis elbow release involves releasing the damaged tendon from the bone on the outer side of your elbow. For the small percentage of people who do not respond to non-operative care, surgery provides near 90% satisfaction rates. The aim is to relieve your pain and restore function in your arm. We will discuss this with you as a shared decision.
Before the operation¶
Before your surgery, you will need to stop eating and drinking for seven hours. We ask for seven hours rather than six so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when. Bring a list of everything you take, including tablets, drops and creams. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. Imaging such as an X-ray, MRI or ultrasound may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist.
On the day¶
You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, who will go through your health and your medicines with you. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed.
When the operation is finished, you will wake up in the recovery area. Nurses will monitor you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and your recovery. Many people go home the same day. Before you leave, we will explain how to care for your elbow and what to expect over the coming days.
What the operation involves¶
Your surgeon performs a tennis elbow release through a single cut on the outer side of your elbow, over the bony bump you can feel there. The damaged part of the tendon is separated from that bone. This releases the tendon from its attachment, which is where the pain has been coming from. The worn, frayed tissue at the tendon's origin is cleaned away, and the surface of the bone beneath it is smoothed.
The cut is then closed with stitches. A dressing goes over the wound before you leave theatre.
The operation is done through this one incision rather than several small keyhole cuts. Your surgeon works directly on the tendon and bone, so the damaged area can be seen and treated in full.
After the operation¶
You will wake up in the recovery area with nurses nearby while the anaesthetic wears off. Your elbow will have a soft dressing over the wound, held in place with a bandage. You may feel some pain around the outer side of your elbow; tell the nurses, as they can give you medicine to keep you comfortable. You can move around soon after waking, and most people walk to the bathroom with help on the same day. Someone should stay with you for the first 24 hours after you get home. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.
Recovery¶
For the first few days your elbow will be sore and may look swollen around the outer side. This settles gradually. Keeping your hand raised when you are resting can ease the swelling, and simple pain medicine helps with the discomfort. Your dressing stays on until we see you, so you can shower as usual without touching the wound.
You will use your arm for light tasks at home almost straight away. You can dress yourself, eat and move around normally. Avoid heavy lifting, pushing up from chairs with that arm, and anything that strains the outer side of your elbow. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will guide your exercises and make a splint if you need one. The exercises keep your wrist and elbow moving and rebuild your grip strength step by step.
Sleeping can be awkward at first. Many people find it comfortable to rest with a pillow under or beside the arm.
Once the swelling settles and movement feels easier, you will notice your grip returning. When you can hold and squeeze without pain, everyday tasks feel normal again. Once your splint is off and you can grip the wheel and react quickly, driving is usually fine again. We have more detail at Driving after upper-limb surgery. Returning to work depends on what your job involves, and we will talk that through with you.
Everyone heals at their own pace. Your timeline may differ, and your surgeon and therapist will guide you along the way.
What can go wrong¶
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
Sometimes the body forms small patches of new bone where it should not, inside or around the elbow joint. This is called heterotopic ossification. You might notice a stiff, grating feeling when you bend or straighten your arm, or a sense that the elbow will not move as freely as it did. If movement feels blocked or the joint feels hard and swollen, bring it up at your next review.
A few people find their elbow does not bend or straighten through its full range afterwards. You may notice this when reaching for a high shelf or turning a door handle. Gentle, regular movement as guided by your therapist helps. If the tightness is not improving, mention it at your review so it can be assessed.
In some people the operation does not settle the pain the way we hoped. The outer side of the elbow keeps aching, or the pain returns after a period of relief. If that happens, we will reassess your elbow and talk through the options with you, which may include further surgery. Tell us early if the pain is not easing as expected.
Having several injections into the same elbow before surgery makes it more likely that further surgery will be needed later. If you have had injections elsewhere for this problem, let us know, as it helps us plan your care.
If you notice spreading redness around the wound, fluid leaking from it, a fever, or pain that keeps getting worse rather than easing, contact the clinic straight away. These signs need prompt attention.
The complications table on this page lists typical rates if you want the specifics.
When to call us¶
Call us straight away if you have a fever, spreading redness around the wound, fluid leaking from it, or pain that keeps getting worse rather than easing. Go to emergency if you have sudden severe pain, calf swelling or shortness of breath, or if you lose feeling in your hand or cannot move your arm. These signs need urgent assessment. If something feels wrong and you are not sure, call the clinic. We would rather hear about it early.
Where to read more about the condition¶
This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Tennis Elbow page.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology¶
- The pathologic tissue in tennis elbow involves the extensor carpi radialis brevis tendon [1].
