So, you have a stubborn case of Tennis Elbow… When is it 'time' to start thinking about surgery? – Five key things to consider
At some point, after struggling with Tennis Elbow for months or even years – Seeing Doctors, Physical Therapists and other professionals and trying all manner of Tennis Elbow related treatments, tricks and tips – You may eventually have to ask yourself, “Is it time for surgery?”
If you're like most people, however, you regard surgery as a last resort – A serious decision not to be rushed into or taken lightly.
So how do you know when it's time – that you've completely exhausted your more conservative options, and it's time to step aboard the ship to the “last resort” AKA: Scalpel Island?
Here are five important things to consider in your decision:
Table Of Contents (Links jump down the page to various sections of this article.)
- Are you a "good candidate" for Tennis Elbow surgery? – (Is your case of Golfer’s or Tennis Elbow severe enough to warrant surgery?) Are you a good surgical candidate?
- What's the success rate for Tennis Elbow surgery? – (The success rate is fairly high and the failure rate low - but it doesn't always succeed.) What if surgery fails and you're worse off?
- There's a long recovery time – (You'll be facing a significant post-surgical recovery period and months of rehab time) Recovery and rehab time after surgery
- The placebo effect – (Are you aware that even surgery has a well-documented, often significant placebo effect!?) The surgical placebo effect
- Are you SURE you need it? – (Are you sure it's the last resort - you've tried everything and you really need Tennis Elbow surgery?) Is surgery really your last resort?
And then there are several types of surgery to choose from, including: Open surgery vs. closed / Arthroscopic, the new 'Tenex' procedure and the semi-surgical therapies like Platelet-Rich Plasma, Prolotherapy, and Dry Needling / Fenestration, but that's a topic to be covered in another article.
Podcast Episode On The Surgical Question
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One of the biggest considerations you're going to face is whether your case of Tennis or Golfer's Elbow is severe enough to warrant surgery.
First of all, your Orthopedic Surgeon should have a clear, strong opinion about whether your injury is surgically repairable or not, based on all the information he or she has.
Of course, you're the ultimate authority on your health. You have to make the decision about having surgery or not and bear the consequences of it, so the more you know going in, the better.
So, what exactly is the criteria which makes you a good, great or poor candidate for surgery?
It's not entirely about how much pain you're in, how debilitating your injury is or how long you've been injured – although, those are the factors you're most familiar with (too familiar with!) and care a great deal about, naturally.
It's ultimately about those factors PLUS the objective measures – As is how much damage the scan of your elbow shows.
In other words, just because you have extreme pain and limited function does not automatically mean you have extreme tendon damage that necessitates surgery…
And, conversely, it's actually possible to have extensive tendon damage and to NOT be in that much pain (Or any pain!) – And to not have much if any strength or mobility limitations.
So, what you really “want” is the combination of a clear diagnosis of significant tendon damage and significant pain and loss of your normal function.
The Diagnosis: What Does The MRI Show?
Depending on the type of surgery you're looking at, you can expect to have either an MRI scan or a Sonogram (Diagnostic Ultrasound) in advance to get a definitive diagnosis.
What your surgeon is looking for is one or several conditions:
- Tendinosis – Which is tendon degeneration. Your tendon is breaking down and not repairing. This is the essence of Tennis Elbow, but there are degrees of severity
- Tendon tearing – Usually the tendon is tearing away from where it attaches to the bone (Lateral or Medial Epicondyle) And, again, there are degrees of severity
- Bone Spurs – In a small percentage of cases bone spurs form where the tendon attaches to the bone
Chances are, if you've had Tennis or Golfer's Elbow for 6 months or longer and haven’t been able to recover from it, you likely have at least some Tendinosis (tendon degeneration.)
But if tendon degeneration is all the MRI scan or Sonogram shows, and it's mild – or even moderate, and not too severe – that alone doesn't make your injury a slam-dunk, obvious case for surgery.
There is still a good chance of recovering from mild or even moderate degeneration / Tendinosis.
However, if the scan shows severe degeneration and / or a tear in your tendon, that's a lot more conclusive evidence for surgery.
Tendon tears are the most serious and persuasive findings.
- First comes chronic muscle tension, which puts excessive load on the tendon,
- That causes the tendon to gradually break down (degenerate) which weakens it,
- And eventually, the weakened tendon tears, in some cases and the longer that persists the worse the tear tends to get.
