Lateral tennis elbow: "Is there any science out there?"

As orthopaedic surgeons, we are besieged by myths that guide our treatment of lateral epicondylitis, or "tennis elbow." This extends from the term used to describe the condition to the nonoperative and operative treatments as well. The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found. Numerous nonoperative modalities have been described for the treatment of lateral tennis elbow. Most are lacking in sound scientific rationale. This has led to a therapeutic nihilism with respect to the nonoperative management of this condition. An examination of the literature can only lead us to believe that most, if not all, common nonoperative therapeutic modalities used for the treatment of tennis elbow are unproven at best or costly and time-consuming at worst. Most of the published literature on the nonoperative treatment of patients with lateral tennis elbow consists of poorly designed trials. The selection criteria are nebulous, the control group is questionably designed, and the number of patients is often too low to avoid a serious loss of study power. These studies therefore have a high beta error, implying an inability to detect a difference between groups, even if one truly existed. If clinical signs and symptoms persist beyond the limit of acceptability of both patient and surgeon, then an array of surgical options are available. These range from a 10-minute office procedure (the percutaneous release of the extensor origin with the patient under local anesthetic) to an extensive joint denervation, in which all radial nerve branches ramifying to the lateral epicondyle are directly or indirectly divided. How is the surgeon to choose, given the fact that most of the published surgical studies are case series of one type of operation or another, consisting of patients operated on and evaluated by the same surgeon, who has a vested interest in his or her own patients' successful outcome? The orthopaedic surgeon therefore has very little on which to "hang his hat" when it comes to objective data to guide treatment of patients with lateral tennis elbow syndrome. In the final analysis we are guided simply by our own subjective viewpoint and clinical experience. In 1999, to have such a common clinical condition have such a paucity of peer-reviewed published data of acceptable scientific quality is disappointing. In this review article we will examine the "myths" of tennis elbow: the name, the salient features on history and physical examination, the diagnostic modalities, the pathology of the "lesion," the anatomy of the lateral elbow and extensor origin and why it has led to such confusion in differential diagnosis, the nonoperative and operative treatment of tennis elbow, and finally the various studies that have been carried out on elbow biomechanics as it relates to the pathoetiology of true "tennis elbow." It is our hope that the reader will emerge with a clearer picture of the pathoetiology of the condition and the scientific rationale (or lack thereof) of the various operative and nonoperative treatment modalities.