The American Journal of Medical Sciences and Pharmaceutical Research
45
https://www.theamericanjournals.com/index.php/tajmspr
TYPE
Original Research
PAGE NO.
45-49
10.37547/tajmspr/Volume07Issue01-06
OPEN ACCESS
SUBMITED
18 October 2024
ACCEPTED
20 December 2024
PUBLISHED
21 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Bianca Gabriella de Oliveira, Heitor Ribeiro Mendonça, Gabriella Trindade
Fernandes, Wander Júnior Ribeiro, & Melissa Alves Aires Marques. (2025).
Efficacy of arthroscopy in the treatment of lateral epicondylitis: a
systematic review with meta-analysis. The American Journal of Medical
Sciences and Pharmaceutical Research, 7(01), 45
–
49.
https://doi.org/10.37547/tajmspr/Volume07Issue01-06
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Efficacy of arthroscopy in
the treatment of lateral
epicondylitis: a systematic
review with meta-analysis
Bianca Gabriella de Oliveira
Medical Student at the University of Salvador, Salvador, BA, Brazil
Heitor Ribeiro Mendonça
Resident physician in orthopedics and traumatology at the Santa Maria
Regional Hospital, Brasília, DF, Brazil
Gabriella Trindade Fernandes
Resident physician in orthopedics and traumatology at the Santa Maria
Regional Hospital, Brasília, DF, Brazil
Wander Júnior Ribeiro
Resident physician in orthopedics and traumatology at the Santa Maria
Regional Hospital, Brasília, DF, Brazil
Melissa Alves Aires Marques
Medical Student at the Iguaçu University, Itaperuna, RJ, Brazil
Abstract:
Lateral epicondylitis, popularly known as tennis
elbow, has a high incidence in athletes, around 50%, with
a high prevalence in beginners learning the one-handed
backhand. It is a clinical orthopaedic condition with a
major impact on public health due to its high frequency in
manual workers, 10.5% of whom may have lateral elbow
pain and 2.4% of whom have a confirmed diagnosis. The
aim of this study is to compare the effectiveness of
arthroscopic versus non-arthroscopic techniques (open
and percutaneous). This is a systematic review with meta-
analysis. There is no need for approval by the ethics
committee or institutional scientific review board. The
reference lists of the included and previously published
articles were searched for more relevant studies that met
the eligibility criteria. Based on the Preferred Reporting
Items for Systematic Reviews and Meta-analyses
(PRISMA) guidelines. Five articles were selected
containing patients diagnosed with lateral epicondylitis
who underwent surgical treatment by arthroscopy, open
surgery and/or percutaneous surgery. A total of 544
patients were included, with a mean age of 46 years. Of
The American Journal of Medical Sciences and Pharmaceutical Research
46
https://www.theamericanjournals.com/index.php/tajmspr
these, 347 were treated by arthroscopy, 81 by open
surgery and 42 by percutaneous surgery. The results
were analyzed using the DASH (Disabilities of the arm,
shoulder and hand) score, which assesses dysfunctions
of the arm, shoulder and hand. In addition, some studies
analyzed the VAS (Visual Analogue Scale) index, patient
satisfaction, complications and other clinical assessment
scales.Arthroscopic, open and percutaneous surgeries
proved to be effective methods for treating lateral
epicondylitis.However, because arthroscopy is a method
that allows a complete intra-articular evaluation and
adequate release of the tendons without ligament
involvement, it was associated with a better prognosis in
terms of pain, limb mobility and consequent patient
satisfaction when compared to open and percutaneous
procedures.
Keywords:
Lateral
epicondylitis;
Arthroscopy;
Treatment.
Introduction:
Lateral epicondylitis, popularly known as
tennis elbow, has a high incidence in athletes, around
50%, with a high prevalence in beginners learning the
one-handed backhand. It is a clinical orthopaedic
condition with a major impact on public health due to
its high frequency in manual workers, 10.5% of whom
can present with lateral elbow pain and 2.4% of whom
have a confirmed diagnosis. ¹,²
This condition affects 1 to 3% of the general
population, mainly between the ages of 35 and 50.
