网球肘 WANGQIU ZHOU - TENNIS ELBOW - LATERAL EPICONDYLITIS

BI ZHENG – BI PATTERNS

Bi means obstruction or blockage. Bi pattern describes a set of patterns in which the invasion of external evils such as wind, cold, dampness and heat obstruct the flow of Qi and Blood through the channels and connections. This affects the muscles, bones, tendons and joints, presenting symptoms of aching, pain, heaviness, numbness, difficulty of movement or redness and swelling. Bi patterns include several disorders known in Western medicine as osteoarthritis, rheumatoid arthritis, rheumatic fever, fibrositis, frozen shoulder, gout, sciatica and others; but here we are focusing on Lateral Epicondylitis, commonly known as ‘Tennis Elbow.’

In TCM, it is traditionally known as zhou lao, meaning “pain at the outside elbow”. Lateral epicondylitis is the most common overuse injury of the elbow and it is observed more frequently than medial epicondylitis. The lateral epicondyle is a small bony protuberance that can be easily overburdened by the strong forces that it is subjected to as the attachment site of the wrist extensor muscles.

Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and it is a common injury in racket sports. Overuse of the wrist extensors and lateral epicondylitis is also common among electricians, plumbers, carpenters, butchers, hair stylists, or anyone who spends a significant amount of time working on a computer keyboard. The primary muscles involved in lateral epicondylitis are the extensor carpi radialis brevis ─the most commonly affected, extensor carpi radialis longus, extensor carpi ulnaris and extensor digitorum communis.

The diagnosis of lateral epicondylitis can usually be made from physical examination alone and it is evidenced by pronounced tenderness at the tendinous attachment onto the lateral epicondyle The patient will often present with sharp pain at the lateral epicondyle with activity and periodic dull, aching pain in the region of SHOUSANLI LI10 – QUCHI LI11 during rest. While lateral epicondylitis typically presents with a fixed pain site on the lateral epicondyle, there are three other injuries that occur in very close proximity to this bony protuberance: anconeus strain, triceps tendinopathy and supinator syndrome.

Etiology and Pathogenesis

The etiology of bi patterns usually combines an internal or preexisting deficiency of correct Qi with external evils entering the body: wind, cold, damp or heat. Simultaneous invasion by wind, cold and damp is the most common. Bi patterns are considered in four classes based on the specific external evil and the differing clinical manifestations. Bi patterns involve LV, SP and KD. LV controls tendon, SP controls muscles, and KD controls bones.

1.Wind bi or feng bi, also known as wandering bi Xing bi, is characterized by wind evil with pain roving through various locations. Major pain in joints.

2.Cold bi han bi, also known as painful bi Tong bi, is characterized by the accumulation of cold with severe pain in the channels.

3.Damp bi ji bi, also known as fixed bi Zhao bi, is characterized by the accumulation of dampness with muscular and joint numbness, aching, heaviness, swelling and pain of fixed location.

4.Heat bi re bi, is characterized by fever and red, swollen, and painful joints. Its causes include invasion by heat evil; untreated and chronic Wind-Cold-Dampness-bi that has transformed into heat; or constitutions of either profuse Yang or deficient Yin, that  have transformed external evils to heat.

All bi patterns involve obstruction of the channels and connections inhibiting the flow of Qi and Blood. Chronic cases of bi, regardless of a particular evil’s dominance, present three major categories of pathological change.

The first includes manifestations of blood-stasis and phlegm-turbidity such as stasis macules on the tongue, nodes in the area of affected joints and swelling, and difficulty moving the joints.

The second involves symptoms of deficient Qi and Blood. The severity will vary according to the injury and depletion of Qi and Blood during the illness.

The third includes pathological changes from the progress of evils from the channels and connections into the viscera and bowels. Most commonly observed is heartbeat with palpitations, cyanosis, asthma, and edema.

