Lateral Epicondylalgia - Medical Acupuncture Based Treatment Approach

A Case Study

Introduction

Lateral epicondylalgia (LE), otherwise known as tennis elbow, is a common condition causing pain at the lateral elbow and forearm, as well as a lack of strength and function of the elbow and wrist.1 From a clinical point of view, many patients presenting with this condition are sports people. However others have developed the condition either by working in very manually orientated jobs, or in more sedentary jobs with repetitive use of computers for example. I used to approach the condition with some trepidation, as from experience LE had always been a very difficult condition to treat. However since using a primarily Medical Acupuncture (MA) based approach, my results have been more positive as the following case illustrates.

Presenting complaint

Mr. D complained of severe local tenderness at and just below the lateral epicondyle of the right elbow, associated with radiating pain through the dorsal forearm as far as the wrist. On the day of assessment his pain level was 6 on the VAS. He found certain activities involving the wrist and hand painful and ‘weak’ e.g. lifting boxes, carrying objects as well as playing golf. Mr. D mentioned that his forearm muscles felt very tight and that his wife had found very sore points when trying to assist with local massage. There was no altered sensation or paraesthesia to report and he had no neck pain or stiffness.

History

Dr. D is a self employed importer of goods that are boxed and need to be lifted, transported and delivered to various locations. He developed his symptoms gradually over a period of two weeks, and had experienced daily pain over the last month prior to his physiotherapy assessment. He had tried oral anti-inflammatory drugs which had no effect. He could not account for the onset of his symptoms but feels that playing golf more often over the summer may have been responsible. There was a history of a couple of bouts of neck pain over the years which had always settled without intervention. He had no other medical conditions or concerns.

Examination

Severe local tenderness was present at and just distal (over the radio-humeral joint space) to the lateral epicondyle over the common extensor tendon. Taut bands were found in the forearm extensor muscles. Two trigger points (TrP) were identified, one in the extensor carpi radialis brevis and the other in extensor digitorum communis, both were active and referred pain familiar to Mr. D distally and slightly proximally towards the elbow. These would be common muscles in which to locate TrP’s associated with LE.1 His range of elbow and wrist movement was full. Pain at the elbow was provoked by resisted wrist extension from a forearm pronated position, on resisted third digit extension, and on gripping. His neck mobility was unrestricted. From a neurological point of view he showed no sensory change or reflex loss, and his neural tension provocation tests were negative.

Impression

Mr. D was suffering from an enthesopathy of the common extensor tendon bringing about a lateral epicondylalgia. In the absence of positive neurological tests and with no current cervical restriction on assessment, no radiculopathic type segmental sensitivity issues were suspected. Any underlying elbow joint arthritis was considered unlikely due to a full range of elbow movement, however would be considered as a possible differential diagnosis depending on response to treatment.

Treatment Plan

Mr. D. had an appointment booked with an orthopaedic surgeon for six weeks time. He had been encouraged by his wife, but mentioned he had little faith in ‘the cortisone injection’ as many of his friends with the same condition had not benefitted from this approach. As such he wanted to try physiotherapy. I proposed an acupuncture based approach alongside graded loading exercises if his pain levels could be reduced.

Treatment would be guided by the MA approach described by Harrsion et al.2 This would involve needling the TrP sites located on assessment along with LI11 and LI4. LI11 may have been chosen on the basis of a myotomal segmental innervation overlapping with that of the common extensor tendon. LI4 is a well known analgesic point according to traditional Chinese principles of treatment.3 Furthermore a local periosteal needling technique would be directed at the lateral epicondyle when appropriate.

Treatment would take place on a weekly basis, and gradually integrate specific graded loading exercises. Mr. D had not received MA treatment previously, as such we had a detailed discussion regarding the technique. It was explained that following MA he may experience certain minor adverse reactions such as treatment soreness, bruising, dizziness and sedation. It was also explained that anatomically, the elbow region presents few hazards, as long as safe penetration depths are used. Major adverse events such as infection could be avoided by using single use, sterile disposable needles along with good hygiene practice.

A trial of four sessions would be given, with at least three being at an optimum dose to determine responsiveness. The optimum dose would be defined as the maximum sensory input to the central nervous system without aversive pain or reaction, and would be determined by the patient’s relative sensitivity. The dose could be increased if required by increasing the level of manual stimulation, increasing the number of needles, or increasing the depth within safe limits. If there were no symptomatic improvements following four sessions, treatment would be discontinued or the approach revised.

Outcome measures would include pain levels on the VAS, local tenderness, and the objective pain provocation tests used on assessment. The overall functional goal was a return to playing golf.

Vinco 25mm x 0.22mm needles would be used.

