1 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

3 Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran


Background: Lateral epicondylitis (LE) also known as tennis elbow is a common disease of middle-aged population.
Surgery is a treatment of choice in patients not responded to the conservative management. Open and arthroscopic
release are the two main choices for LE surgery; however, an overall consensus is not available. This study was aimed
to compare the clinical outcomes after conventional open and arthroscopic procedures.
Methods: An electronic search of databases including, Medline, Web of Science, Embase, Cochrane Library, and
Scopus was conducted to identify all eligible studies describing the post-operative clinical outcomes of patients with
LE, up to October 2018. All studies considering the non-pediatric cases who received at least 6-month preoperative
conservative treatment and were followed more than 6 months after surgery were included. Data on patient satisfaction,
functional outcomes, pain, and complication rates, were extracted for each study. If appropriate, the meta-analysis
was performed to combine the results for all outcomes that were reported in a minimum of 3 studies utilizing the same
surgical technique.
Results: A total of 34 eligible articles including 15 open studies, 13 arthroscopic studies, and 6 studies in both
techniques were enrolled. Studies were from different parts of the world with a whole sample size of 1508 cases.
Various outcome measuring methods including Quick DASH and VAS, and different clinical outcomes were reported.
The results indicated no significant difference between arthroscopic and open surgery methods in terms of VAS,
DASH score, time for returning to work, overall outcomes, and patients’ satisfaction (P >0.05). However, postoperative
complications were significantly higher in the open group when compared with the arthroscopic procedure (57.3%
vs 33.4% P=0.001).
Conclusion: The present study suggests that despite no superiority for each techniques regarding the pain relief,
subjective function, and better rehabilitation, arthroscopic method have been associated with less complications.
Level of evidence: II


Main Subjects

1. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M.
Prevalence and determinants of lateral and medial
epicondylitis: a population study. Am J Epidemiol.
2006; 164(11):1065-74.
2. De Smedt T, de Jong A, Dossche L, van Leemput W, Van
Glabbeek F. Lateral epicondylitis in tennis: update on
aetiology, biomechanics and treatment. Br J Sports
Med. 2007; 41(11):816-9.
3. Nirschl RP, Pettrone FA. Tennis elbow. The surgical
treatment of lateral epicondylitis. J Bone Joint Surg
Am. 1979; 61(6A):832-9.
4. Savoie FH 3rd, O’Brien M. Arthroscopic tennis elbow
release. Instr Course Lect. 2015; 64(1):225-30.
5. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis
elbow. Clin Sports Med. 2003; 22(4):813-36.
6. Shiri R, Viikari-Juntura E. Lateral and medial
epicondylitis: role of occupational factors. Best Pract
Res Clin Rheumatol. 2011; 25(1):43-57.
7. Smidt N, van der Windt DA, Assendelft WJ, Devillé
WL, Korthals-de Bos IB, Bouter LM. Corticosteroid
injections, physiotherapy, or a wait-and-see policy for
lateral epicondylitis: a randomised controlled trial.
Lancet. 2002; 359(9307):657-62.
8. 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.
9. 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.
10. 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):939.

11. Coonrad RW, Hooper WR. Tennis elbow: its
course, natural history, conservative and surgical
management. J Bone Joint Surg Am. 1973;
12. Beckert A, Biskop M, Clemen G. Diagnostik und therapie
der epicondylitis humeri–eine gemeinschaftsstudie.
Beitr Orthop Traumatol. 1981; 28(1):278-87.
13. Nirschl RP. Prevention and treatment of elbow and
shoulder injuries in the tennis player. Clin Sports Med.
1988; 7(2):289-308.
14. Tasto JP, Richmond JM, Cummings JR, Hardesty R,
Amiel D. Radiofrequency microtenotomy for elbow
epicondylitis: midterm results. Am J Orthop. 2016;
15. Tasto JP, Cummings J, Medlock V, Hardesty R, Amiel
D. Microtenotomy using a radiofrequency probe
to treat lateral epicondylitis. Arthroscopy. 2005;
16. Wilhelm A, Gieseler H. Die behandlung der
epicondylitis humeri radialis durch denervation.
Chirurg. 1962; 33(1):118-22.
17. Wilhelm A. Treatment of therapy refractory
epicondylitis lateralis humeri by denervation. On the
pathogenesis. Handchir Mikrochir Plast Chir. 1999;
18. Hohmann G. Ü􀇆 ber den tennisellenbogen. Verh Dtsch
Orthop Ges. 1927; 21(1):349-54.
19. Karkhanis S, Frost A, Maffulli N. Operative
management of tennis elbow: a quantitative review.
Br Med Bull. 2008; 88(1):171-88.
20. Baumgard SH, Schwartz DR. Percutaneous release of
the epicondylar muscles for humeral epicondylitis.
Am J Sports Med. 1982; 10(4):233-6.