1,2,3 In most cases it can be successfully treated
conservatively, with relief within one year. 3 However,
4% to 11% of patients persist with complaints, leading
to a surgical approach which results in “good” or
“excellent” results in 80% to 90% of cases.4,5
The mechanism of trauma is often ergonomics, hence
the high prevalence and higher incidence in heavy
manual workers and workers who perform repetitive
movements or fine motor skills3. However,
degenerative factors can contribute to the
development due to the inflammatory process
characterized by angiofibroblastic hyperplasia, high
cell counts, hyperplasia of blood vessels and
degradation of collagen fibers, which can evolve into
partial or total tendon ruptures and even fibrosis and
calcification 4
In most studies, the etiology has been correlated with
the initial location of the tendon lesions, originating in
the extensor carpi radialis brevis (ECRB), as a result of
inflammation, generating a significant pain process.
This can be explained biomechanically when playing
tennis, and most notably when performing a
backhand, by placing much greater loads on the ECRB
tendon than on the other epicondyle tendons. Since
anatomically, the other extensors are muscular and this
one is tendinous⁵.
Another scientific hypothesis is that epicondylitis is a
clinical manifestation of elbow instability, anatomically
justified by the proximity between the extensor carpi
radialis brevis and the collateral ligaments. This may
justify the ligament laxity found in patients undergoing
diagnostic arthro
scopy for this pathology⁵.
Historically, this pathology was thought to be a self-
limiting disease, however, persistent pain is detected in
most patients, even when treated for a year with
conservative methods8 and subsequent local injections
of corticosteroids have also shown unfavorable results,
especially in those with a pain duration of more than 6
months8 .
Numerous forms of conservative treatment have been
established, with immobilization, avoidance of manual
work, physiotherapy, systemic or local anti-
inflammatories
and
radiofrequency
to
relieve
pain.12,13,14 However, patients who don't respond
positively or those with a period of 6 months of
complaints
become
candidates
for
surgical
intervention.9
Numerous techniques have been proposed to free the
origin of the common extensor.12 Firstly, it was
performed by the open route, first described by Nirschl
and Pettrone in 1979. 13Later, in 1982, Baumgard and
Schwartz 14 were the first to describe percutaneous
release, with the patient under local anesthesia, for the
treatment of lateral epicondylitis.13,14
With the popularity of elbow arthroscopy, the use of
arthroscopic methods has been explored for the
treatment of this pathology in refractory cases.15 It was
first described in 2000 by Blaker et al 16 in a small series
of cases with 42 releases. Since then, numerous articles
have established that this is a viable option for cases
that are refractory and chronic to non-operative
treatment.17,18 Therefore, the aim of this study is to
compare the effectiveness of the arthroscopic
technique versus non-arthroscopic techniques (open
and percutaneous).
METHODOLOGY
Data search
Bibliographic survey through the electronic databases:
Scielo, PubMed/MEDLINE and Cochrane Library without
language restriction of publications until November 31,
2023, through a search strategy combining keywords
and MeSH terms and the Boolean operator AND/OR.
The health descriptors (DECS)/MESH TERMS selected
were: Lateral epicondylitis OR Tennis elbow AND
Arthroscopy AND Orthopaedic procedures.
Type of study
The American Journal of Medical Sciences and Pharmaceutical Research
47
https://www.theamericanjournals.com/index.php/tajmspr
This is a systematic review with meta-analysis. There is
no need for approval by the ethics committee or
institutional scientific review board. The reference lists
of the included and previously published articles were
searched for more relevant studies that met the
eligibility criteria. Based on the Preferred Reporting
Items for Systematic Reviews and Meta-analyses
(PRISMA) guidelines 6.
Eligibility criteria
The PICOS principle (Population, Intervention,
Comparison, Outcomes and Study Design) was used.
1)
Population: patients diagnosed with lateral
epicondylitis
2)
Intervention:
arthroscopic,
open
or
percutaneous surgical treatment.
3)
Comparator: DASH score (Disabilities of the
arm, shoulder and hand)
4)
Outcome: arthroscopic treatment of lateral
epicondylitis is associated with better prognosis when
compared to other techniques.
Criteria for classifying studies
Excluded
(1)
Studies with incomplete data for the proposed
work
(2)
Non-randomized
controlled
trials,
comparative studies, editorial articles, letters to the
editor, cohort studies, review articles, meta-analyses,
expert opinions, conference papers, or books; (3) Same
publications by the same author or institution; (4)
Articles that did not evaluate the patients' DASH
(Disabilities of the arm, shoulder and hand) score; (5)
Articles that did not analyze the arthroscopic
technique in the treatment of lateral epicondylitis; (6)
Articles analyzing techniques other than arthroscopy,
open and percutaneous.