TCM Patterns

Painful Obstruction Wind-Dominant Bi
Qi and Blood Stagnation Cold-Dominant Bi
Dampness-Dominant Bi
Heat-Dominant Bi
Bi with Blood Stasis and Phlegm-Turbidity
Bi with Depletion of Qi and Blood, KD and LV Deficiency

1. Painful Obstruction Wind-Dominant Bi

Symptoms: Roaming pain in the joints and limbs, pain of indeterminate locations, difficulty in flexion and extension of joints, aversion to cold and in some cases, fever.

Tongue: Thin white coating.
Pulse: Wiry, floating.

Treatment Strategy: Dispel wind, clear the connections, dissipate cold, and drain dampness. For wind problems treat blood first with UB17 and SP10, then needle the rest.

Combination Points

DAZHUI DU14 
QUCHI LI11
BINGFENG SI12 
YANGXI LI5 
YANGCHI SJ4 
YINLINGQUAN SP9 
FENGLONG ST40 
LIEQUE LU7

2. Qi and Blood Stagnation Cold-Dominant Bi

Symptoms: Severe pain of the joints and limbs, pain of fixed location accompanied by sensation of cold, decrease in pain with application of heat, increase in pain upon exposure to cold, without redness or feverishness of joints, with difficulty moving the affected parts.

Tongue: Thin white coating.
Pulse: Tight, wiry.
Treatment Strategy: Dissipate cold, warm the connections, dispel wind, and drain dampness.

Combination Points

YANGXI LI5 
WENLIU LI7 
QUCHI LI11
DAZHONG KD4
TAICHONG LV3

3. Dampness-Dominant Bi

Symptoms: Heaviness and aching of the joints and limbs, distention and swelling in some cases, pain of fixed location, local numbness or loss of sensation, with symptoms often increasing during overcast or rainy weather. Swollen joints and dull pain equals Dampness.

Tongue: White slimy coating.
Pulse: Soft, tardy.
Treatment Strategy: Drain dampness, clear the connections, dispel wind, and dissipate cold.

Combination Points

ZUSANLI ST36
YINLINGQUAN SP9
PISHU UB20
DAZHUI DU14
GESHU UB17

4. Heat-Dominant Bi

Symptoms: Severe pain, local heat, redness and swelling; difficulty of movement affecting one or more joints accompanied with fever, sore throat, thirst, irritability and dark, scanty urine.

Tongue: Yellow coating.
Pulse: Rapid, slippery.

Treatment Strategy: Drain heat, clear the connections, dispel wind, drain dampness.

Combination Point

DAZHUI DU14
QUCHI LI11

5. Bi with Blood Stasis and Phlegm-Turbidity

Symptoms: In each of the above bi patterns, chronic illnesses that have not been properly treated lead to blood stasis and phlegm-turbidity. This blocks the channels, connections and joints. Symptoms include swelling, stiffness and deformity of the joints, incessant pain and complete immobility.

Tongue: Dark or purple, with white slimy coating.
Pulse: Deep-rough, or deep-slippery.

Treatment Strategy: Dispel stasis, transform phlegm, free the connections, relieve pain.

Combination Points

FENGMEN UB12
XUEHAI SP10
GESHU UB17

6. Bi with Depletion of Qi and Blood and Blood Stagnation, KD and LV Deficiency

Symptoms: Prolonged cases of bi pattern often present symptoms of depletion of Qi and Blood as well as deficiency of the LV and KD. These include aching pain in the lower back and knees, difficulty in the flexion and extension of joints, numbness or loss of sensation in affected areas, palpitations and shortness of breath, in some cases aversion to cold and symptoms relieved by warmth.

Tongue: Pale with white coating.
Pulse: Weak, thready.
Treatment Strategy: Supplement Qi and Blood, benefit LV and KD, dispel wind, cold and dampness.