The truth is, mild or moderate Tendinosis / degeneration can and does heal. (Tendons have to be able to heal otherwise we would be in big trouble!)
At What Point Is The Damage "Too Much" To Recover From?
Tendon degeneration past a certain point of severity, (somewhere in the moderate to severe range) becomes unlikely to heal without drastic intervention - Of course, precisely where that “line of demarcation” lies for you or any individual is very hard to say.
However, it's more cut and dry when it comes to tendon TEARS:
- It's possible for mild tears to heal without surgery,
- But, for moderate tears, the difficulty of healing gets very high.
- Severe tears are impossible to recover from without surgery.
Again, it's up to you, but if all your MRI or Sonogram shows is mild to moderate Tendinosis and no tearing, you may not need surgery and may be able to recover without it.
There are a huge number of other factors to take into consideration, of course, like your age, overall level of health and whether you've had any Cortisone shots. (They are a known risk of weakening the tendon and make recovering a lot more difficult.)
How motivated you are is also a big factor - How hard are you willing to work at it in order to avoid the surgeon's scalpel or Arthroscope?
On the other hand, if your diagnosis includes severe Tendinosis – And especially if it includes a tear, worse still, if that tear is moderate to severe, you may be a very good candidate for surgery.
This surgery has an 80 to 90% success rate, which may sound pretty good...
But that still means a failure rate of 1-2 cases out of 10. (It's difficult to pin down any closer than that, since it's based on statistics.)
No, there's never a guarantee that any treatment or intervention with work in every case, but surgery is also a big investment with a fairly significant wait to find out if it worked.
And one of the big advantages to most conservative approaches to treating Tennis and Golfer's Elbow is that, although they may not work there is no big downside.
Surgery itself is in a category all its own, however. It's a traumatic intervention itself with significant risks.
If your surgical procedure fails to address your injury and restore you to full painless function, there's a good chance you will actually be worse off, unfortunately.
Even if your surgery goes entirely according to plan (depending on the type of surgery) you will face a limiting a post-surgical recovery period.
During this recovery period you may be in a restrictive brace or cast that doesn't allow you to bend your elbow, or use your arm or hand for 1 to 2 weeks.
(This is especially true for the classic “gold standard” open surgical procedure, and likely the case after Arthroscopic Surgery.)
Followed by a less restrictive brace that allows elbow movement for a few more weeks, but you'll have to be very careful in how you use your arm to avoid traumatizing your recently repaired and vulnerable tendons.
That's really just the beginning of your healing and rehab, however. After that the real work begins: Rehab exercises.
How Long Does It Take To Recover From Tennis Elbow Surgery?
Surprisingly, after 6 months to a year of pursuing “conservative” measures – including months of rehab exercise – You can still face the prospect of up to 6 more months to a year to fully heal and recover from your Tennis Elbow surgery!
And you may actually experience mild soreness for 3 to 6 months.
Then, at some point after your initial post-surgical recovery, (3-6 weeks?) you'll need to begin a course of rehab exercises.
No matter how long and hard you tried to recover with exercises before surgery, you basically have to start all over again, as if from scratch – and continue exercising diligently for 3-6 months, minimum.
And to top it off, you may need to do those rehab exercises for as long as a year.
(Not that there's any way to complete avoid rehab exercises when you have Golfer's or Tennis Elbow – Exercise is an essential part of making a full recovery. And it never hurts to go into surgery with strong muscles rather than being in a weakened, de-conditioned state.)
Now, none of this is necessarily such a terrible imposition – IF it works, right!?...
But, the fact is, you will have to undergo all these inconveniences, including the surgery itself and months of rehab before you know if it was a complete success, a modest improvement or a dismal failure.
And as we already covered, surgery doesn't always work.
How long will you have to wait and do rehab exercises before you know if you're recovering or not?
That's difficult to say, but be prepared to put in 3 to 4 months of rehab before you start to conclude it's not getting better and you want to give up.
Ian Harris, an Australian Orthopedic Surgeon, Professor and Author has confessed to performing surgery "that doesn't work" in response to pressure from patients and other factors, in his book, 'Surgery, The Ultimate Placebo'
One of the dozen or more surgeries he specifically criticizes is that for Tennis Elbow. In his opinion, surgery for Lateral Epicondylitis / Tennis Elbow is:
"Another procedure that is in decline. The condition largely gets better over time and surgery doesn't add anything to that process."