Statistical analysis
The methodological quality was guided by the
inclusion and exclusion criteria of the studies, assessed
with the Cochrane Collaboration tool for determining
risk of bias in the Review Manager program, version 5.3
(The Nordic Cochrane Centre, The Cochrane
Collaboration, Copenhagen, Denmark). 7
The systematic review protocol was registered in the
International prospective register of systematic
reviews (PROSPERO) under ID CRD42024504346.
RESULTS
The selection of studies began with 192 articles, and
after excluding those published more than 15 years
ago, 51 were selected. After evaluating the titles and
abstracts that were not in line with the proposal of the
study, 26 were left for full reading. Finally, 5 were
selected for discussion, analysis and construction of
the study (Figure 1).
Five articles were selected containing patients
diagnosed with lateral epicondylitis who underwent
arthroscopic, open and/or percutaneous surgical
treatment. A total of 544 patients were included, with a
mean age of 46 years. Of these, 347 were treated by
arthroscopy, 81 by open surgery and 42 by
percutaneous surgery. The results were analyzed using
the DASH (Disabilities of the arm, shoulder and hand)
score, which assesses dysfunctions of the arm, shoulder
and hand. Some studies also analyzed the VAS (Visual
Analogue
Scale)
index,
patient
satisfaction,
complications and other clinical assessment scales.
Table 1 contains the selected studies and their
outcomes.21,22,23,24,25
Table 2 shows the analysis of the pre- and post-
operative DASH score results obtained using the
arthroscopic technique and other techniques used in
the
treatment of
lateral
epicondylitis (table
2).21,22,23,24,25
Figure 2 contains an analysis of the results obtained
using the arthroscopic technique and other techniques
used in the treatment of lateral epicondylitis (figure 2).
Clark et al's study showed that the DASH score and
PRTEE showed no significant differences between the
two surgical modalities (open and arthroscopic), the
VAS SCORE 12 months after surgery represented better
results for those patients who underwent arthroscopy
(30.6 +- 4.9 for open surgery and 26.9 +- 4.2 for
arthroscopic). While for Solheim et al, at medium
follow-up, the DASH score showed significantly better
results in the arthroscopic group compared to the open
group. The study also pointed out that serious
complications such as chronic nerve damage, elbow
stiffness or deep infections were not found in any of the
patients 21,22.
Ertem et al. analyzed the efficacy of arthroscopic
treatment alone, and found a significant improvement
in the post-operative DASH score compared to that
recorded before surgery. The MEPS (Mayo Elbow
Performance Scores), an instrument that tests elbow
limitations during daily physical activities, showed a
substantial improvement from 48.5 +- 1.5 to 101.2 +-
22.9 after surgery.19
For Othman et al, arthroscopy showed more favorable
results in the DASH score, in the post-operative VAS
score (2 +- 1 for the arthroscopy group and 2.1 +- 1 for
the percutaneous technique) and in the degree of
satisfaction compared to percutaneous release. Szabo
et al. evaluated the percutaneous, open and
arthroscopic techniques. When taking into account the
Andrews - Carson score, arthroscopic surgery showed
better post-operative indices compared to the others:
The American Journal of Medical Sciences and Pharmaceutical Research
48
https://www.theamericanjournals.com/index.php/tajmspr
195.4, 195.3 and 193 for arthroscopic, percutaneous
and open, respectively. The post-operative VAS index
also showed better results for the arthroscopic
technique, with records of 1.0, 1.1 and 1.2 for the
arthroscopic, percutaneous and open routes.24,25
DISCUSSION
Arthroscopic, open and percutaneous surgeries have
proven to be effective methods for treating lateral
epicondylitis. However, because arthroscopy is a
method
that
allows
complete
intra-articular
assessment and adequate tendon release without
ligament involvement, it was associated with a better
prognosis in terms of pain, limb mobility and
consequent patient satisfaction when compared to
open and percutaneous procedures 21,22,23.
In addition to the patient's choice and the orthopaedic
surgeon's familiarity with each technique, there are
three factors discussed that affect the choice of
treatment such as (1) the ability to visualize the elbow
joint; (2) the complication rate and (3) the duration of
the surgical procedure..26 Supporters of the
arthroscopic and open techniques refer to the
theoretical benefit of intra-articular visualization,
which makes it possible to identify other possible
pathologies causing this lateral elbow pain, masked or
coexisting with tendinosis of the ECRB, reducing the
number of refractory cases26.