Combination points

SHANGYANG LI1
YANGXI LI 5
JIANYU LI15
ZHONGZHU SJ3
SANYANGLUO SJ8
TAICHONG LV3
QUQUAN LV8
YANGLINGQUAN GB34  
SANYINJIAO SP6
PISHU UB20
ZUSANLI ST36  
QIHAI REN6

BIOMEDICAL PERSPECTIVE

CLINICAL PRESENTATION
The majority of the patients complain of pain located just anterior to, or in, the bony surface of the upper half of the lateral epicondyle, usually radiating in line with the common extensor mass. The pain can vary from intermittent and low-grade pain to continuous and severe pain which may cause sleep disturbance. It is typically produced by wrist and finger extensor and supinator muscle contraction against resistance. The pain lessens slightly if the extensors are stressed with the elbow held in flexion.

On inspection, there is no remarkable alteration in the early stages. As the disease evolves, a bony prominence over the lateral epicondyle can be detected. Muscle and skin atrophy as well as detachment of common extensor origin can be seen as a result of corticosteroid injections or long-standing disease.

Range of motion is not usually affected. Motion may be painful in more advanced stages where it can be elicited in full elbow extension with the forearm pronated. If limited motion exists, other concomitant pathology needs to be excluded.

There are several tests employed in LE physical examination, such as Maudley’s test, Thomson’s maneuver, diminished grip strength and the ‘chair’ test.

DIFFERENTIAL DIAGNOSIS
In a middle-aged patient with pain on the lateral side of the elbow and typical symptoms and signs, lateral epicondylitis should undoubtedly be the main diagnosis, but one must rule out other potential conditions which can cause lateral pain. The following should be considered:

1.Cervical radiculopathy with pain in the elbow and forearm.

2.Elbow overuse to compensate for a disease in an adjacent joint, i.e. frozen shoulder.

3.Posterior interosseous nerve, PIN, entrapment, also known as ‘radial tunnel syndrome.’ Nerve compression produces neuropathic pain in the lateral forearm. However, pain is not reproduced by wrist extension. Resisted supination can produce pain as the supinator is one of the possible areas of PIN compression. An anesthetic block of PIN can be diagnostic, but injection should be performed selectively to avoid diffusion of the local anesthetic to the lateral epicondyle area. The middle finger extension test resisted supination of the forearm and nerve conduction studies have all been described to assist in the diagnosis of radial tunnel syndrome.

4.Degenerative changes of the capitellum. It has been observed that 59% of cases of lateral elbow pain refractory to conservative treatment have some chondral changes in the radiocapitellar joint.

5.Inflammation and edema of the anconeus muscle. Some studies have reported a relatively high incidence of anconeus edema, shown in MRI of patients complaining of lateral elbow pain. Fasciotomy of the muscle can solve that problem.

6.Posterolateral elbow instability should definitely be ruled out in every patient suffering from lateral elbow pain. The association between instability and epicondylitis has been established, following excessive use of steroids or the local pathogenic insult. The presentation is low-grade and may require examination of the patient under anesthesia to test it properly. The presence of cubitus varus, previous surgery or dislocations of the elbow should be assessed.

7.Other causes of pain include low-grade infection or other inflammatory diseases such as rheumatoid arthritis.

TREATMENT
To date, no universally accepted treatment protocol exists; however, some general principles of treatment should be taken into consideration. The treatment of LE should be focused on the management of pain, preservation of movement, improvement in grip strength and endurance, return to normal function and control of further clinical deterioration.

NON-SURGICAL TREATMENT
Non-surgical treatment includes a wide variety of possibilities with a rate of improvement in 90% of cases. Several new techniques have been developed in last decade including percutaneous radiofrequency treatment and injections with different preparations of growth factors. It is wise to involve the patient and gain their commitment to the management program as it may be months before improvement is observed:

1.Rest, modification or avoidance of painful activities usually leads to symptomatic relief.

2.Physiotherapy is another alternative. Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favorable results than rest and reduced activity at short-term follow-up. No standard regime has been established as superior to any other method. The fundamental principle is to load the tendon as close as possible to its limit but without surpassing it. Eccentric exercises and partial load-favoring tendon healing are the mainstay of physiotherapy regimes.