21. Baker CL Jr, Murphy KP, Gottlob CA, Curd DT.
Arthroscopic classification and treatment of lateral
epicondylitis: two-year clinical results. J Shoulder
Elbow Surg. 2000; 9(6):475-82.
22. Stapleton TR, Baker CL. Arthroscopic treatment of
lateral epicondylitis: a clinical study. Arthroscopy.
1996; 12(3):365-6.
23. Owens BD, Murphy KP, Kuklo TR. Arthroscopic
release for lateral epicondylitis. Arthroscopy. 2001;
24. Peart RE, Strickler SS, Schweitzer JK Jr. Lateral
epicondylitis: a comparative study of open and
arthroscopic lateral release. Am J Orthoped. 2004;
25. 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):721-7.
26. Sperling JW, Smith AM, Cofield RH, Barnes S. Patient
perceptions of open and arthroscopic shoulder
surgery. Arthroscopy. 2007; 23(4):361-6.
27. Othman AM. Arthroscopic versus percutaneous
release of common extensor origin for treatment
of chronic tennis elbow. Arch Orthop Trauma Surg.
2011; 131(3):383-8.
28. Yeoh KM, King GJ, Faber KJ, Glazebrook MA, Athwal GS.
Evidence-based indications for elbow arthroscopy.
Arthroscopy. 2012; 28(2):272-82.
29. Savoie FH 3rd, VanSice W, O’Brien MJ. Arthroscopic
tennis elbow release. J Shoulder Elbow Surg. 2010;
30. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati
A, Petticrew M, et al. Preferred reporting items for
systematic review and meta-analysis protocols
(PRISMA-P) 2015 statement. Syst Rev. 2015; 4(1):1.
31. Gummesson C, Atroshi I, Ekdahl C. The disabilities
of the arm, shoulder and hand (DASH) outcome
questionnaire: longitudinal construct validity and
measuring self-rated health change after surgery.
BMC Musculoskelet Disord. 2003; 4(1):11.
32. Wells G, Shea B, O’connell D, Peterson J, Welch V,
Losos M, et al. The Newcastle-Ottawa Scale (NOS)
for assessing the quality of nonrandomised studies
in meta-analyses. Ottawa (ON): Ottawa Hospital
Research Institute; 2009.
33. Ruch DS, Orr SB, Richard MJ, Leversedge FJ, Mithani
SK, Laino DK. A comparison of debridement with
and without anconeus muscle flap for treatment of
refractory lateral epicondylitis. J Shoulder Elbow
Surg. 2015; 24(2):236-41.
34. Barth J, Mahieu P, Hollevoet N. Extensor tendon and
fascia sectioning of extensors at the musculotendinous
unit in lateral epicondylitis. Acta Orthop Belg. 2013;
35. Manon-Matos Y, Oron A, Wolff TW. Combined
common extensor and supinator aponeurotomy for
the treatment of lateral epicondylitis. Tech Hand Up
Extrem Surg. 2013; 17(3):179-81.
36. Reddy V, Satheesan KS, Bayliss N. Outcome of Boyd-
McLeod procedure for recalcitrant lateral epicondylitis
of elbow. Rheumatol Int. 2011; 31(8):1081-4.

