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Abstract

T ennis elbow (lateral elbow pain) has a prevalence of 1.3% with no gender predominance. The pathology is thought to be due to an overuse syndrome of the long extensor muscles of the forearm leading to a localized fas-ciitis or enthesopathy at lateral epicondyle where the ex-tensor tendons insert. Lateral elbow pain is brought on by resisted supination (e.g., wringing a towel or back-hand tennis serve), or simply gripping heavy objects. Tennis elbow pain was described in ancient texts of Traditional Chinese Medicine as zhu láo, which is due to repetitive injury of the tendons with stagnation of blood and excess moisture in the corresponding Large Intestine meridian. In my clinical practice, for treating tennis elbow pain, 1–2 Ah Shi points (maximum tenderness) are normally se-lected, together with Shusa ¯nlı (LI 10), Q € u u € u uchı (LI 11), and Zhuliáo (LI 12). Needles, 0.20mmÂ20 mm, are inserted perpendicularly except at the Ah Shi points which are at 208 to the skin surface. If pain is mild to moderate, it would be beneficial to add 2 Hz low frequency electrical stimulation from a TENS machine. For severe pain, TENS is not recommended and manipulation of needles should be performed to maintain De Qi. During cold and damp weather, indirect moxibustion can be added to the area with a moxa stick to activate the Qi and alleviate blood stagnation. The duration for each acupunc-ture treatment should be 30–35 minutes, to be repeated 2 to 3 times weekly, for a period of 4 weeks. Across the board, over 60% of patients report pain relief and improvement of functionality of their forearm. T he issue in tennis elbow is stagnation in an area between Large Intestine and Triple Energizer meridi-ans. A French Energetics technique is successful for 90% of cases within 4–6 treatments—using either LR 3, LR 8, and GB 34 circuit, or SP 6, SP 9, and ST 36 tonified at 2 Hz along Yin meridian with local points LI 8 to LI 11 as tender plus Ah Shi tender points. The underlying pathology is tendinosis (degeneration without inflammation); the local points are crucial to promote improved blood flow and organized scar tissue formation at the lateral epicondyle. If there is cervical pain referred from the elbows, then the neck should also be treated.
CLINICAL PEARLS
How Do You Treat Tennis Elbow in Your Practice?
T
ennis elbow (lateral elbow pain) has a prevalence
of 1.3% with no gender predominance. The pathology
is thought to be due to an overuse syndrome of the long
extensor muscles of the forearm leading to a localized fas-
ciitis or enthesopathy at lateral epicondyle where the ex-
tensor tendons insert. Lateral elbow pain is brought on by
resisted supination (e.g., wringing a towel or back-hand
tennis serve), or simply gripping heavy objects. Tennis
elbow pain was described in ancient texts of Traditional
Chinese Medicine as zho
ˇ
ula
´
o, which is due to repetitive
injury of the tendons with stagnation of blood and excess
moisture in the corresponding Large Intestine meridian.
In my clinical practice, for treating tennis elbow pain,
1–2 Ah Shi points (maximum tenderness) are normally se-
lected, together with Sho
ˇ
usa
¯
nlı(LI 10), Q
uu
uuchı(LI 11), and
Zho
ˇ
ulia
´
o (LI 12). Needles, 0.20mm20 mm, are inserted
perpendicularly except at the Ah Shi points which are at 208
to the skin surface. If pain is mild to moderate, it would be
beneficial to add 2 Hz low frequency electrical stimulation
from a TENS machine. For severe pain, TENS is not
recommended and manipulation of needles should be
performed to maintain De Qi.
During cold and damp weather, indirect moxibustion can
be added to the area with a moxa stick to activate the Qi and
alleviate blood stagnation. The duration for each acupunc-
ture treatment should be 30–35 minutes, to be repeated 2 to
3 times weekly, for a period of 4 weeks. Across the board,
over 60% of patients report pain relief and improvement of
functionality of their forearm.
Lawrence Leung, MD, MBBChir, BChinMed,
MFM(Clin), FRACGP, FRCG P
Assistant Professor, Department of Family Medicine
Queen’s University
220 Bagot Street
PO Bag 8888
Kingston, Ontario K7L 5E9
Canada
E-mail: leungl@queensu.ca
T
he issue in tennis elbow is stagnation in an area
between Large Intestine and Triple Energizer meridi-
ans. A French Energetics technique is successful for 90% of
cases within 4–6 treatments—using either LR 3, LR 8, and
GB 34 circuit, or SP 6, SP 9, and ST 36 tonified at 2 Hz along
Yin meridian with local points LI 8 to LI 11 as tender plus
Ah Shi tender points. The underlying pathology is tendinosis
(degeneration without inflammation); the local points are
crucial to promote improved blood flow and organized scar
tissue formation at the lateral epicondyle. If there is cervical
pain referred from the elbows, then the neck should also be
treated.
Peter T. Dorsher, MD, MS
Department of Physical Medicine and Rehabilitation
Mayo Clinic Jacksonville
4500 San Pablo Road
Jacksonville, FL 32224
E-mail: dorsher.peter@mayo.edu
A
cupuncture is an effective treatment for tennis
elbow and in my view, may well be the treatment of
choice. It avoids the potential side effects of NSAIDs and
steroid injections, and frequently works with 1 or 2 treat-
ments. Anatomical acupuncture can be a simple initial ap-
proach, supplemented if necessary with meridian-related
points. In a typical case, palpation of the forearm will gen-
erally reveal a number of trigger points in the wrist exten-
sors, but there will often be a more extensive tension pattern
involving triggers up into the shoulders, neck, upper back,
and occasionally even the lower back.
Locally, the site of pain can be surrounded with needles,
and satellite sensitive points needled and desensitized.