A stable shoulder and scapula are necessary for correct elbow function; strengthening exercises of the scapular stabilizers including the lower trapezius, serratus anterior and rotator cuff muscles is mandatory.

3.Epicondylar counterforce braces work by reducing tension in the wrist extensors. Elbow straps, clasps or sleeve orthoses have been demonstrated as superior for pain relief and grip strength when compared with placebo orthoses. However, no differences between braces were shown in a systematic review and we do not use them in our practice. We have seen patients with secondary nerve problems due to prolonged use of a counterforce brace.

4.Non-steroidal anti-inflammatory drugs ─NSAIDs can be useful for the short-term relief of symptoms. Even if their use is superior to a placebo, no differences between oral and topical NSAIDs have been established.

5.Corticosteroid injections are commonly used to treat LE. The way in which they work is currently unknown; they probably help to control local inflammatory response and pain mediation. Corticosteroid injections seem to be superior to NSAIDs at four weeks, but no differences are observed at a later stage. Cortisone injections should be avoided in all cases, unless a short-term good result is advisable (such as a professional tennis player in mid-season), as most patients improve without corticosteroids and better long-term results can be achieved without them. Patients should be advised of potential side-effects including changes in coloration of the skin, fat atrophy and muscle wasting.

6.Autologous blood injections are thought to work by stimulating an inflammatory response which will bring in the necessary nutrients to promote healing. Short-term good results have been reported recently; however, no benefit in the long-term follow-up has been found and its use is only recommended for those recalcitrant cases when other modalities of treatment have failed.

7.Platelet-rich plasma injections ─PRP. These preparations are thought to contain high concentrations of growth factors, which could theoretically enhance tendon healing. General technique involves patient-blood extraction, centrifugation and re-injection of the plasma into the lateral epicondyle. Good outcomes have been reported. However, no differences were seen between PRP and whole blood injections. Moreover, significant differences among available commercial systems and variations in the technique make it difficult to draw clear conclusions about the use of PRP in this pathology. New legal regulations could slow down the adoption of these last techniques.

8.Percutaneous radiofrequency thermal treatment. A radiofrequency electrode is introduced percutaneously under ultrasound guidance which produces a thermal injury when activated, inducing a microtenotomy and removing all pathological tissue. Good outcomes have been reported, and no reduction of tendon size has been observed.

9.Extracorporeal shock-wave therapy ─ECSW has been proposed as an alternative to non-operative management. The mechanism of action is not fully known. A generator of specific frequency sound waves is applied directly onto the overlying skin of the extensor carpi radialis brevis ─ECRB tendon. It has not been demonstrated to be more beneficial than other treatment modalities.

10.The use of low-level laser therapy has been proposed due to the stimulating effect of laser on collagen production in tendons. Although laser was not initially viewed as particularly useful among LE therapies, a recent study has demonstrated some short-term benefits when using an adequate dose and wavelength.

11.Acupuncture has demonstrated good outcomes on short-term follow-up. However, long-term results remain unclear.

12.Botulinum toxin A injections act by diminishing muscle tone. Reducing the tension on the ECRB insertion could be beneficial for pain relief. Good short-term results have been published, but as yet there is no consensus on its use and the effects may be conditioned by the technique, the operator and the dose.

Conclusion
Lateral elbow epicondylitis is frequently a self-limiting entity, with a normal course of between 12 and 18 months. In the vast majority of patients, symptoms resolve with non-operative treatment, physiotherapy and activity modification. Multiple non-operative treatments have been proposed, but none of them has demonstrated superiority over others, therefore no specific recommendations can be made. Operative treatment is reserved for those patients with persistent symptoms who have failed a well-performed non-operative program. However, there is no evidence to support a specific technique. New treatment alternatives have been developed in recent years, but more information is necessary to support their standard use in LE treatment.

 

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-Above Article Written by Dr. Osorio, Gloria DAOM, L.Ac., MQP. 2020.