Arthroscopy allows visualization of the entire elbow
joint and avoids splitting the overlying common
extensor origin, which may or may not be associated
with the pathological process, while the open surgical
approach can be altered with a capsulotomy allowing
partial visualization of the elbow joint28.
It is argued that arthroscopy of this limb has a high
learning curve with possible serious complications
such as peripheral nerve damage, while percutaneous
and open techniques require less technical skill in the
hands of most surgeons with a thorough knowledge of
elbow anatomy.29 However, two studies show that
the complication rate of arthroscopic treatment of
lateral epicondylitis is lower than that of non-
arthroscopic techniques.27,30
Studies present evidence to show a faster return to
work with percutaneous and arthroscopic procedures
versus open techniques with a decrease in grip
strength to 90% on the non-compromised side, and an
equivalent “success rate” for the three tech
niques,
covering pain, multiple outcome measures, return to
activities and function. 31,32
It was found that patients may have better functional
results with open and arthroscopic releases as
opposed to percutaneous releases. However, those
who underwent arthroscopic and percutaneous
releases may have less post-operative pain than those
who underwent an open approach. They also found that
complication rates were similar between the
techniques, with the exception of superficial wound
infections, which were more prevalent among those
who opted for open release.The individuals reported
equally high levels of satisfaction, regardless of the
technique.12
The three techniques mentioned above for the
treatment of lateral epicondylitis show excellent results.
Since patients may report less pain with percutaneous
and arthroscopic techniques, even if the risk of
complications are similar between them, patients can
be informed that the risk of infectious complications
may be higher in open procedures.12
CONCLUSION
Both the arthroscopic method and the open and
percutaneous approach showed excellent results and
are effective for the treatment of lateral epicondylitis.
The risk of complications between them is similar, but
patients should be warned that open releases may have
a higher level of infectious complications. However,
arthroscopic treatment was associated with a better
DASH score, better VAS scores and patient satisfaction.
REFERENCES
Abrams GD, Renstrom PA, Safran MR. Epidemiology of
musculoskeletal injury in the tennis player. Br J Sports
Med 2012;46:492-498.
De Smedt T, de Jong A, Van Leemput W, Lieven D, Van
Glabbeek F. Lateral epicondylitis in tennis: Update on
aetiology, biomechanics and treatment. Br J Sports Med
2007;41:816-819.
Karkhanis S, Frost A, Maffulli N. Operative manage-
ment of tennis elbow: a quantitative review. Br Med
Bull. 2008;88(1):171-188.
Pomerantz ML. Complications of lateral epicondylar
release. Orthop Clin North Am. 2016;47(2):445-469.
Calfee RP, Patel A, DaSilva MF, et al. Management of lat-
eral epicondylitis: current concepts. J Am Acad Orthop
Surg. 2008;16(1):19-29.
van Hofwegen C, Baker CL III, Baker CL Jr. Epicondylitis
in the athlete’s elbow. Clin Sports Med. 2010;29(4):577
-
597.
Bot SD, van der Waal JM, Terwee C, van der Windt D,
Bouter LM, Dekker J. Course and prognosis of elbow
complaints: a cohort study in general practice. Ann
Rheum Dis. 2005;64(9):1331
–
6
Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE,
Smith J, Morrey BF. The epidemiology and health care
burden of tennis elbow: a population-based study. Am J
Sports Med. 2015;43(5):1066
–
71
The American Journal of Medical Sciences and Pharmaceutical Research
49
https://www.theamericanjournals.com/index.php/tajmspr
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino
B. Mobilisation with movement and exercise,
corticosteroid injection, or wait and see for tennis
elbow: randomised trial. BMJ. 2006;333(7575)
Tasto JP, Richmond JM, Cummings JR, Hardesty R,
Amiel D. Radiofrequency microtenotomy for elbow
epicondylitis: midterm results. Am J Orthop.
2016;45(1):29
–
33.
Tasto JP, Cummings J, Medlock V, Hardesty R, Amiel D.
Microtenotomy using a radiofrequency probe to treat
lateral epicondylitis. Arthroscopy. 2005;21(7):851
–
60
Pierce TP, Issa K, Gilbert BT, Hanly B, Festa A,
McInerney VK, Scillia AJ. A Systematic Review of Tennis
Elbow Surgery: Open Versus Arthroscopic Versus
Percutaneous Release of the Common Extensor Origin.
