David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

TENNIS ELBOW

Tennis elbow or “lateral epicondylitis” was initially described in 1882 as a common lawn tennis injury that arose due to the backhand stroke. It was initially believed that the pain was due to inflammation caused by a partial tear of the tendon of one of the major wrist extensors where it attached to the bony prominence on the outer aspect of the elbow i.e. the lateral epicondyle. It is now thought the pain is due to an inadequate repair process of this tear rather than acute inflammation. This may be due to relative lack of blood supply to the undersurface of this tendon which impairs its ability to heal.

Clinical aspects
It occurs equally in men and women, usually between the ages 35 and 50. Typically one will complain of pain over the lateral aspect of the elbow that is worsened by lifting or gripping but even simple activities such as brushing the teeth or picking up a coffee cup can cause considerable discomfort. Point tenderness over the lateral epicondyle is present which is exacerbated by resisted wrist and finger extension. Patients with radial tunnel syndrome often have coexisting lateral epicondylitis and require careful examination to determine if one or both diagnoses apply. X-rays are usually normal although calcification along the lateral epicondyle may be seen.

Nonoperative treatment
The hallmark of treatment is activity modification, with avoidance of activities requiring prolonged gripping, such as holding a hand bag, or activities requiring repetitive grasping or torquing such as using a hammer or screwdriver. Patient are counseled to lift with their palms up, which uses the forearm flexor muscles and spares the extensors. A tennis elbow splint can be worn over the upper forearm, which works by limiting the muscle excursion of the extensor muscles. A wrist splint may help by holding the wrist in extension which puts the forearm wrist extensor muscles at rest.

Therapy can be of use and includes ultrasound, iontophoresis, massage, stretching and gradual strengthening exercises. The most commonly injected substance is a combination of local anesthetic and corticosteroid. Up to three injections at least 6 weeks apart can be beneficial. Multiple injections however should be avoided since tendon rupture can occur. The risks of corticosteroid injections include skin atrophy and discoloration. Other substances injected into the lateral epicondyle include autologous blood, botulinum toxin (Botox) and glycosaminoglycans with varying success rates. Acupuncture has been shown to provide short-term pain relief. Extracorporeal shock wave therapy (ESWT) has been tried as a nonoperative but recent reports have shown little benefit compared with other treatments, with morbidity from ESWT including pain, reddening of the skin, hematoma, and swelling.

Surgical Treatment
Surgery is recommended only after a patient fails conservative treatment, which includes activity modification, splinting, therapy, and injection. Multiple surgical techniques have been described for this problem.

The majority of lateral epicondylitis surgeries involve some type of release or lengthening of the extensor carpi radialis brevis tendon, which is one of the major wrist extensor muscles. Most of the recent studies of ECRB release or lengthening have shown a 69% to 100% success rate with decreased pain and improved function
Debridement of the Extensor Origin (link to video)

In 1979, Nirschl and Pettrone described incising and retracting the ECRL to reveal the ECRB tendon origin, which was incised with debridement of fibrous or granulation tissue, removal of necrotic-appearing ECRB origin, inspection of the lateral aspect of the joint, and excision of a small amount of bone over the lateral epicondyle. In 88 patients treated for chronic lateral epicondylitis, 97.7% showed improvement over their preoperative status and 85.2% were able to return to work, having achieved complete pain relief by 3 months. Later studies showed 83% to 94% pain relief in patients treated with ECRB release and debridement.

Work Considerations
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 12 - 16 weeks but recurrences with repetitive gripping activities are common hence gripping restrictions may be necessary..