Tennis Elbow: When Is It Time to Consider Surgery?

Tennis elbow is one of the most common causes of pain on the outside of the elbow.

Despite its name, you do not need to play tennis to develop it. It commonly affects people whose work, sport or hobbies involve repetitive gripping and lifting.

The good news is that most cases improve without surgery. However, a small proportion of patients develop persistent symptoms despite appropriate treatment.

So when is it reasonable to consider an operation?

What is tennis elbow?

Tennis elbow, or lateral epicondylitis, is a condition affecting the tendons that attach the forearm muscles to the outside of the elbow.

The tendon most commonly involved is the extensor carpi radialis brevis (ECRB).

Although it is often described as “tendonitis”, persistent tennis elbow is usually better thought of as a degenerative tendinopathy. The tendon develops areas of abnormal and weakened tissue rather than simply being inflamed.

Typical symptoms include:

• Pain over the outside of the elbow
• Pain when gripping or lifting
• Pain opening jars or turning door handles
• Discomfort using tools
• Pain during gym exercises or racquet sports
• Reduced grip strength because of pain

For some people it is a minor nuisance. For others, even simple activities such as picking up a coffee cup can become uncomfortable.

How long does tennis elbow take to get better?

One of the frustrating features of tennis elbow is that it can take a long time to settle.

Symptoms often fluctuate. You may have several good weeks followed by another period of discomfort.

The important point is that tennis elbow has a strong tendency to improve over time, even if recovery is slow.

For this reason, surgery is rarely recommended when symptoms have only been present for a few months.

What should I try before surgery?

Treatment is generally aimed at managing symptoms while allowing the tendon time to recover.

This may include:

• Modifying activities that repeatedly aggravate the elbow
• Appropriate pain relief or anti-inflammatory medication
• Physiotherapy
• Progressive strengthening of the forearm muscles and tendons
• Adjustments to sporting or workplace technique
• A brace or forearm strap in selected patients

The aim is not necessarily to completely stop using the arm. Instead, we try to reduce excessive loads while progressively improving the tendon’s ability to tolerate activity.

What about injections?

Several different injections have been used to treat tennis elbow.

Cortisone

Corticosteroid injections can sometimes provide good short-term pain relief.

However, repeated cortisone injections are generally avoided because they do not necessarily improve the underlying tendon problem and may be associated with poorer longer-term outcomes.

PRP

Platelet-rich plasma, or PRP, involves injecting a preparation derived from your own blood into the affected tendon.

Some patients report improvement following PRP, but research results have been variable. It is therefore not a guaranteed solution and its role remains debated.

An injection is also not necessarily something you need to have before being considered for surgery.

When should surgery be considered?

There is no exact point at which everyone with tennis elbow should have an operation.

In general, surgery becomes reasonable when three things are present:

1. The diagnosis is correct.

2. Symptoms have persisted despite an adequate period of non-operative treatment.

3. The symptoms are significant enough to justify the recovery and risks associated with surgery.

Symptoms have been present for a long time

Most surgeons would consider surgery only after symptoms have persisted for approximately 6–12 months or longer.

This gives the condition a reasonable opportunity to improve without an operation.

Simply having pain for six months does not mean you need surgery. If symptoms are gradually improving and remain manageable, continuing non-operative treatment may be entirely appropriate.

You have tried appropriate rehabilitation

Before considering surgery, it is reasonable to have attempted a structured rehabilitation program.

This usually involves progressive strengthening rather than simply resting the elbow indefinitely.

If you have completed appropriate rehabilitation and remain significantly limited, surgery becomes a more reasonable option.

The pain is affecting your quality of life

Ultimately, the severity of your symptoms matters more than the appearance of a scan.

You may consider surgery if persistent elbow pain is preventing you from:

• Performing your job
• Playing sport
• Exercising
• Lifting or gripping normally
• Performing everyday activities without pain

The decision is therefore not simply “Do I have tennis elbow?”

The more useful question is:

“Is my tennis elbow affecting my life enough that I am prepared to undergo an operation and rehabilitation to improve it?”

Do I need an MRI?

Not everyone with tennis elbow requires an MRI.

The diagnosis can often be made from your history and examination.

Imaging becomes more useful when symptoms are persistent, the diagnosis is uncertain or surgery is being considered.

An ultrasound or MRI may demonstrate degeneration or tearing of the common extensor tendon.

However, scans need to be interpreted carefully. Tendon abnormalities can sometimes be present in people who have relatively few symptoms.

We therefore treat the patient, not simply the MRI scan.

Could something else be causing the pain?

Yes.

Pain around the outside of the elbow is not always tennis elbow.

Other potential causes include:

• Radial tunnel or nerve-related pain
• Arthritis within the elbow
• Ligament injuries
• Referred pain from the neck
• Other tendon or joint conditions

If symptoms have failed to improve despite prolonged treatment, it is particularly important to reconsider the diagnosis before proceeding with surgery.

What does tennis elbow surgery involve?

When surgery is required, the aim is to remove the abnormal portion of the tendon and stimulate healing.

A typical procedure involves debridement of the diseased portion of the common extensor tendon, particularly the ECRB tendon.

Depending on the extent of the tendon involvement and the surgical technique used, the tendon may then be repaired back to the bone.

The procedure can be performed using an open or arthroscopic technique.

The exact technique is less important than correctly identifying the source of the pain and appropriately treating the abnormal tendon.

What does recovery from surgery look like?

Recovery is gradual.

During the first few weeks, the priority is allowing the surgical site and tendon to begin healing while maintaining appropriate elbow movement.

Lifting is initially very restricted.

From approximately six weeks, strengthening and lifting can usually begin progressively, depending on the procedure performed.

Over the following months, strength and function gradually improve.

Patients should understand that full recovery is not expected immediately. It is reasonable to think of tennis elbow surgery as having a recovery period of approximately six months, particularly when returning to heavy work, gym activities or sport.

Is surgery always successful?

No operation can guarantee complete relief of pain.

However, appropriately selected patients with persistent, well-localised tennis elbow can achieve substantial improvement following surgery.

The key is patient selection.

Surgery is less likely to solve the problem if the pain is coming from another source, if symptoms are poorly localised or if the diagnosis is uncertain.

This is why surgery should generally be considered only after the diagnosis has been carefully confirmed and reasonable non-operative treatments have been exhausted.

The bottom line

Most people with tennis elbow do not need surgery.

The condition often improves with time, activity modification and appropriate rehabilitation, although this can take many months.

Surgery becomes reasonable when symptoms have persisted for 6–12 months or longer, the diagnosis is clear, appropriate non-operative treatment has failed, and pain continues to significantly interfere with work, sport or everyday life.

There is usually no urgency to operate.

The decision is ultimately about balancing how much the elbow is affecting you against the inconvenience, recovery and risks of surgery.

For the relatively small group of patients whose symptoms simply will not settle, surgical debridement and repair can provide a reliable option for returning to comfortable use of the arm.

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