Arthroscopy. 2017 Jun;33(6):1260-1268.e2
Nirschl RP, Pettrone FA. Tennis elbow. The surgical
treatment of lateral epicondylitis. J Bone Joint Surg Am
1979;61:832-839.
Baumgard SH, Schwartz DR. Percutaneous release of
the epicondylar muscles for humeral epicondylitis. Am
J Sports Med 1982;10:233-236
Adams JE, King GJ, Steinmann SP, Cohen MS. Elbow
arthroscopy: Indications, techniques, outcomes, and
complications. Instr Course Lect 2015;64:215-224
Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthro-
scopic classification and treatment of lateral
epicondylitis: Two-year clinical results. J Shoulder
Elbow Surg 2000;9: 475-482.
Jerosch J, Schunck J. Arthroscopic treatment of lateral
epicondylitis: Indication, technique and early results.
Knee Surg Sports Traumatol Arthrosc 2006;14:379-
382.
Kim JW, Chun CH, Shim DM, et al. Arthroscopic treat-
ment of lateral epicondylitis: Comparison of the
outcome of ECRB release with and without
decortication. Knee Surg Sports Traumatol Arthrosc
2011;19:1178-1183.
Mullett H, Sprague M, Brown G, Hausman M. Arthro-
scopic treatment of lateral epicondylitis: Clinical and
cadaveric studies. Clin Orthop Relat Res 2005;439:123-
128.
Othman AM. Arthroscopic versus percutaneous
release of common extensor origin for treatment of
chronic tennis elbow. Arch Orthop Trauma Surg
2011;131:383-388.
Clark T, McRae S, Leiter J, Zhang Y, Dubberley J,
MacDonald P. Arthroscopic Versus Open Lateral
Release for the Treatment of Lateral Epicondylitis: A
Prospective Randomized Controlled Trial. Arthroscopy.
2018;34(12):3177-3184.
doi:10.1016/j.arthro.2018.07.008
Solheim E, Hegna J, Øyen J. Arthroscopic versus open
tennis elbow release: 3- to 6-year results of a case-
control
series
of
305
elbows.
Arthroscopy.
2013;29(5):854-859. doi:10.1016/j.arthro.2012.12.012
Ertem K, Ergen E, Yoloğlu S. Functional outcomes of
arthroscopic treatment of lateral epicondylitis. Acta
Orthop
Traumatol
Turc.
2015;49(5):471-477.
doi:10.3944/AOTT.2015.15.0048
Othman AM. Arthroscopic versus percutaneous release
of common extensor origin for treatment of chronic
tennis elbow. Arch Orthop Trauma Surg. 2011
Mar;131(3):383-8. doi: 10.1007/s00402-011-1260-2.
Epub 2011 Jan 21. PMID: 21253755.
Szabo SJ, Savoie FH 3rd, Field LD, Ramsey JR, Hosemann
CD. Tendinosis of the extensor carpi radialis brevis: an
evaluation of three methods of operative treatment. J
Shoulder
Elbow
Surg.
2006;15(6):721-727.
doi:10.1016/j.jse.2006.01.017
Burn MB, Mitchell RJ, Liberman SR, Lintner DM, Harris
JD,
McCulloch
PC.
Open,
Arthroscopic,
and
Percutaneous
Surgical
Treatment
of
Lateral
Epicondylitis: A Systematic Review. Hand (N Y). 2018
May;13(3):264-274.
Pomerantz ML. Complications of lateral epicondylar
release. Orthop Clin North Am. 2016;47(2):445-469.
Cohen MS, Romeo AA. Open and arthroscopic manage-
ment of lateral epicondylitis in the athlete. Hand Clin.
2009;25(3):331-338.
Dodson CC, Nho SJ, Williams RJ III, et al. Elbow arthros-
copy. J Am Acad Orthop Surg. 2008;16(10):574-585.
Karkhanis S, Frost A, Maffulli N. Operative manage-
ment of tennis elbow: a quantitative review. Br Med
Bull. 2008;88(1):171-188.
Yeoh KM, King GJ, Faber KJ, et al. Evidence-based indica-
tions
for
elbow
arthroscopy.
Arthroscopy.
2012;28(2):272- 282.
Lo MY, Safran MR. Surgical treatment of lateral
epicondylitis: a systematic review. Clin Orthop Relat
Res. 2007;463:98-106.
