A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis

Lateral epicondylitis (tennis elbow) is a common occurrence in the general population with an incidence of 4-7/1000/year [1–3]. More recent literature describes a 1–3 % rate over the course of a lifetime, most typically affecting individuals between the ages of 35 and 50 [4]. Despite its name, this condition affects a wide variety of individuals, including politicians, municipal utility employees, cooks, meat industry employees as well as nonlabor workers. One study looking at the financial burden of elbow epicondylitis in Washington State from 1987 to 1995 found that it accounted for 11.7 % of work-related injury claims, costing $6,593 per case in average direct workers’ compensation [5].

Although tennis elbow can present acutely, the onset is often insidious secondary to repetitive wrist extension and alternating forearm pro-supination. Symptoms include lateral elbow pain and forearm weakness that is exacerbated by repetitive extension and/or rotation of the wrist. Grip strength is also typically diminished. Its natural history is often reported as 6–24 months, [6–8] with more than 80 % of cases achieving complete resolution at 1 year [9–11]. However, some studies report a full recovery rate as low as 34 % by 12 months [12].

Non-operative treatment consists mainly of activity modification, nonsteroidal antiinflammatory medications, physical therapy, counterforce bracing and corticosteroid injection [13]. Many authors recommend at least 6 months of non-operative management before considering operative intervention [14, 15]. Despite these measures, some patients will develop chronic symptoms refractory to conservative care.

Surgical indications for the management of lateral epicondylitis include persistent pain and failed adequate conservative management. The goals of surgery are to directly address that area of pathology through a procedure that involves resection of the involved tissue, to stimulate neovascularization and to produce a healthy scar while doing the least possible damage to surrounding tissues [16]. Current surgical options can be classified into open, percutaneous and arthroscopic, with arthroscopic tennis elbow release (ATER) having gained popularity over the past fifteen years with improved understanding of three-dimensional elbow anatomy and advances in arthroscopic procedures and equipment. When performed by experienced specialists, arthroscopic surgery allows for the assessment and debridement of concomitant intra-articular pathology such as synovitis, radiocapitellar plicae, osteochondral defects and intra-articular loose bodies that are often missed and can be a frequent cause of residual pain following extensor carpi radialis brevis (ECRB) release [17–20]. For example, in a retrospective review of 36 patients treated arthroscopically for tennis elbow, 28 % had significant intra-articular synovitis requiring debridement [21]. The rehabilitation process and time back to work following arthroscopic treatment is faster in comparison to the other surgical approaches and the outcomes are generally reported as equal or better [17, 19, 22, 23]. A recent retrospective cohort study on 341 consecutive patients comparing arthroscopic to open release demonstrated significant differences in Disability of the Shoulder and Hand (DASH) scores and total number of excellent outcomes between groups, favoring arthroscopy [24].

Despite the increased popularity of ATER in recent years, there have been no randomized-controlled trials evaluating its efficacy. A recent systematic review concluded that there is fair-quality evidence for elbow arthroscopy in the treatment of lateral epicondylitis (grade B recommendation) on the basis that outcomes appear to be similar to open surgery [25]. This recommendation is based on two cohort studies (Level III) and eight case series (Level IV) all reporting good to excellent results for arthroscopic surgery. However, a subsequent Cochrane review concluded that due to the small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for tennis elbow [26].

The arthroscopic approach to the treatment of lateral epicondylitis has been widely adopted in North America. However, no comparative studies have demonstrated its efficacy. In order to provide optimal care to patients and to justify the increased cost and utilization of resources required for this treatment, a high level of evidence study is essential. This study aims to elicit whether ATER is efficacious at treating chronic tennis elbow.