Table of Contents
- Case Overview
- Statement of Consent
Lateral epicondylitis (LE), commonly referred to as “tennis elbow,” is a common condition of the extensor tendons of the forearm that can lead to pain along the lateral epicondyle with radiation into the forearm, decreased grip strength, and difficulty lifting objects. When LE symptoms progress and can no longer be managed with non-operative measures, LE debridement may be indicated. The approach presented here is an open debridement of the extensor carpi radialis brevis (ECRB) tendon origin. A 3–4-cm longitudinal incision was placed longitudinally over the lateral epicondyle, radial head, and capitellum. The ECRB was exposed then debrided, the lateral epicondyle was decorticated, the lateral collateral ligament was repaired, the wound was closed in layers, and a soft dressing and splint were placed.
Lateral epicondylitis (LE), commonly referred to as “tennis elbow,” is a common condition of the extensor tendons of the forearm, which allows the pronated hand to extend at the wrist.1 This condition affects 1–3% of the population each year and is typically seen in adults.2 LE results in symptoms such as pain over the lateral elbow that extends down the forearm, weakened grip, and difficulty lifting objects.3 The site of the pain is typically the extensor carpi radialis brevis (ECRB) tendon origin. Although commonly associated with activities such as racket sports, golf, and baseball due to repetitive wrist movements that irritate and inflame the elbow, the exact etiology is likely multifactorial with risk factors including patients’ age, gender, previous injuries, and medical comorbidities such as metabolic disorders.3, 4 The majority of LE cases can be treated non-operatively with resting, bracing, therapeutic exercises, medications, and corticosteroid injections. When LE symptoms progress and non-operative measures are no longer helpful, surgery can be indicated. The technique being presented here is the open lateral epicondyle debridement of the ECRB tendon origin.
A 44-year-old right-hand-dominant female presents with six months of right elbow pain localized to the outside of the elbow with radiation down her forearm. She works as a mechanic and enjoys playing golf and tennis on the weekends but cannot think of any traumatic event that may have caused the pain. The pain has progressively gotten worse and has begun to affect her ability to grip and lift objects. She has no associated numbness or tingling. She has tried taking Advil and Tylenol as well as placing ice over the elbow; however, she has had minimal pain relief. Additionally, she tried a wrist brace and physical therapy prescribed by her primary physician, but these have also not helped.
Examination of the patient’s right elbow does not show any acute deformity, asymmetry, or signs of trauma. She has tenderness to palpation along the lateral epicondyle. She has full range of motion and strength of the elbow and wrist, although pain is elicited with wrist supination and extension, particularly against resistance.
History and physical exam are typically sufficient to diagnose LE; however, imaging may be warranted. Radiographs are generally the first-line imaging to rule out any traumatic or degenerative etiologies of elbow pain, and calcifications along the lateral epicondyle in cases of LE may be seen. Ultrasound (US) may also be used to evaluate LE. Some findings on US include calcifications and focal lesions within the tendon. MRI has also been used but is not necessary for diagnosis but may be helpful for preoperative planning and/or to assess associated lateral collateral ligament (LCL) dysfunction.4
The first-line treatment for LE is activity modification with rest with ice and non-steroidal anti-inflammatory medications (NSAIDs) for pain. Splints may also be used and are placed at either the wrist to keep the wrist or the proximal forearm in the form of a counterforce strap. Therapy is widely recommended and includes manipulation, massage, strengthening, and stretching protocols. Ultrasound, phonophoresis, iontophoresis, and shockwave therapy may be used in conjunction with therapy. Up to three corticosteroid injections may be given for recurrent symptoms.4
Surgery is recommended if the patient fails conservative treatment after 6–12 months. Special consideration must be given if there is suspicion of non-compliance with non-surgical management as this is a contraindication. The main operative options include release and debridement of the ECRB tendon origin.
LE debridement surgery is indicated for patients with prolonged symptoms that fail to improve after non-surgical management. History and physical are typically sufficient to indicate a patient for surgery.
