Type 1 failure occurs when an inaccurate initial diagnosis is made or a concomitant diagnosis contributing to symptomatology persists [1]. As the underlying source of pain is not sufficiently addressed at the time of surgery, the patient will report lingering elbow pain that is comparable to discomfort experienced before surgery [1, 30]. Causes for Type 1 failure include nerve irritability, a synovial plica, osteoarthritis, osteochondritis dissecans (OCD) of the capitellum, a snapping triceps tendon, lateral ligament insufficiency, an anconeus compartment syndrome, and an osteoid osteoma of the capitellum (Fig. 15.2).

Radial tunnel syndrome, signifying irritability of the posterior interosseus nerve (PIN) in the proximal forearm without a clearly identified impinging structure, is the most common cause of Type 1 failure [1, 9, 13, 30, 39, 40, 44–49]. Werner et al. [46] found that 13 % of failures after tennis elbow surgery were due to this condition. Lateral elbow pain from entrapment of the PIN by a ganglion cyst has also been reported [50]. Other potential neurological causes of lateral elbow pain include cervical radiculopathy, brachial plexopathy, and entrapment of the lateral antebrachial cutaneous nerve or the posterior brachial cutaneous nerve [27, 51].

A synovial plica represents a focal thickening of synovial tissue [1, 30, 48, 52]. Patients may describe a snapping sensation or pain in the elbow with inclusion of the redundant tissue in the radiocapitellar joint [52]. Underlying structural defects in the radiocapitellar joint such as osteoarthritis and OCD of the capitellum can lead to discomfort, clicking, and catching sensations [1, 13, 30, 39, 40, 47, 48, 53]. Sasaki et al. [54] arthroscopically investigated the correlation of radiocapitellar cartilage integrity with lateral epicondylitis and detected cartilage defects in the capitellum and radial head in 65 and 81 % of elbows, respectively. Other authors have found intraarticular pathology in 11–69 % of patients with lateral epicondylitis [4, 13, 40, 42, 55] (Fig. 15.3).

Snapping triceps syndrome involves painful translation of the lateral margin of the triceps tendon over the lateral epicondyle during elbow flexion [56]. Patients with a cubitus valgus deformity of the elbow may be particularly susceptible to this condition. A less common cause of Type 1 failure includes lateral ligament insufficiency with varus posterolateral rotatory instability of the elbow [1, 35]. Painful instability may develop following trauma or insidiously, as has been reported in patients with a preexisting cubitus varus deformity, and after local steroid injections into the common extensor tendon origin [47, 57, 58] (Fig. 15.4).

Very infrequent causes of lateral elbow pain include a muscle compartment syndrome (e.g., anconeus muscle) or an osteoid osteoma [1, 14, 44, 59]. The possibility of an osteoid osteoma should be considered in a younger patient with atypical pain, especially at night [60].

Type 2 failures result from inadequate debridement of pathological tissue from the common extensor tendon origin [1]. Patients will typically describe residual pain at the same site as being less severe or different in character from their pain experienced before surgery [1, 30]. This scenario may require revision debridement to address the problem.

Type 3 failures result from the introduction of new pathology following surgical intervention [1]. Patients may describe a myriad of upper extremity symptoms including pain, numbness, weakness, joint laxity, stiffness, swelling, and catching.

Injuries to the radial nerve, the posterior interosseus nerve, and the anterior interosseous nerve have been reported [41, 61]. Formation of a troublesome synovial fistula can result from extensive debridement of the extensor origin and joint capsule [33, 47]. Overly aggressive removal of tissue may also lead to disruption of the lateral collateral ligament complex and varus posterolateral rotatory instability of the elbow (Figs. 15.5 and 15.6).

Less common etiologies of Type 3 failure include infection and osteophyte formation [62]. Growth of an osteophyte at the lateral epicondyle may lead to a snapping sensation with joint motion [62]. Elbow pain, swelling, and stiffness in the presence or absence of systemic symptoms may be indicative of a deep joint ­infection.

Misguided rehabilitation and patient noncompliance have been conjectured as the most common causes of persistent lateral elbow pain after tennis elbow release surgery [1, 13]. Studies have shown higher levels of pain and longer periods of convalescence in patients receiving workers’ compensation benefits when compared to patients not receiving benefits. Das De et al. [63] recently proposed psychological dysfunction as a primary etiology for lateral epicondylitis. In a cross-sectional study of persons with an upper-extremity-specific disability, these authors found that lower preoperative DASH scores correlated significantly with anxiety, depression, and kinesiophobia in patients undergoing treatment for lateral epicondylitis [63].