Successful Surgery For Difficult Cases of Tennis Elbow
Tennis elbow has been around for a long time -- and not just in tennis players. The typical patient with chronic tennis elbow is between 30 and 60 (most often around 50 years old) and involved in heavy lifting or repetitive work. The dominant arm is usually the painful one and it's been going on for months without relief. That's true even for the folks who get some kind of treatment for the problem.
In this study, a group of surgeons from Canada show how measurable results can be obtained with surgery for chronic lateral epicondylitis (the medical term for tennis elbow along the outside of the elbow). They performed an arthroscopic release of thecarpi radialis brevis (ECRB) tendon to reduce pain and improve elbow motion, function, and strength.
The extensor carpi radialis muscle and tendon unit extend the wrist (move the hand toward the face) when the palm is facing down. It inserts along the lateral (outside) epicondyle of the humerus (lower part of the upper arm bone). It travels down the middle of the forearm as a flat tendon and then connects at the wrist.
Other studies have reported on case series of patients treated surgically for tennis elbow. But this study is different because a group of 36 patients were included (not just isolated cases or half a dozen cases). Data on each patient was collected. Before and after valid and standardized functional tests were performed to measure outcomes.
The patients all had lateral tennis elbow that lasted more than a year despite conservative (nonoperative) care. Most of them (but not all) were workers involved in jobs with high occupational demands (repeated actions) and/or on worker's compensation.
Several assessment tools were used to measure results. These included the Patient-Rated Tennis Elbow Evaluation (PRTEE), the American Shoulder and Elbow Surgeons Elbow (ASIS-e), the Short Form-12 (SF-12), and the Work Limitations Questionnaire (WL-26).
The PRTEE and ASIS both measure pain and function. The SF-12 measures general health (physical and mental) for a sense of the patient's well-being. The Work Limitations Questionnaire assesses five areas of function including mental, physical, social, scheduling, and work demands. This test helps show if the patient has trouble doing the job and gives some idea of how much of the day they are compromised (all day, half-day, one-third of the day).
Other tests measured grip and forearm strength, motion, and the patient's sense of their own prognosis (expect to get better, much better, be cured completely, get worse, or stay the same). Computer analysis was used to evaluate the patients in a variety of ways and look for subgroups that might respond differently from other patients.
The surgeon reported on what was found at the time of the procedure. The presence of inflammation, fraying of the tendon, and tendon tears or ruptures were recorded and described. The patients weren't restricted in any way after surgery. They could move the hand, wrist, and forearm as tolerated (within a comfortable range of motion). Daily activities were gradually added over the next few days to weeks. No heavy lifting or repetitive motions were allowed for six weeks.
The results were pretty good. Thirty of the 36 patients were improved with the surgery. Pain was less, grip strength was stronger, and function was improved. One-third of the group was completely better with no symptoms at all after recovery. It was clear that the patients with high workplace demands involving heavy lifting or repetitive motion had the poorest results. The same was true for those who had active worker's compensation claims.
They also found that patients who got temporary relief from their pain before surgery with cortisone shots seemed to do better after surgery when compared with those who got the injections but no relief. Some things didn't seem to make a difference, like age, how long the symptoms had been present before surgery, or what the lesion looked like.
Returning to full-time work at the level required by the job wasn't in the cards for some patients. Only two of the patients required to engage in heavy labor could do it. Most of the patients who made it back to work either changed their workload or changed their jobs. Several patients ended up retiring after surgery.
Workers on worker's compensation benefits took twice as long to return to work as those who were not on any benefits. And their final results weren't as good as the other workers. With all workers they found that those who didn't think they would make it back to work were less likely to have a successful return to work. They had more physical and mental limitations all around.
The authors conclude that their study shows the benefit of arthroscopic release of the extensor carpi radialis brevis tendon for cases of work-related chronic tennis elbow. The patients selected for this procedure made up a challenging subgroup of workers who were engaged in heavy work demands and who had not gotten relief from their symptoms with prior treatment.
The two ways this study was different from other studies was in the fact that a specific surgical technique was studied and specific outcomes were assessed before and after using valid tools of measure.
Patients most likely to respond to this type of surgery include those who had a favorable response to steroid injections, patients with less physically demanding jobs, and those who were not involved in a worker's compensation claim. Limitations in work performance can be expected for those involved in heavy labor or jobs requiring repetitive motions.
The authors point out that mental and social aspects of the job should be taken into consideration. Patients seem fairly accurate in predicting their own outcomes. Whether that's because they really know themselves well or it's just a self-fulfilling prophecy remains the subject of future studies. It does suggest the importance of selecting patients carefully for surgery.
Ruby Grewal, MD, et al. Functional Outcome of Arthroscopic Extensor Carpi Radialis Brevis Tendon Release in Chronic Lateral Epicondylitis. In The Journal of Hand Surgery. May/June 2009. Vol. 34A. No. 5. Pp. 849-857.