Debridement of the ECRB origin was first described by Nirschl and Pettrone in 1979. The ECRB tendon was incised with debridement of fibrous or necrotic tissue at the origin followed by inspection of the lateral aspect of the joint and decortication of the lateral epicondyle. Only the extensor carpi radialis longus (ECRL) origin was repaired.5
The patient is positioned in the supine position with the affected arm adducted, elbow flexed, and forearm across the chest. The patient is draped, and a sterile tourniquet is applied. Local anesthetic is injected into the incision site and into the deep structures. Prior to incision, the tourniquet may be inflated if desired.
The incision is marked out by identifying the lateral epicondyle, radial head, and capitellum. A 3–4-cm incision is made along the anterior border of these structures.
Following the incision, any superficial bleeding is cauterized. Blunt dissection is performed down to the level of the fascia, and the extensor origin is identified. The fascia is then incised along the interval between the ECRL and extensor digitorum communis (EDC) to expose the ECRB. The incision is elongated to expose the ECRB origin. The top of the capitellum and the top of the radial head may be used as landmarks.
Once the ECRB origin is exposed, in many cases, such as in this video, the ECRB may already be detached from the lateral epicondyle. The ECRB origin may then be excised and debrided off the lateral epicondyle. The tissue quality will confirm a compromised state known as angiofibroblastic hyperplasia. A lateral arthrotomy of the joint capsule is recommended to confirm complete debridement. This must be done with care as to not disrupt the posterior ligamentous structures. Proximal debridement should proceed until only the muscular origin of the extensor mass and brachioradialis are in contact with the bone. Final debridement of the ECRB origin is completed with decortication of the lateral epicondyle extensor mass origin down to bleeding bone with a rongeur.
Following decortication, the LCL is examined. If the LCL origin is damaged or incompetent, it can be repaired with a suture anchor at the LCL origin. In this video, a #2 non-absorbable braided suture anchor with locking Krackow-style stitch is used to repair the LCL back to its origin. The stitch is run distally and posteriorly towards the ulna and back anteriorly and proximally towards the epicondyle. A simple stitch is then placed in the lateral soft tissue complex. The stitches are then tied down, leaving the two suture ends uncut. The suture ends are then run through the anterior tendinous interval for later closure to reinforce the LCL repair.
The wound and joint are washed out with normal saline, and the deep tendinous interval is closed with multiple absorbable sutures. The two limbs of the braided non-absorbable suture anchor are then tied in a pants-over-vest manner over the deep tendons. Next an interrupted subcutaneous closure is performed with absorbable sutures followed by a running subcuticular closure. Dressings are then applied followed by a posterior splint applied with the elbow at 90 degrees of flexion with slight wrist extension and pronation.
The postoperative splint is worn and kept on and dry for 1–2 weeks until the first postoperative visit. Supervised therapy is initiated at 2–4 weeks postoperatively.
Outcomes after LE debridement are typically positive. Pain relief has been reported to range from 83–98%.4
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.”
- Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007 Sep 15;76(6):843-8.
- Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med. 2003 Oct;22(4):813-36. doi:10.1016/s0278-5919(03)00051-6.
- Park HB, Gwark JY, Im JH, Na JB. Factors associated with lateral epicondylitis of the elbow. Orthop J Sports Med. 2021 May 13;9(5). doi:10.1177/23259671211007734.
- Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am. 2007 Oct;32(8):1271-9. doi:10.1016/j.jhsa.2007.07.019.
- Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep;61(6A):832-9.
Cite this article
Sobol KR, Ilyas AM. Lateral epicondylitis debridement. J Med Insight. 2023;2023(332). doi:10.24296/jomi/332.
Table of Contents
- 1. Patient Preparation
- 2. Incision
- 3. Exposure of Extensor Origin
- 4. Develop Interval Between ECRL and EDC to Expose ECRB Origin
- 5. Debridement of ECRB Origin off the Lateral Epicondyle Origin
- 6. Examination of LCL Complex Origin
- 7. LCL Origin Repair with Suture Anchor and Locking Krackow-Style Stitch Configuration
- 8. Closure
- Mark Incision
- Injection of Local Anesthesia
- Confirmation of Complete Debridement and Lateral Elbow Arthrotomy
- Decortication of Lateral Epicondyle Extensor Mass Origin
- Close Deep Tendinous Interval
- Pants-Over-Vest Closure of Suture Anchor Limbs to Reinforce LCL Complex Repair
- Post-op Remarks
With the operative limb prepped and draped and a sterile tourniquet applied, the incision's marked out, first by identifying the lateral epicondyle, then the radial head, and then the capitellum. The incision is placed along the anterior border of these structures.