This would include forearm points like LI 10,11, LI 4,
LU 5,7, TH 5, PC 3, and HT 3. In the neck, GB 20 is useful,
as are any tender Hua-Tuo-Jia-Ji points in the neck and
upper back. Commonly sensitive points in the rhomboids
might include: BL 13,14,15, and 38(43); in the shoulder:
Medical Acupuncture is pleased to continue this regular feature, Clinical Pearls, which we have found to be very useful and practical
to the readership, and a very popular regular feature in the Journal. All of us are confronted with clinical challenges, especially when
dealing with therapeutic strategies. We hope this ongoing collection of Clinical Pearls will be easily accessible and ready to put into
action for the benefit of our patients, and even ourselves. How often do we ask our colleagues, ‘How do you treat ...?’ This time, we
posed the question: ‘How do you treat tennis elbow in your practice?’ Herein lie your contributions. We trust that our readership will
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MEDICAL ACUPUNCTURE
Volume 22, Number 2, 2010
# Mary Ann Liebert, Inc.
DOI: 10.1089=acu.2010.2013
73
GB 21, TH 15, and SI 10,11,12. General points like GB 34,
GV 20, and LV 3 can be added during the initial treatment
and the patient sent home with an ear tack on the elbow
point.
For those who want to use Meridian Energetics, Con-
trary and Inverse points can be used for a case of recent
onset, while for more recalcitrant cases, more formal
NNþ1 circuit may be necessary, with the goal of mov-
ing energy stagnation in the Yang Ming. In this situation,
high frequency (100–150 Hz) electrical stimulation may be
used with the black lead on the Arm Yang Ming and the
red lead decussated to the contralateral Leg Yang Ming or
Tai Yin.
Many patients will obtain significant improvement within
a few treatments scheduled once or twice a week. However,
he=she should be cautious about returning to the offending
activity (since the problem may then return).
Michael T. Greenwood, MD, (MB), BCHIR, FCFP, FAAMA
103–284 Helmcken Road
Victoria, BC, V9B 1T2
Canada
E-mail: michaeltgreenwood@shaw.ca
T
he method I use to treat tennis elbow is the same
method I would use to treat most types of pain, whether
external or internal. Called Acupuncture 1, 2, 3,
1
this is a
treatment system composed of 3 steps:
1. Identify the ‘imbalanced’ meridian
2. Identify which meridians can treat the imbalanced
meridian
3. Identify the appropriate points to image the imbal-
anced meridian; then, plan a treatment strategy.
If the correct choices are made, results should be almost
instantaneous. Dr Tan (the instructor of this approach) says,
‘Li Gan Jian Ying (stand a pole under the sun and you
should immediately see its shadow).’
1
First, treatment is based on treating the imbalanced
channel (is not based on Zang-Fu theory).
1,2
Second, nee-
dling must achieve a strong De Qi sensation. Third, during
treatment, the patient often needs to move the ‘injured’
part; thus, treatment is distal and not local. Fourth, needling
must be appropriate for the level of the problem: skin-to-
skin, muscle-to-muscle, bone-to-bone.
Tennis elbow usually occurs around the lateral humeral
epichondyle LI 11 (Quchi), or the annular ligament of the
radius SJ 10 (Tianjing). In the case for simplicity, I examine
and treat LI 11.
The last caveat related to treatment strategy is left-
right=up-down. For example, when the problem is on the
right upper body, treat on the lower body, either the left or
the right side. If the choice is to treat on the upper body, treat
on the contralateral side. (There is an exception to same-side
needling discussed below.)
Step 1: Identify the ‘‘imbalanced’’ meridian; in this case,
Large Intestine (LI).
Step 2: Identify the meridian(s) to treat the imbalanced
meridian. There are at least 7 ‘systems’ to do
this as noted in Table 1.
Step 3: Image where the treatment will occur and select
appropriate point(s). Just as one can image the
body on the ear or the hand, other body imaging
patterns exist. There are many imaging options
available; a simple example is presented in
Table 2.
Since the pain is in the LI Meridian at the elbow, identify
comparable points at the level of the left elbow and=or the
right and left knee.
Imbalanced meridian LI, level LI 11; thus, treatment
options would be: System 1 ST 35 (Dubai) contralateral;
System 2 LR 8 (Ququan) ipsilateral or contralateral;
System 3 LU 5 (Chize) contralateral; System 4 KI 10
(Yingu) ipsilateral or contralateral; System 5 same as
System 1; System 6, the exception, LI, treat a distal point
such as LI 3 (Sanjian) or LI 4 (Hegu) or special point
Ling Ku ipsilateral; System 7 SP 9 (Yinlingquan) ipsilat-
eral or contralateral.
Table 1. Seven Systems to Identify the Treating
Meridian (LI Hand Yang Ming)
System System Name
Balanced
With
Side to
Needle
1 ST Contralateral
Yin-Yin Sharing
1
Foot
Yang-Yang Yang Ming
2 Bie-Jing LR Ipsilateral
Yin-Yang Branching Channels
1
Foot Contralateral
Yang-Yin Jue Yin
3 Biao Li LU Contralateral
Yin-Yang Internal=External
1
Yang-Yin
4 Chinese Clock KI Ipsilateral
Yin-Yang Opposites
1
Contralateral
Yang-Yin
5 Chinese Clock ST Contralateral
Yin-Yin Neighbors
1
Yang-Yang
6 Imbalanced Meridian
3
LI Ipsilateral
Yin-Yin
Yang-Yang
7 Ba Gua SP Ipsilateral
Bu Gua
Heritage
Fu Zi
4
Contralateral
74 CLINICAL PEARLS
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