Anatomy of the Elbow

The elbow is made up of three joints within a single capsule: the hinge joint between the humerus and the ulna (humeroulnar), the joint between the humerus and the radial head (radiocapitellar), and the joint between the upper ends of the two forearm bones (proximal radioulnar). Together they allow the elbow to bend and straighten and the forearm to rotate.

Three major nerves run around the joint: the radial nerve and its posterior interosseous branch in front and to the outside, the median nerve in front and to the inside, and the ulnar nerve behind and to the inside. These nerves lie only a few millimetres from the joint capsule. The safety of elbow arthroscopy depends on placing the portals correctly in relation to these nerves and on distending the joint with fluid to push them away from the capsule.

The extensor muscles of the forearm and wrist attach to the bony prominence on the outer side of the elbow (the lateral epicondyle). The origin of the extensor carpi radialis brevis (ECRB) tendon is where the damage of tennis elbow occurs.

Indication 1 — Articular Cartilage Damage and Elbow Arthritis

Cartilage damage and arthritis are less common in the elbow than in the knee and hip, but they occur in heavy manual workers, throwing athletes (baseball, javelin, handball), after elbow fractures and dislocations, and in people who had osteochondritis dissecans at a young age.

• Primary elbow osteoarthritis: Typically in middle-aged men who use their arms heavily; bony spurs (osteophytes) are more prominent than cartilage loss. Osteophytes on the olecranon and coronoid mechanically block full straightening and bending
• Post-traumatic arthritis: Due to joint-surface incongruity after a fracture or dislocation
• Osteochondritis dissecans (OCD) of the capitellum: Particularly in gymnasts and throwers aged 12 - 16; loosening of a cartilage-bone fragment on the capitellum
• Valgus extension overload: Osteophytes and cartilage damage on the back-inner olecranon in throwing athletes
• Loose bodies: Detached cartilage or bone fragments causing locking and catching
• Synovitis and adhesions: From inflammatory disease or after trauma

Indication 2 — Tennis Elbow (Lateral Epicondylitis)

Despite its name, tennis elbow is unrelated to tennis in most patients. It affects about 1 - 3% of the general population, most often between the ages of 35 and 55, in the dominant arm. It is fundamentally not an inflammation but a degenerative tendon disorder (tendinosis) at the ECRB origin caused by repetitive strain: microscopic tears, disorganised collagen and a failed healing response.

The condition is largely self-limiting: about 80 - 90% of patients improve markedly within a year without surgery. Surgery is for the small group whose pain continues to affect daily life and work despite 6 - 12 months of consistent, correctly applied non-operative treatment.

• Repetitive gripping and wrist extension: Using a computer mouse, screwdriver or hammer, carrying heavy bags, working with hand tools
• Racquet sports: Particularly faulty backhand technique, an unsuitable grip size or string tension
• Occupational risk: Butchers, carpenters, painters, plumbers, heavy computer users
• Smoking and obesity: Impair tendon healing and increase the risk
• Diabetes and certain medications (fluoroquinolones): Impair tendon quality

Symptoms

• Cartilage damage and arthritis: Pain at the end of the range when fully straightening or bending the elbow (end-range pain)
• Loss of movement: Particularly inability to straighten the elbow fully; patients often do not notice a few degrees of loss until it progresses and affects daily tasks
• Catching, locking and clicking: With loose bodies
• Morning stiffness and swelling after activity
• Tennis elbow: Pain localised to the outer elbow, just in front of and below the bony prominence
• Tennis elbow: Pain with gripping, shaking hands, lifting a cup, turning a door handle or carrying a bag with the palm down
• Tennis elbow: Reduced grip strength; some patients drop objects
• Pain radiating along the outer forearm
• Ulnar nerve involvement (common with arthritis): Numbness and tingling in the ring and little fingers

Diagnosis

The diagnosis is based on a detailed history, examination and imaging. Occupational and sporting use, previous injuries, previous injections and treatments are reviewed.

Elbow range of movement is measured and compared with the other side, end-range pain is checked, and tender points around the joint are identified. In tennis elbow, pinpoint tenderness just in front of the lateral epicondyle and pain on resisted wrist and middle-finger extension (Cozen's and Maudsley's tests) are typical. Ulnar nerve examination (Tinel's sign, elbow flexion test, hand muscle strength) is performed in every patient; in arthritis it may change the surgical plan.