The surgical site is then infiltrated with a local anesthetic. My preferred anesthetic is 0.5% bupivacaine with epinephrine. It's injected both in the incision site as well as deep.
If desired, the limb is exsanguinated, and the tourniquet is inflated. The incision is then placed. Superficial bleeders are cauterized.
Blunt dissection is then performed down to the level of the fascia where the extensor origin can be identified.
With the extensor origin exposed, ideally, the interval between the ECRL and the EDC is developed to approach the ECRB, which will be deep to it. It can be difficult to identify, so a landmark that can be used as a proxy is the top of the capitellum and the top of the radial head. That tendinous interval is then split and then raised proximally and distally, in order to identify the ECRB origin. With the interval between the ECRL and EDC developed, the ECRL is elevated. And deep to it, the ECRB origin will be identified. It is often detached from its origin at the lateral epicondyle, as shown here with the freer, and should be superficial to the joint capsule.
Once identified, the ECRB origin can be sharply excised, or debrided, off of the lateral epicondyle origin. Upon removal and inspection of the tissue, its quality will confirm a compromised state, often referred to as angiofibroblastic hyperplasia.
To confirm complete debridement of the ECRB origin, the interval can be extended proximally and distally. A concomitant release of the lateral joint capsule with a formal arthrotomy is recommended to confirm complete debridement. However, dissection should not be taken aggressively posteriorly again as to not compromise the lateral collateral ligament origin, although that will also be assessed later. Debridement is recommended to proceed proximally until only the muscular origin of the extensor mass and brachioradialis is in contact with the bone.
Finally, the debridement of the ECRB origin is completed by a decortication of the lateral epicondyle extensor mass origin, down to bleeding bone. The origin will then be repaired back down and the interval closed back down on this bleeding surface to enhance healing.
Finally, the lateral collateral ligament complex origin is identified and examined. Tears are often present. These degenerative tears often cause pain but do not cause instability. The LCL origin can be assessed by carefully elevating the tissue off of the lateral aspect of the capitellum and epicondyle with a blunt instrument like a freer. If it raises off readily, the origin is compromised.
If the LCL origin is confirmed, compromised and warrants repair, the LCL origin can be repaired with either a suture anchor or bone tunnels. In this illustration, a suture anchor is placed at the footprint of the LCL origin with a number 2 non-absorbable braided suture emanating from the anchor. With the anchor in position, a locking, Krackow-Style stitch is run distally and posteriorly towards the ulna and then back anteriorly and proximally towards the epicondyle. This repair, once tensioned is meant to serve as a hammock for the radial head and tension the lateral soft tissues proximally and anteriorly once sewn. Once the leading limb of the suture has been run distal and proximal as shown, the second limb is then also run in a simple fashion through the lateral soft tissue complex, resulting in the suture configuration shown here. Once satisfied, the lateral soft tissue and lateral collateral ligament complex is then sewn down with the knob placed over the soft tissue complex, but the limb ends are not cut. The two limb ends that are not cut are then run through the anterior tendinous interval for a later pants-over-vest closure to reinforce the lateral collateral complex ligamentous repair.
Once satisfied with the ECRB origin debridement, lateral elbow capsulotomy, decortication of the lateral epicondyle, and evaluation and repair of the lateral collateral ligament complex if needed, closure is undertaken.
The wound and joint is first washed out thoroughly. The deep tendinous interval is closed with multiple absorbable figure-of-eight sutures. In this case, an 0 Vicryl is being used.
Once the interval is closed, as discussed previously, the two limbs of the braided non-absorbable suture anchor limbs are then tied over top in a pants-over-vest fashion. Next, an interrupted subcutaneous closure using 3-0 Vicryl is performed. Next, a subcuticular closure is performed with a running 4-0 Monocryl suture.
Lastly, a dressing is applied followed by a posterior splint. The splint is applied with the elbow in 90 degrees of flexion, slight forearm pronation, and wrist extension, to be worn for 1 to 2 weeks prior to initiating therapy. Thank you.