- The origin of the extensor carpi radialis brevis is located on the lateral epicondyle [1].
- The lateral epicondylar ridge is an anatomical structure associated with the lateral epicondyle [1].
Investigations¶
History and Physical Examination¶
- History should include the duration of the elbow contracture, initial injury, previous surgical procedures, trials of splinting/therapy/injections, complications of surgery, and the patient’s work/life demands and goals [3].
- Physical examination should assess the function of the upper extremity (shoulder, wrist, and hand) [3].
- The soft tissue surrounding the elbow should be examined for previous skin incisions/grafts, eschar, or infection [3].
- Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [3].
- The contralateral elbow should be examined for comparison during range of motion assessment [3].
- If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [3].
- Pain should be assessed during the mid arc or at the terminal ends of motion [3].
- Mid arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [3].
- The ulnar nerve is of utmost importance due to its anatomic proximity to the elbow [3].
- The posterior bundle of the MCL forms the floor of the cubital tunnel along the course of the ulnar nerve [3].
- Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [3].
- An assessment for ulnar nerve subluxation should be performed [3].
- Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [3].
- If there is a history of prior surgical procedures, verify if the ulnar nerve has been transposed [3].
- The physical exam is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [5].
Imaging¶
- Radiographs should always be obtained for elbow evaluation [3].
- Standard radiographic views include AP, lateral, and oblique views [3].
- Serial radiography is used as follow-up when heterotopic ossification is present [3].
- Primary bony landmarks on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [3].
- CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [3].
- Three-dimensional CT is used to check for heterotopic ossification [3].
- CT is not necessary when the stiffness is entirely soft-tissue related [3].
- CT is beneficial if any joint incongruity or abnormal bony anatomy is present [3].
- MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [3].
- Plain radiographs remain the hallmark and the best screening test for elbow evaluation [5].
- CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes posteromedial olecranon osteophytes and loose bodies in valgus extension overload syndrome [6].
- MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [6].
- Radiographic evaluations are essential when diagnosing an osteochondritis dissecans (OCD) lesion of the elbow [7].
- Important aspects of OCD lesions may be better seen with MRI [7].
- Standard AP and lateral radiographs typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa in elbow osteoarthritis [8].
- In elbow osteoarthritis, joint spaces at the ulnohumeral joint usually are preserved, and those at the radiocapitellar joint are mildly narrowed [8].
- Radiographs typically underestimate the number of loose bodies present in elbow osteoarthritis [8].
- CT may be useful for surgical planning in elbow osteoarthritis by allowing a detailed assessment of osteophytes and the presence of loose bodies [8].
Treatment¶
Operative Technique¶
- The patient is placed prone on the operating table with two rolled towels longitudinally under the thorax [1].
- All bony prominences are padded well [1].
- The affected extremity is positioned with the ipsilateral shoulder abducted to 90 degrees and supported by a precut foam holder [1].
- The joint is distended with 20 to 30 mL of saline through an 18-gauge needle introduced through the direct lateral portal [1].
- The proximal medial or superomedial portal is located approximately 2 cm proximal to the medial epicondyle and 1 cm anterior to the intermuscular septum [1].
- The trocar and sheath are introduced anterior to the intermuscular septum while maintaining contact with the anterior aspect of the humerus [1].
- The trocar is directed toward the radial head [1].
- A 2.7-mm, 30-degree arthroscope is inserted into the joint to perform the diagnostic portion of the procedure [1].
- The superolateral portal is established with an 18-gauge needle through the lesion after pathologic tissue is identified [1].
- A full-radius resector is used to excise the capsule to identify the undersurface of the extensor carpi radialis brevis tendon [1].
- The origin of the extensor carpi radialis brevis is viewed [1].
- The capsule and pathologic tendinous attachment of the extensor carpi radialis brevis are debrided using a curet and motorized shaver [1].
- The lateral epicondyle is decorticated [1].
- Decortication of the lateral epicondyle and lateral epicondylar ridge can be performed with an arthroscopic burr, handheld instruments, or electrocautery [1].
- A 30-degree arthroscope is adequate to view around the corner for most of the procedure [1].
- A 70-degree arthroscope may be required in rare instances [1].
References¶
[1] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > ARTHROSCOPIC TENNIS ELBOW RELEASE.
[3] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.
[5] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.
[6] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.
[7] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.
[8] Aaos Comprehensive Orthopaedic Review 3. Arthritis and Arthroplasty of the Elbow > I. Osteoarthritis.