Treatment and results

Session 1:

LI11 and LI4 (care taken not to angle needle towards the palmar branch of the radial artery) were needled to a depth of 1.5cm and left in situ without further added stimulation. A vague dull de qi type sensation was reported local to both needles. A needle was then placed locally at the lateral epicondyle to make contact with the periosteum, this caused a sharp pain sensation. LI11 and LI4 were left in place for 10 minutes and the periosteal needle in place for 30 seconds. Mr. D found the periosteal needle painful but not intolerable. Following treatment advice was given regarding postural control, modification of aggravating activities and complete rest from golf. A forearm extensor stretch was given.4

Session 2:

On follow up visit a week later, he reported no change in symptom severity and an increase in local tenderness at the lateral epicondyle. It was decided to continue with LI4 and LI11, but to discontinue use of the periosteal needle in favour of needling the TrP sites. It was reasoned the common extensor tendon insertion to the lateral epicondyle may be too irritable and tender to needle directly at this stage. The extensor carpi radialis brevis and extensor digitorum communis were needled to a depth of 1cm each. A similar de qi sensation was evoked at the TrP sites with familiar referred pain through the forearm. Needling duration was 15 minutes with some added manual stimulation after 5 minutes to maintain the comfortable de qi sensation.

Sessions 3/4:

At his third visit he reported improvements in pain and function, with a slight decrease in local tenderness at the lateral epicondyle. Treatment was repeated in the same manner for both sessions.

Sessions 5/6:

By this stage Mr. D’s forearm muscle tone had significantly improved with less local tenderness over the TrP sites. There was still local tenderness over the common extensor tendon. The sensitivity had improved such that it was possible to needle it locally using the periosteal technique for 2 minutes without the pain response initiated at the first session. Other points needled at this session were LI4, LI11, as well as the above TrP’s, again for a duration of 15 minutes. As the TrP sensitivity to palpation and referred pain severity was improving, it was felt trying to elicit local twitch responses was not necessary. At this stage a strength programme was introduced with a gradual progression from concentric to eccentric loading planned.4

Session 7:

After another two weekly sessions, Mr. D’s pain was now very intermittent and was given a 2 on the VAS. The objective tests including resisted wrist, third finger extension and gripping were non provocative. He reported being able to work with no real discomfort albeit in ways modified. Mr. D went to see the orthopaedic consultant the following week. He was very pleased with his progress in physiotherapy and declined the offer of a cortisone injection. It was left that if required, one could be performed at a future date.

Session 8:

After a total of seven sessions Mr. D had improved sufficiently to return to golf having been able to progress his loading exercises and with it develop a greater functional tolerance. He had no pain on objective testing and minimal tenderness at the lateral epicondyle. His pain level was now an intermittent 1 on the VAS, and had been at this level over most of the previous week. Mr. D was discharged to continue his home exercises.

Discussion

A fairly recent systematic review concluded that there was strong evidence suggesting that MA is effective in the short term relief of lateral epicondyle pain.5 Similar conclusions were also made following an earlier systematic review, where no benefit lasting longer than 24 hours was demonstrated.6 As with any condition, if predisposing factors are not addressed, and aggravating activities not modified, one would expect pain relief derived from treatment to be short lived. Furthermore from clinical experience, it is important to recondition the forearm muscles before recommencing activates like golf for example. It was not possible to determine if any of these issues were addressed in the clinical trials reviewed. If they were not this may in part explain the short lived pain relief following acupuncture treatment.

When considering the aetiology of the TrP’s located in the forearm muscles, it is possible they may have developed as a result of central sensitisation changes at the dorsal horn in response to continued nociceptive input arising from the common extensor tendon. 7 This is turn may have resulted in a lowering of sensory pain threshold’s and a widening of receptor fields resulting in the development of ‘secondary’ TrP’s through the forearm muscles, some of which would share the same segmental innervation as the tendon. Another hypothesis is the TrP’s were the primary dysfunction brought about by repetitive strenuous extensor movements at the wrist, resulting in direct mechanical strain being placed on the forearm extensor muscles.1 This progressive muscle shortening may have resulted in the enthesopathy at the insertion of the common extensor tendon.

Although not relevant in this case, it is important to consider the possibility of TrP’s in the muscles of the neck and shoulder region e.g. supraspinatus 8 which may cause lateral elbow pain.D

r. D responded better than most I have treated for this condition. However, since using an MA based approach my results have been better. I would often find a plateau is reached at around 80% improvement. At this stage a cortisone injection is usually required to settle any residual pain, often located at the lateral epicondyle. However the long term effectiveness of steroid injections remains inconclusive.9 Furthermore, as equally good results have been achieved regardless of the injected substance,10 the effect may be due to the high intensity stimulus of the needle.

Previously I have treated this condition using a manual therapy approach11 combined with acupuncture, but was interested to note that in this case apart from some strengthening exercises, an acupuncture approach alone was sufficient to achieve good results.

by Simon.

References