What is the recommended operative treatment for a 30-50 year old adult patient with tennis elbow who has not responded to conservative treatments such as physical therapy, bracing, and pain management with medications like ibuprofen (nonsteroidal anti-inflammatory drug) or naproxen (nonsteroidal anti-inflammatory drug) for at least 6-12 months?

Operative Treatment of Tennis Elbow

For patients with tennis elbow who have failed 6-12 months of conservative treatment, surgical intervention is warranted and typically involves excision of abnormal tendon tissue with longitudinal tenotomies to release areas of scarring and fibrosis. 1

When to Consider Surgery

Surgery should be reserved for carefully selected patients who have persistent pain despite a well-managed conservative treatment trial of at least 6-12 months. 2, 1 The key indication is failure of comprehensive nonoperative management including:

• Relative rest and activity modification 1
• Eccentric strengthening exercises 1
• NSAIDs (oral or topical) 1
• Corticosteroid injections 1
• Physical therapy with stretching and deep friction massage 1
• Counterforce bracing 1

Referral to an orthopedic surgeon for surgical evaluation is appropriate when pain persists despite these measures. 2, 1

Surgical Techniques

Standard Surgical Approach

The primary surgical technique involves:

• Excision of abnormal, degenerative tendon tissue 2, 1
• Longitudinal tenotomies to release areas of scarring and fibrosis 2, 1

Alternative Surgical Options

Percutaneous release using an 18-gauge hypodermic needle is a simple, safe, patient-friendly option that can be performed as an outpatient procedure. 3 This technique achieved excellent outcomes in 48% of patients and good outcomes in 36% of patients who were resistant to conservative treatment. 3

Arthroscopic debridement is another effective option for refractory cases, though it is not superior to open or percutaneous techniques. 4 Recent evidence shows that reduction in MRI signal intensity correlates with pain reduction and functional improvement after arthroscopic treatment. 4

Minimal incision technique provides low complication rates with high patient satisfaction, improving mean VAS scores from 7.2 to 3.5 points and PRTEE scores from 68.7 to 15.8 points. 5

Expected Outcomes

Surgery is effective for patients who have failed conservative therapy. 2 Studies show:

• Time to achieve a pain-free elbow ranges from 1 day to 2 months (average 26.2 days) after percutaneous release 3
• Good to excellent outcomes in the majority of surgical patients 5
• Patients who do not respond to conservative measures are reliably relieved of symptoms by surgery 6

Critical Caveats

Important consideration: Tennis elbow is self-limiting in approximately 80% of cases, with a 50% probability of recovery every 3-4 months regardless of symptom duration. 7, 4 This benign natural history challenges the traditional belief that failed conservative care automatically indicates surgery. 7

The mechanism of surgical healing promotion is not entirely understood, but surgery remains an effective treatment option when appropriately selected. 2

Avoid premature surgical intervention - ensure a full 6-12 months of comprehensive conservative management has been attempted before proceeding to surgery. 1 The condition's self-limiting nature means many patients will improve with continued nonoperative care or even no treatment. 7