Elbow Pain

Chris C., Chatsworth, California, 2001. Tendonitis.

Chris is a 14 years old student, suffered an injury on his right elbow during baseball playing on May 1, 2001. He experienced persistent moderated pain in his elbow with mildly limitation of movement. X-ray of the right elbow did not show any bony destruction and tendinitis was diagnosed. Anti-inflammatory and pain relieve medicine could not help his pain. On 8/22/01, he came to our clinic for acupuncture treatment. Marked tenderness over the posterior and medial side of the right elbow was detected. Pain induced by turning the forearm and flexing of the elbow. Neurological examination revealed nothing abnormal. Electro-acupuncture treatment started to perform with local needling plus heat applied.

At the 4^th treatment, 8/29/01, he started to feel better relief. The degree of pain became lesser and the range of motion increased markedly. His condition was improved with treatment and was dismissed with very mild degree of pain after the 9^th treatment.  

Unfortunately, he re-injury his right elbow on 10/3/01 by throwing baseball. Repeat acupuncture and heat treatment were performed. And the pain of his right elbow was found to be completely resolved after 6 more treatments on 11/7/01with no limitation of movement.

 Structure of the elbow joint

The elbow is a hinge joint formed by the meeting of three bones, humerus of the upper arm, radius and ulna of the forearm. The contacting of the humerus and the ulna formed an anterior flexible joint, and the radius meet the ulna in the elbow to allow for rotation of the forearm. The Biceps is the major muscle that flexes the elbow and the triceps is the muscle that extends the elbow. Medial and Lateral epicondyles are the bony prominence in the inner and outer portion of the elbow. Muscle tendons are attached to these epicondyles. A bursa, fluid-filled sac which serves to reduce friction, overlies the tip of the elbow.

Causes of elbow pain

1. Tendinitis.

• Lateral epicondylitis (Tennis Elbow) Tennis elbow results with injury of the tendons which attached to the outer bony prominence of the elbow causing pain over that area. The tendon can be injured by trauma or repetitive motions of the forearm, such as hitting a backhand in tennis play, using a manual screwdriver or washing windows. Lateral epicondylitis is considered more of a mechanical problem with degeneration of the tendon than inflammatory changes.
• Medial epicondylitis (Golf’s elbow) Inflammation of the tendon which attached to the inner prominence of the elbow causing results Golf’s elbow. This tendon can become strained in a golf swing or by other repetitive motions. Activities which require twisting or straining the forearm tendon can elicit pain and worsen the condition.

1. Bursitis. Olecranon bursitis is an inflammation of the bursa at the tip of the elbow. Bursitis can occur from injury or minor trauma, as a result of systemic diseases (gout or rheumatoid), or can be due to a local infection.
2. Arthritis. Inflammation of the elbow joint can occur as a result of many systemic of arthritis, including gouty, rheumatoid, psoriatic, reactive arthritis. Sign of local inflammation, e.g. heat, swelling, pain, tenderness and decreased range of motion can be seen.
3. Fracture. Broken of bone of the elbow usually was caused by trauma.
4. Infection. Infection of the joint, called septic arthritis, is uncommon. It is most often seen in patient with suppressed immunity. Infection of the skin, called cellulitis, commonly occurs as a result of abrasion or puncture to the area.
5. Ulnar nerve entrapment. The ulnar nerve is travels between the tip of the elbow and the inner elbow bone on the posterior portion of the elbow. This nerve can be pinched or entrapment by normal or swollen structures after injury. Pain over the forearm, especially the inner side and numbness of the little and ring finger can be experienced.
6. Tumor. Bone tumors of the elbow are rare. It can be pain or painless.

The role of acupuncture in the treatment of elbow pain

The principle of acupuncture treatment is based on the theory of Traditional Chinese Medicine (TCM). According to TCM, pain occurs when there is “obstruction” in the energy flow. The meaning of obstruction can be translated into modern concept which will be blockage of circulation, spasm of muscles, compression of nerve and stasis of lymphatic vessels. The acupuncture points used mostly are analgesic points, muscle relaxing points, mental clamming points and energy enhancing points. When the flow of different energies are return to floating ahead, no more obstruction, pain will eventually disappeared.  

One of the most frequent injuries suffered by athletes likely is lateral epicondylitis, Tennis elbow. It is caused by repeated twisting of the wrist or frequent rotation of the forearm and can be lead to elbow pain, weakened grip, and damage to the bone of the upper arm, humerus.