37. Solheim E, Hegna J, Øyen J. Extensor tendon release
in tennis elbow: results and prognostic factors in 80
elbows. Knee Surg Sports Traumatol Arthrosc. 2011;
38. Coleman B, Quinlan JF, Matheson JA. Surgical treatment
for lateral epicondylitis: a long-term follow-up of
results. J Shoulder Elbow Surg. 2010; 19(3):363-7.
39. Dwyer AJ, Govindaswamy R, Elbouni T, Chambler
AF. Are “knife and fork” good enough for day case
surgery of resistant tennis elbow? Int Orthop. 2010;
40. Rayan F, Rao V Sr, Purushothamdas S, Mukundan
C, Shafqat SO. Common extensor origin release in
recalcitrant lateral epicondylitis-role justified? J
Orthop Surg Res. 2010; 5(1):31.
41. Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten-to 14-year
follow-up of the Nirschl surgical technique for lateral
epicondylitis. Am J Sports Med. 2008; 36(2):261-6.
42. Cho BK, Kim YM, Kim DS, Choi ES, Shon HC, Park KJ, et
al. Mini-open muscle resection procedure under local
anesthesia for lateral and medial epicondylitis. Clin
Orthop Surg. 2009; 1(3):123-7.
43. Thomas S, Broome G. Patient satisfaction after
open release of common extensor origin in treating
resistant tennis elbow. Acta Orthop Belg. 2007;
44. Balk ML, Hagberg WC, Buterbaugh GA, Imbriglia JE.
Outcome of surgery for lateral epicondylitis (tennis
elbow): effect of worker’s compensation. Am J Orthop.
2005; 34(3):122-6.
45. Thornton SJ, Rogers JR, Prickett WD, Dunn WR, Allen
AA, Hannafin JA. Treatment of recalcitrant lateral
epicondylitis with suture anchor repair. Am J Sports
Med. 2005; 33(10):1558-64.
46. Rayan GM, Coray SA. V-Y slide of the common extensor
origin for lateral elbow tendonopathy. J Hand Surg.
2001; 26(6):1138-45.
47. Yoon JP, Chung SW, Yi JH, Lee BJ, Jeon IH, Jeong WJ,
et al. Prognostic factors of arthroscopic extensor
carpi radialis brevis release for lateral epicondylitis.
Arthroscopy. 2015; 31(7):1232-7.
48. Soeur L, Desmoineaux P, Devillier A, Pujol N, Beaufils
P. Outcomes of arthroscopic lateral epicondylitis
release: Should we treat earlier? Orthop Traumatol
Surg Res. 2016; 102(6):775-80.
49. Oki G, Iba K, Sasaki K, Yamashita T, Wada T. Time
to functional recovery after arthroscopic surgery
for tennis elbow. J Shoulder Elbow Surg. 2014;
50. Rhyou IH, Kim KW. Is posterior synovial plica excision
necessary for refractory lateral epicondylitis of the
elbow? Clin Orthop Relat Res. 2013; 471(1):284-90.
51. Sauvage A, Nedellec G, Brulard C, Gaumet G, Mesnil
P, Fontaine C, et al. Arthroscopic treatment of lateral
epicondylitis: a prospective study on 14 cases. Chir
Main. 2013; 32(2):80-4.
52. Kim JW, Chun CH, Shim DM, Kim TK, Kweon SH,
Kang HJ, et al. Arthroscopic treatment of lateral
epicondylitis: comparison of the outcome of ECRB
release with and without decortication. Knee Surg
Sports Traumatol Arthrosc. 2011; 19(7):1178-83.