Differential diagnosis matters: radial tunnel syndrome (compression of the posterior interosseous nerve), referred pain from the neck and lateral ligament instability of the elbow (posterolateral rotatory instability) can mimic tennis elbow and must not be missed.

Plain radiographs (AP and lateral) show osteophytes, loose bodies, joint-space narrowing and OCD lesions; they are usually normal in tennis elbow. CT shows the location and size of osteophytes and loose bodies in detail and is valuable for planning arthritis surgery. MRI assesses cartilage lesions, OCD stability, tendon degeneration and partial tears, and ligament injuries. Ultrasound quickly shows tendon thickening and tears. If there are ulnar nerve symptoms, nerve conduction studies (EMG) are requested.

Non-operative Treatment

In both conditions, treatment starts non-operatively. In tennis elbow this alone is sufficient for the great majority of patients.

• Activity modification: Temporarily reducing the gripping and lifting that provoke pain; learning to lift with the palm facing up
• Physiotherapy and exercise: The foundation of treatment for tennis elbow. Eccentric and isometric strengthening of the forearm extensors, stretching and grip strength work; the effect usually appears within 6 - 12 weeks
• Counterforce brace: Reduces load on the tendon origin and gives relief during activity
• Wrist splint: Particularly at night, reduces pain in some patients
• Analgesics and anti-inflammatory medication (NSAIDs): Short-term, under medical supervision
• Corticosteroid injection: Gives marked relief in the first weeks; however, studies have shown that in tennis elbow, one-year outcomes after corticosteroid injection are worse than with a wait-and-see approach or physiotherapy, with a higher recurrence rate. Repeated injections can thin the tendon and subcutaneous tissue. It is therefore not the first choice for tennis elbow
• PRP (platelet-rich plasma) injection: Used as an option in chronic cases; study results on its effectiveness are inconsistent
• Extracorporeal shock wave therapy (ESWT): An option for resistant cases
• Ergonomic adjustment: Workstation, mouse and keyboard position, tool handle thickness, racquet choice and technique
• Arthritis: Intra-articular injections (corticosteroid, hyaluronic acid), activity modification and range-of-movement exercises; mechanical locking and marked loss of movement do not improve with non-operative treatment

Surgical Treatment — Who Is a Candidate?

• Repeated locking or catching from a loose body: Surgery is appropriate without waiting for non-operative treatment
• Elbow arthritis with loss of movement and end-range pain that affects daily life and work
• Unstable or displaced capitellar OCD lesions
• Olecranon osteophytes from valgus extension overload in throwing athletes
• Tennis elbow: Pain that continues to affect daily life and work despite at least 6 - 12 months of consistent physiotherapy, activity modification and appropriate injections
• Additional advantage of arthroscopy in tennis elbow: The joint can be inspected in the same session, and associated problems (synovial plica, cartilage damage, loose bodies) found and treated
• Not suitable: Tennis elbow in which non-operative treatment was abandoned early; an infected or severely unstable elbow; advanced widespread arthritis (arthroscopy offers limited benefit)

Surgical Options

• Arthroscopic debridement: Removal of damaged, loose cartilage and inflamed synovial tissue
• Loose body removal: The elbow arthroscopy indication with the most predictable result
• Arthroscopic osteocapsular arthroplasty: Shaving of osteophytes on the olecranon and coronoid and release of the contracted anterior capsule; markedly increases range of movement
• OCD treatment: Fixation of stable fragments; removal of unstable fragments with microfracture of the base; mosaicplasty for large lesions
• Arthroscopic ECRB release (tennis elbow): Degenerate tendon tissue is freed from its origin and debrided
• Open (Nirschl) tennis elbow surgery: Removal of degenerate tissue through a small incision; similar success to the arthroscopic method has been reported
• Ulnar nerve release or anterior transposition: Planned in the same session if there is nerve involvement or if preoperative loss of movement is marked (the nerve may be stretched when movement is restored)

Expected Outcomes

Results are most predictable after loose body removal; locking symptoms largely disappear. In elbow arthritis, most patients have less end-range pain and a marked gain in range of movement after arthroscopic debridement and osteocapsular arthroplasty; however, not all lost movement is always regained, and because arthritis is progressive, osteophytes may recur over the years.

