Tennis elbow surgery: when it is considered, how it is done and what to expect

Tennis elbow is pain at the outside of the elbow where forearm tendons attach. Despite the name, many people who have it never play racket sports. The Norwich leaflet describes the tendon becoming degenerative and tearing or becoming inflamed.

The first line is not surgical. The NHS recommends resting the arm, simple painkillers or anti-inflammatory gel, hot or cold packs, gentle arm exercises and sometimes a forearm strap, and says it usually improves within weeks. Surgery is a conversation for people who are still limited after a long, properly tried course of other care.

After a period of self-care, the NHS says physiotherapy may help if symptoms have not improved after six weeks of home treatment. It lists massage, stretching and strengthening exercises and ultrasound therapy as examples, and says a GP may prescribe anti-inflammatory tablets.

The NHS page does not mention injections, so this page does not describe them. If an injection is offered to you, ask what the evidence is for people in your situation, and what the effect may be on later surgery.

• Change the tasks that bring on pain, such as repetitive gripping or lifting with the palm down.

• Try the strengthening programme through to the end before judging whether it has worked.

• Ask whether imaging is needed, and what it would change.

The Norwich leaflet describes a pre-admission assessment 1 to 6 weeks before surgery, with blood tests or an ECG only if needed, and sometimes by telephone. You are normally admitted on the day, and rings and jewellery on the operated arm must be removed.

Bring simple painkillers as advised, plan a lift home, and arrange for someone to help with tasks that need two arms. If you smoke, the leaflet points to smoking cessation support, which is worth taking up before any tendon surgery.

The leaflet says the operation may be done under a general anaesthetic or a regional one, in which the arm is numbed with an injection near the armpit or neck. A cut is made over the side of the elbow, the affected tendon is assessed and released, and the wound is closed with stitches.

Techniques vary between surgeons, and the leaflet describes an open release, so ask what to expect at your own hospital. After the operation the arm is kept raised in a sling or on a pillow for 24 to 48 hours.

The Norwich leaflet lists wound infection, swelling that may last up to three months, slow functional recovery, a painful first few weeks and the possibility that surgery does not cure the problem. It says pain can take up to 6 weeks to start improving.

Other risks of elbow surgery that are generally recognised, such as stiffness or small nerve irritation, were not itemised in the pages retrieved, so no probabilities are given. Ask your surgeon to explain them in terms of your own situation.

The Norwich leaflet advises avoiding heavy lifting, doing gentle hand, finger, elbow and shoulder exercises to prevent stiffness, and keeping the dressing dry until it is removed. Most people can return to driving after a week according to the same leaflet, with an instruction to discuss it with the surgeon and check the insurer.

The leaflet says most people can return to light work after 2 weeks, depending on the job. Ask your surgeon how this fits your own job and sport.

Increasing pain, redness, swelling or a high temperature after surgery can mean infection; the Norwich leaflet says to see your GP. Use NHS 111 out of hours, and go to A&E or call 999 for severe symptoms such as sudden chest pain, breathlessness or a hand that is blue, cold or numb.

• Have I tried enough non-surgical treatment to justify surgery?

• What proportion of your patients get a good result at six months?

• Will I need a sling, and for how long?

• Who will take out my stitches and when?

• What would we do if the operation does not help?

The operation is much the same wherever it is done. In the NHS, access to elbow surgery may depend on local criteria about how long other treatments should be tried, in line with the NHS 6 to 12 month framing. In the private sector the decision still needs the same clinical justification, but scheduling is usually quicker. Whichever you use, ask who will supervise the physiotherapy afterwards.