Tennis elbow

Tennis elbow (lateral epicondylitis) is probably the commonest condition that is seen in the elbow. It is characterised by pain over the bony prominence on the outside of the elbow and is made worse by use of the arm, particularly in repetitive tasks, but even simple tasks such as picking up a mug or another item off a table often frequently aggravates the pain. It is generally caused by repetitive activities although in some cases can be caused by direct injury to the outside aspect of the elbow. The underlying injury is damage to the attachment of the tendons to the bone on the outer aspect of the elbow. The group of tendons involved are referred to as the extensor tendons which act to straighten the wrist and fingers. For most patients (80%) symptoms will settle within three or four months helped by a combination of rest, ice and anti-inflammatory medication although it is also common for patient's General Practitioners to have administered a steroid injection in the early stages.
Physiotherapy treatment is very important in tennis elbow which attempts to not only treat the swollen, painful tendon attachment but also change the mechanics of how the tendon acts to reduce pain and to prevent recurrence. Surgical aids such as an epicondylar clasp worn around the forearm below the elbow can also be helpful in controlling symptoms. It is important to reassure patients that in the majority of cases the pain from tennis elbow will settle within 12 months with non-operative measures, most importantly physiotherapy exercises
However, in a small proportion of patients the condition persists and is functionally quite disabling causing significant limitation in function. This is often when the patient gets referred to see an orthopaedic specialist who may organise a scan (ultrasound or MRI) as it may be important to exclude other rarer causes of elbow pain before proceeding with further treatment options.  Patients have had all the simple treatments and we would start to consider injections. Commonly steroid injections have been used in previous years but there is some evidence that a new generation of injections known as PRP, or platelet rich plasma injections, are more effective than steroid injections. Steroid injections may be occasionally helpful in an acute flare of symptoms to give temporary relief but there is a risk that steroid injections could weaken the tendon and ultimately increase the total duration of symptoms in the longer term. The other risks of steroid injections include dimpling of the skin or loss of skin pigmentation where the injection was performed. 

For a very small number of patients non-operative treatment, consisting of the above mentioned treatments, fails to improve their symptoms and surgery may then be indicated. At surgery a cut is made over the tendon attachment to the bone and the tendon attachment is raised off the bone with the damaged piece of tendon being removed. The back of the tendon is cleaned along with the bone attachment to create fresh surfaces to allow healing in a slightly different position which again alters the mechanics of the tendon origin. In over 75% of patients the operation will relieve their symptoms. The operation is performed under General Anaesthetic as a daycase procedure and the arm is rested in a sling for 2 weeks. Patients can normally return to driving after 2 weeks but will not be able to do manual work for a at least 6 weeks.
However, even with surgery about 20 to 25% of the patients will not expereince significant improvement in their symptoms. The risks of surgery include infection, haematoma (blood clot), need for further procedure and incomplete relief of symptoms.