After arthroscopic release for resistant tennis elbow, published series report good or excellent results in about 85 - 95% of patients. Complete resolution of pain may take months; full recovery takes 3 - 6 months. The most important factor for success is correct patient selection and excluding conditions that cause similar pain, such as radial tunnel syndrome, before surgery.

Risks Specific to Non-operative Treatment

• Long course in tennis elbow: Recovery with non-operative treatment may take 6 - 12 months, affecting work and daily life
• Repeated corticosteroid injections: Thinning of subcutaneous fat, skin lightening, weakening of tendon tissue and a higher long-term recurrence rate
• Arthritis: Mechanical locking and loss of movement do not improve with non-operative treatment; loss of movement may progress as osteophytes grow
• Loose bodies left in the joint: Repeated locking may cause further cartilage damage

Surgical Risks — Common

• Temporary nerve problems: A temporary change in sensation or weakness after elbow arthroscopy is reported in about 1 - 3% of cases in studies; most resolve on their own within weeks or months
• Prolonged leakage of joint fluid from a portal
• Superficial portal infection (usually treated with antibiotics)
• Postoperative pain, swelling and bruising
• Temporary elbow stiffness — improves with regular exercise
• Small areas of numbness from injury to superficial sensory branches at the portal sites

Surgical Risks — Less Common

• Permanent nerve injury: Ulnar, radial (particularly the posterior interosseous branch) or median nerve; rare but serious. The risk is higher in patients undergoing capsular release and osteocapsular arthroplasty
• Ulnar nerve irritation: When range of movement is markedly increased, particularly flexion, the nerve may be stretched; this is why nerve release is planned in the same session in patients with very limited preoperative flexion
• Loss of the movement gained: The elbow re-stiffens quickly when the exercise programme is not followed
• Heterotopic ossification: Bone formation in soft tissue; may restrict movement
• Deep joint infection (under 1%): Requires arthroscopic washout and antibiotics
• Specific to tennis elbow surgery: Damage to the lateral ligament from extending the release too far back, causing elbow instability (posterolateral rotatory instability) — rare but difficult to treat
• Specific to tennis elbow surgery: Persistent pain, which may reflect a coexisting condition such as radial tunnel syndrome
• Complex regional pain syndrome (CRPS): Rare
• Instrument breakage or retained fragments: Very rare

Risk Factors

• Previous elbow surgery or ulnar nerve transposition: Normal anatomy is altered, making portal placement riskier
• Ulnar nerve subluxation (slipping in front of the bony prominence): If not identified beforehand, risk of injury when the medial portal is made
• A severely stiff elbow: Reduced joint volume means the nerves cannot be pushed far enough from the capsule
• Inflammatory diseases such as rheumatoid arthritis that thin the capsule
• Smoking: Impairs tendon and wound healing
• Poorly controlled diabetes
• Poor adherence to the exercise programme: The most common cause of recurrent stiffness after debridement
• Tennis elbow: Early return to work or sport with heavy loads

Contact Your Doctor Immediately If

• You cannot lift your wrist or fingers
• Numbness, tingling or weakness in the fingers is progressing
• Pain or swelling suddenly increases
• You have a temperature above 38 °C
• There is cloudy or foul-smelling discharge from a portal, or redness and warmth around the wound
• Your fingers become blue, cold or pale
• The movement gained after surgery is rapidly being lost

Long-term Outcomes

After loose body removal and arthroscopic debridement, most patients achieve a pain-free, more mobile elbow. In elbow arthritis, osteophytes may re-form over time, so partial recurrence of symptoms over the years is possible; if advanced arthritis develops, options such as elbow replacement are considered, although this is uncommon.

After arthroscopic release for resistant tennis elbow, good results are largely maintained in the long term and the recurrence rate is low. Return to desk work usually takes 1 - 3 weeks and to heavy manual work 6 - 12 weeks. Full recovery of grip strength may take 3 - 6 months. Ergonomic adjustment and maintaining forearm muscle strength are the most effective ways to prevent recurrence.