For decades, surgeons have been reporting good results with surgery for tennis elbow. In a classic article from 1961, the late, great British surgeon RS Garden, reported that the results of surgery for tennis elbow were such that “no patient failed to benefit in some way from the operation”. Fifty years later in a review of 80 patients undergoing surgery for tennis elbow, 78 were reported to have improved. There are plenty of non-surgical treatments out there for tennis elbow (lateral epicondylitis) - all of them are reported as having good results, yet none of them are any better than placebo. Why then, did it take until now for a randomised trial to be done comparing real surgery with sham surgery?
The sham surgery trial
The study, of course, showed no advantage of real surgery over sham surgery. And, of course, patients in both groups get better. There was, however, one difference in outcome between the sham and real surgical patients; the surgical patients had more pain at two weeks.
Other treatments for tennis elbow
Patients improve after any treatment for tennis elbow, they just don’t improve because of the treatment. Take steroid injections, ultrasound (shock wave) therapy, orthotics and acupuncture – they are all perceived to ‘work’ (in that patients usually feel better afterwards), but they all fail when put up against a well-blinded placebo. (Review of corticosteroid injections here, Cochrane reviews of shock wave therapy here, orthotic devices here, and acupuncture here).
The classic article
The article by Garden from 1961 is worth a read, if only to see the standard of surgical research at that time. It is actually a comprehensive case series, it just contains so many logical and methodological flaws (that are largely hidden to the reader and the author). Most telling is Garden’s attitude: it was clear to him that the operation was successful, and in a sense he was right. It’s just that the patients didn’t get any better because of the surgery, and his study did not prove that they did.
Garden also said that surgery was usually not necessary because the results of steroid injections were so good. Yet at best, steroid injections give short-term benefit and then that’s it. I reckon if you didn’t mix them with local anaesthetic, you wouldn’t even get the short-term relief.
The bottom line
Nearly every operation being performed for subjective complaints (usually pain) today has not been tested against placebo and is performed for the very reason that Garden did his operation on tennis elbow: because the patients seem to get better afterwards (see my previous blog post for a more detailed explanation of the ‘wobbly tripod’ of evidence for surgery).
I was going to say that this is a case of (the logical fallacy of) post hoc, ergo propter hoc on steroids, except that steroids don’t work either.