Surgery for lateral elbow pain
Editorial Group: Cochrane Musculoskeletal Group
Published Online: 16 MAR 2011
Assessed as up-to-date: 12 DEC 2010
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Buchbinder R, Johnston RV, Barnsley L, Assendelft WJJ, Bell SN, Smidt N. Surgery for lateral elbow pain. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD003525. DOI: 10.1002/14651858.CD003525.pub2.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 16 MAR 2011
Surgery is sometimes recommended for persistent lateral elbow pain where other less invasive interventions have failed.
To determine the benefits and safety of surgery for lateral elbow pain.
We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science unrestricted by date or language (to 15 December 2010).
Randomised and controlled clinical trials assessing a surgical intervention compared with no treatment or another intervention including an alternate surgical intervention, in adults with lateral elbow pain.
Data collection and analysis
Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.
We included five trials involving 191 participants with persistent symptoms of at least five months duration and failed conservative treatment. Three trials compared two different surgical procedures and two trials compared surgery to a non-surgical treatment. All trials were highly susceptible to bias. Meta-analysis was precluded due to differing comparator groups and outcome measures. One trial (24 participants) reported no difference between open extensor carpi radialis brevis (ECRB) surgery and radiofrequency microtenotomy, although reanalysis found that pain was significantly lower in the latter group at three weeks (MD -2.80 points on 10 point scale, 95% CI -5.07 to -0.53). One trial (26 participants) reported no difference between open ECRB surgery and decompression of the posterior interosseous nerve in terms of the number of participants with improvement in pain pain on activity, or tenderness on palpation after an average of 31 months following surgery. One trial (45 participants) found that compared with open release of the ERCB muscle, percutaneous release resulted in slightly better function. One trial (40 participants) found comparable results between open surgical release of the ECRB and botulinum toxin injection at two years, although we could not extract any data for this review. One trial (56 participants) found that extracorporeal shock wave therapy (ESWT) improved pain at night compared with percutaneous tenotomy at 12 months (MD 5 points on 100 point VAS, 95% CI 1.12 to 8.88), but there were no differences in pain at rest or pain on applying pressure.
Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. Further well-designed randomised controlled trials and development of standard outcome measures are needed.
Plain language summary
Surgery for elbow pain (tennis elbow)
This summary of a Cochrane review presents what we know from research about the effect of surgery for lateral elbow pain, also known as tennis elbow. The review shows the following.
In people with lateral elbow pain:
- percutaneous (smaller incision) surgery may slightly improve the ability to use your arm normally, compared with open surgery (in people who have had pain for a year or more and have failed to improve with non-surgical treatments);
- radiofrequency microtenotomy applied to the affected tendon probably results in quicker pain improvement in the short term but results are the same in the long term when compared with open surgery;
- there was not enough information in the included studies to tell if surgery would make a difference in quality of life compared with not having surgery or compared with non-surgical treatments.
There was no information about side effects in the included studies. Side effects of surgery may include infection, nerve damage, or loss of ability to straighten the arm.
What is lateral elbow pain and what is surgery?
Lateral elbow pain, or tennis elbow, can occur for no reason or be caused by too much stress on the tendon at the elbow. It can cause the outside of the elbow (lateral epicondyle) and the upper forearm to become painful and tender to touch. Pain can last for six months to two years, and may get better on its own. Many treatments have been used to treat elbow pain but it is not clear whether these treatments work or if the pain simply goes away on its own.
If the pain does not go away by itself or with various treatments like steroid injections or physiotherapy or both, surgery can be performed. Surgery on your elbow can include making a small cut in the arm and trimming damaged tissue from the tendon that joins the extensor carpi radialis brevis (ECRB) to the bone in the elbow (called an ECRB tenotomy), or releasing the tendon from the bone with a scalpel (called an ECRB release). The tenotomy may be done 'percutaneously', with a much smaller (1 cm) incision in the skin, or arthroscopically from within the joint. The ECRB tendon can also be detensioned further down in the mid-forearm with a Z lengthening tenotomy. Another type of surgery that doesn't directly treat the ECRB tendon involves releasing the posterior interosseous nerve (PIN) that might be being compressed by the muscle (PIN decompression).
Best estimate of what happens to people with lateral elbow pain who have surgery
Pain (higher scores mean worse or more severe pain):
- people who had percutaneous (smaller incision) surgery with radio waves applied to the sore part of the elbow (radiofrequency microtenotomy) compared with open surgery (larger incision) rated their pain to be 3 points lower on a scale of 0 to 10 after 3 weeks (28% absolute improvement);
- people who had percutaneous surgery rated their pain to be 3.5 on a scale of 0 to 10 after 3 weeks;
- people who had open surgery rated their pain to be 6.5 on a scale of 0 to 10.
Physical function and disabilty (higher scores mean worse physical function or more disability):
- people who had percutaneous (smaller incision) surgery compared with open surgery (larger incision) rated their disability to be 4 points lower on a scale of 0 to 100 after 12 months (4% absolute improvement);
- people who had percutaneous surgery rated their disability to be 49 on a scale of 0 to 100;
- people who had open surgery rated their disability to be 53 on a scale of 0 to 100.