A recent medical study from 2012 lends credence to Dr. Harris' claims - especially when it comes to surgery for Tennis Elbow.
This looks to be the first time a study was done to compare the standard Tennis Elbow surgical procedure against the placebo effect by giving a "fake" / sham surgery to the control group.
The surprising result was that a "fake" placebo procedure performed no better than a genuine Tennis Elbow surgery!
Here's the kicker: Both groups actually improved - (The control group apparently only because of the placebo effect)…
The key takeaway, however, is that the group which received the real surgery didn't end up doing any better – and were in more pain at the 2-week mark because of the surgery!
The ultimate question: Are you sure it's your last resort, you've done everything you possibly could to treat your Tennis or Golfer's Elbow conservatively?
And even if you believe you do need it, are you prepared for the hassles, risks and inconveniences of surgery?
(Not to mention the long recovery and rehab time.)
It gets a lot easier to decide, of course, if you have an MRI and it shows severe Tendinosis (degeneration) and/or a moderate to severe tear in your tendon, and all logic suggests you're not going to be able to heal that damage without surgery to remove the damaged tendon and repair it.
AND you have severe or persistent pain or weakness and it's interfering with your work, hobbies or sport – generally making your life miserable, so you just can't live with it.
But what if you're on the “border line,” so to speak?
Your MRI is not conclusive; the damage is mild to moderate and you have no significant tendon tearing…
And your pain is manageable – and although it's a nuisance – it's not terribly debilitating…
You could consider Platelet-Rich Plasma injections. That's still a kind of surgery, but it's a lot less invasive and has a much shorter recovery period.
But I would ask you, have you had any therapy that's designed to treat what I believe is the root of the problem? (at least locally in your forearm)
Have You Treated The Root Causes Of Your Tennis Or Golfer’s Elbow?
- Chronic muscle tension in your Wrist Extensor Muscles, (if you have Tennis Elbow) or in your Flexor Muscles (if Golfer's Elbow)
- Deep, sticky adhesions in those muscles (which shorten and restrict them, putting an excessive load on the tendon)
- And the degeneration and Scar Tissue in your tendon(s) which weakens them and causes the worst of the pain.
The VAST majority of treatments, therapies, remedies and so-called cures do not treat and address these muscle and tendon “root issues” – At least not with any efficiency.
You might assume before going into Physical Therapy / Physiotherapy that the therapist will do some actual 'Manual Therapy' (hands-on manipulation therapy of your muscles and tendons)
But it's rare (at least in the United States – Europe may be different) to receive anything more that a token “rub” for a few minutes – if that.
Most of the emphasis is on insurance-billable but clinically-unproven tech, like E-stim, Ultrasound, Extracorporeal Shock Wave Therapy and various forms of Cryotherapy (icing) - and on the rehab exercises you're assigned and have to do on your own, anyway.
None of this has any significant effect on muscular adhesions, Scar Tissue and tendon degeneration, in my opinion and experience.
(And any potential marginal benefit must be weighed against your cost – As in the time, travel, inconvenience and cost of repeated trips to the PT clinic to receive these treatments.)
Before deciding that you've “tried everything,” giving up and scheduling surgery – (especially if you're on that borderline, diagnostically)…
I would recommend going to see a practitioner like myself who specializes in manipulating muscles and tendons – and actually treats these root causes.
But to be honest, that can be rather expensive, so one other alternative – Especially if you're highly motivated to avoid surgery, is my self-help program.
The cost is minimal, there's a solid guarantee, there's almost no downside (unlike the risks associated with surgery) and it's something you can do at home without going anywhere - And put as much energy into as you're motivated to.
(Which, to be clear and upfront, may be a lot - if have some moderate tendon damage and you're "on the verge" of surgery, but want to avoid it if at all possible!)
Learn more about the programs below:
Learn To Treat And Heal Your Own Tennis Elbow Or Golfer's Elbow At Home With This Video Program
I'll be your personal tutor guiding you through step-by-step video lessons, where you'll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)
Just watch the videos, follow along and start putting an end to your elbow pain today, whether you have Golfer's or Tennis Elbow from playing your guitar - or other stringed instrument or ANY instrument, for that matter!)
Tennis Elbow sufferers: Learn more about the Tennis Elbow program here
Golfer's Elbow sufferers: Learn more about the Golfer's Elbow program here