53. Lattermann C, Romeo AA, Anbari A, Meininger AK,
McCarty LP, Cole BJ, et al. Arthroscopic debridement
of the extensor carpi radialis brevis for recalcitrant
lateral epicondylitis. J Shoulder Elbow Surg. 2010;
54. Grewal R, MacDermid JC, Shah P, King GJ. Functional
outcome of arthroscopic extensor carpi radialis brevis
tendon release in chronic lateral epicondylitis. J Hand
Surg Am. 2009; 34(5):849-57.
55. Wada T, Moriya T, Iba K, Ozasa Y, Sonoda T, Aoki
M, et al. Functional outcomes after arthroscopic
treatment of lateral epicondylitis. J Orthop Sci. 2009;
56. Baker CL Jr, Baker CL 3rd. Long-term follow-up of
arthroscopic treatment of lateral epicondylitis. Am J
Sports Med. 2008; 36(2):254-60.
57. Jerosch J, Schunck J. Arthroscopic treatment of
lateral epicondylitis: indication, technique and early
results. Knee Surg Sports Traumatol Arthrosc. 2006;
58. Mullett H, Brown G, Hausman M. Arthroscopic
treatment of lateral epicondylitis: clinical and
cadaveric studies. Clin Orthop Relat Res. 2005;
59. Kwon BC, Kim JY, Park KT. The Nirschl procedure
versus arthroscopic extensor carpi radialis brevis
debridement for lateral epicondylitis. J Shoulder
Elbow Surg. 2017; 26(1):118-24.
60. Solheim E, Hegna J, Øyen J. Arthroscopic versus open
tennis elbow release: 3-to 6-year results of a casecontrol
series of 305 elbows. Arthroscopy. 2013;
61. Yan H, Cui GQ, Liu YL, Xiao J, Yang YP, Ao YF. A
randomized comparison of open and arthroscopic
Nirschl debridement for refractory lateral
epicondylitis. Zhonghua Wai Ke Za Zhi. 2009;
62. Rubenthaler F, Wiese M, Senge A, Keller L, Wittenberg
RH. Long-term follow-up of open and endoscopic
Hohmann procedures for lateral epicondylitis.
Arthroscopy. 2005; 21(6):684-90.
63. Paoloni JA, Appleyard RC, Murrell GA. The
orthopaedic research institute-tennis elbow testing
system: a modified chair pick-up test-interrater
and intrarater reliability testing and validity for
monitoring lateral epicondylosis. J Shoulder Elbow
Surg. 2004; 13(1):72-7.
64. Kroslak M, Murrell GA. Surgical treatment of lateral
epicondylitis: a prospective, randomized, doubleblinded,
placebo-controlled clinical trial. Am J Sports
Med. 2018; 46(5):1106-13.
65. Cusco X, Alsina M, Seijas R, Ares O, Alvarez-Diaz
P, Cugat R. Proximal disinsertion of the common
extensor tendon for lateral elbow tendinopathy. J
Orthop Surg. 2013; 21(1):100-2.
66. Khashaba A. Nirschl tennis elbow release with or
without drilling. Br J Sports Med. 2001; 35(3):200-1.
67. Kraushaar BS, Nirschl RP. Current concepts reviewtendinosis
of the elbow (tennis elbow). Clinical features
and findings of histological, immunohistochemical,
and electron microscopy studies. J Bone Joint Surg
Am. 1999; 81(2):259-78.
68. Lo MY, Safran MR. Surgical treatment of lateral
epicondylitis: a systematic review. Clin Orthop Relat
Res. 2007; 463(1):98-106.
69. Nirschl RP. Lateral extensor release for tennis elbow. J
Bone Joint Surg Am. 1994; 76(6):951.
70. Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ. Salvage
surgery for lateral tennis elbow. Am J Sports Med.
1997; 25(6):746-50.
71. Brummel J, Baker CL 3rd, Hopkins R, Baker CL Jr.
Epicondylitis: lateral. Sports Med Arthrosc Rev. 2014;
72. Bosworth DM. Surgical treatment of tennis elbow:
a follow-up study. J Bone Joint Surg Am. 1965;
73. Garden RS. Tennis elbow. J Bone Joint Surg Br. 1961;
74. Cyriax JH. The pathology and treatment of tennis
elbow. J Bone Joint Surg. 1936; 18(4):921-40.
75. Goldie I. Epicondylitis lateralis humeri (epicondylalgia
or tennis elbow). a pathogenetical study. Acta Chir
Scand Suppl. 1964; 57(Suppl):339.
76. Laratta J, Caldwell JM, Lombardi J, Levine W, Ahmad
C. Evaluation of common elbow pathologies: a focus
on physical examination. Phys Sportsmed. 2017;
77. Pederzini L, Di Palma F. Medial and lateral epicondylitis.
Muscle Tendon Injur Evaluat Manag. 2017; 21(2):223.
78. Pederzini LA, Di Palma F, Safran MR, Bain GI. Elbow
arthroscopy: state of the art. J ISAKOS. 2017;
79. Grifka J, Boenke S, Krämer J. Endoscopic therapy in
epicondylitis radialis humeri. Arthroscopy. 1995;