Traditional therapy of tennis elbow consists of rest, braces, heat, physical therapy and medications. The majority of these treatments is effective in relieving pain but serves little for restoring the function of the elbow, joint and tendon, and to prevent the condition from recurring. Clinical practices and researches suggest that acupuncture not only relieves the symptoms of tennis elbow, it appears to resolve the condition completely.

What we do

Standard steps we approach to patient with elbow pain:

1. Record detail history of illness to sort out the cause of the pain.

2. Review test data and imaging result (X-ray, CT scan, MRI).

3. Perform physical examination and movement test to picture the illness tissues.

4. Propose a treatment plan.

5. Common acupuncture points used include: Ear liver, kidney, and adrenal; Local analgesic and trigger point. Distal points for low energy or hormonal imbalance.

6. Add Electric stimulation or cupping as needed.

7. Rest, ergonomic activity modification, and extensor muscle strengthening exercise are recommended to the patients.

Demography of elbow pain patient and treatment results of our clinic

Study data draw from 2003 to 2007. Age: 45 to 80, average 63. Gender: F: M=3:1

 

Diagnosis	% of total pain patients	% of Improvement	% of marked improvement	Average treatment
Tendinitis	4.5	76.8	57.2	10

Be noted that the result of treatment relate closely with many factors include age, gender, length of sickness, severity of sickness, treatment that have used and current combined therapy. Many people who have tennis elbow cannot avoid long time of using keyboard of computer that resulted acupuncture less effective. And because of that many had their pain recurred in the later time.

Documentation on treatment of tennis elbow with acupuncture

Dorsher PT. Treatment of chronic lateral epicondylitis with acupuncture: a pilot study. Presented at the annual meeting of the American Academy of Physical Medicine and Rehabilitation, San Francisco, CA, November 4, 2000

Dr. Peter Dorsher, a medical doctor certified in acupuncture, reported 22 patients, performed acupuncture treatment with varying degrees of tennis elbow. Subjects in this study group suffered symptoms for 8 months in average, 6 of them had symptoms for more than 2 years. Every patient had previously attempted to cure the disease through multiple conventional therapies without success before trying acupuncture.

Of 22 patients in this study group, 14 patients had undergone extensive interventions, 17 had used an elbow brace or splint, 7 received corticosteroid injections for pain relief, and one patient had elbow surgery.

All the patients were treated with needle insertion on the local points around the elbow joint in tight myofascial bands. Each patient was treated between 2-10 times. A maximal response was achieved with disappearance of symptoms after an average of 3.9 treatments. The response also appeared to last much longer than that usually seen in patients using other traditional methods.

Follow-up for average 8.5 months after receiving acupuncture, 77.3% (n=17) of patients experienced a resolution of symptoms and had returned to full, normal activities; another 2 patients had returned to normal activities except those that involved heavy lifting in the affected arm.

From this small group study, it is clearly showed that acupuncture helps patient in the early and latter stages of tennis elbow, with immediately loosen the tight muscles around the elbow joint. Acupuncture is an extremely powerful tool for pain and very helpful to tennis elbow. It might consider acupuncture as a primary form of treatment.

Su X el at. Effects of electroacupuncture of different frequencies for treatment of patients with refractory tennis elbow syndrome. Zhongfuo Zhen Jiu 2010 Jan;30(1):43-5.

Eighty five patients with refractory tennis elbow syndrome were randomly divided into continuous wave electro-acupuncture group (n=41) and rarefaction wave group (n= 44). The same acupuncture points were selected in both groups, and the major acupuncture points were the trigger points around affected area in both groups. The Visual Analogue Scale (VAS) was used to evaluate the tenderness score of each patient in both groups. The effectiveness was evaluated by the tenderness score. The results shown that the effective rate was 82.9% in the continuous wave group and 84. 1% in rarefaction wave group. The healing rate was 56.8% in rarefaction wave group, better than the 31. 7% in continuous wave group. There was significant difference in decreasing the VAS score between two groups after treatment, and the rarefaction wave group was better than the continuous wave group.

J. Mark Geard. What treatment works best for tennis elbow? The J. of Fam. Practice March 2009 Vol. 58, No. 3:159-161

In the article he coded that topical or oral nonsteroidal anti-inflammatory medications (NSAIDs), corticosteroid injection, and acupuncture are more helpful than placebo in treating lateral epicondylitis, or tennis elbow which had shown by evidence-based results. A corticosteroid injection is effective for short-term therapy, as long as 6 weeks, but produces no long-term improvement. Physiotherapy or a wait-and-see approach is superior to corticosteroid injection at 52 weeks. There’s insufficient evidence to support specific physiotherapy methods or braces, shock wave therapy, ultrasound, or deep friction massage. Surgery may succeed in refractory cases that have failed extensive conservative measures.