What is the best treatment approach for a patient with refractory elbow tendinitis?

Treatment of Refractory Elbow Tendinitis

For refractory elbow tendinitis that has failed 3-6 months of conservative therapy, surgical débridement with excision of abnormal tendon tissue and longitudinal tenotomies is the definitive treatment, with success rates demonstrating significant pain reduction and functional improvement. 1, 2

Defining Refractory Disease

Refractory elbow tendinitis is defined as persistent symptoms despite 3-6 months of well-managed conservative treatment. 1, 3 At this point, the pathology has typically progressed to angiofibroblastic tendinosis rather than acute inflammation, characterized by collagen disorientation and fiber separation rather than inflammatory changes. 4, 5

Conservative Management Prerequisites

Before considering surgical intervention, ensure the patient has completed an adequate trial of:

• Relative rest with activity modification to reduce repetitive loading while preventing muscle atrophy 1
• Eccentric strengthening exercises to stimulate collagen production and guide proper fiber alignment 1
• NSAIDs (topical preferred) for pain control, though these provide only short-term benefit 1, 6
• Corticosteroid injections may provide acute relief but do not alter long-term outcomes and should be used cautiously as they may inhibit healing and reduce tensile strength, predisposing to rupture 4, 1
• Tennis elbow bracing to unload the tendon during activities 1

The critical caveat here is that approximately 80% of patients recover with conservative treatment alone within 3-6 months, so patience is warranted before proceeding to surgery. 1

Surgical Intervention for Refractory Cases

Indications for Surgery

Surgical evaluation is warranted when pain persists despite 3-6 months of comprehensive conservative management. 4, 1 Surgery is required in less than 10% of cases overall. 3

Surgical Technique

The procedure involves:

• Excision of abnormal tendon tissue with thorough débridement of angiofibroblastic areas 4, 1
• Longitudinal tenotomies to release scarring and fibrosis 4, 1
• Restoration of the tendon origin using suture anchors when significant tearing is present 2

For medial epicondylitis specifically, a key diagnostic finding is pronation weakness at 90 degrees, which reliably indicates clinically significant pathologic changes requiring surgical intervention. 2

Expected Outcomes

Surgery is highly effective in carefully selected patients. In a large surgical series, the Mayo Elbow Performance Score increased significantly from 58 preoperatively to 88 postoperatively, with pain scores decreasing from 2.2 to 0.6. 2 However, recovery still requires 3-6 months postoperatively with aggressive rehabilitation emphasizing early motion. 3, 2

Modalities of Uncertain or Limited Benefit

Several treatments have been proposed but lack strong evidence for refractory cases:

• Extracorporeal shock wave therapy (ESWT) appears safe but requires further research to clarify optimal treatment strategies 4, 1, and some evidence suggests it is not effective 6
• Therapeutic ultrasonography has weak evidence for consistent benefit 4, 1
• Iontophoresis may provide short-term benefits but lacks well-designed trials 1, 6
• Laser treatment and electromagnetic field therapy do not appear effective 6

Critical Diagnostic Considerations

When evaluating for surgical candidacy:

• MRI or ultrasound should be obtained to confirm the diagnosis and extent of tendon pathology, with MRI showing high reliability for epicondylalgia diagnosis 1
• Lateral epicondylosis is 7-10 times more common than medial epicondylosis and affects the dominant arm 75% of the time 1
• Physical examination reveals well-localized tenderness that reproduces activity-related pain 4, 1
• Consider ulnar neuritis evaluation in medial epicondylitis cases, as 20% may require concurrent nerve decompression 2

Common Pitfalls

The most significant pitfall is premature surgical intervention before completing an adequate 3-6 month conservative trial, as most patients will recover without surgery. 1, 3 Conversely, delaying surgery beyond 6 months of failed conservative care unnecessarily prolongs disability in the minority who truly require operative management. 4, 1