Acupuncture and Epicondylitis

Acupuncture and Epicondylitis: "Tennis Elbow" is Synonymous with Lateral Epicondylitis

Epicondylitis is a frequent reason for consultation in acupuncture clinics. The cause is often linked to repetitive movements at work, i.e., excessive mouse use can sometimes be the cause, or the practice of certain sports. The condition affects 1-3% of the population, and it is more frequent in those aged 35-50.

It is sometimes nicknamed tennis elbow, and in English it is referred to more technically by the term lateral epicondylitis (LEP), since a similar problem can also present on the medial side of the elbow, called medial epicondylitis, or epicondylitis epitrochlearis, in English medial epicondylitis, or commonly golfer's elbow, baseball elbow, literally "golfer's elbow" and "baseball elbow."

These names refer to the movements that become problematic in this condition and which are themselves characteristic of the practice of these respective sports.

Acupuncture and Epicondylitis: the "golfer's elbow" is synonymous with medial epicondylitis

Evaluation in TCM

Generally, very satisfactory results are obtained in the treatment of this painful condition through acupuncture, whether using electroacupuncture, acupuncture, or a combination of the two. According to Gadeau et al., the main Traditional Chinese Medicine (TCM) syndromes of epicondylitis are: Wind-Cold-Dampness, Qi and Blood Deficiency, Dampness-Heat Retention, Qi Stagnation and Blood Stasis.

These syndromes would be characterized by unique symptoms, which constitute important keys to properly understand and pinpoint an individualized treatment based on syndrome differentiation (辨證論治). This is of interest for the treatment of epicondylitis, but also for other musculoskeletal disorders in general. (1)

Acupuncture and Epicondylitis: Demonstrated Efficacy

The 6 clinical studies selected by Trinh et al. for their quality according to the Jadad scale, in their systematic review published in the journal Rheumatology (Oxford) in 2004, suggest that acupuncture is effective in short-term relief of lateral epicondylitis. 5 of these 6 studies also indicated that acupuncture was more effective compared to the control group, leading the authors to conclude that solid evidence supports the efficacy of acupuncture in relieving pain related to lateral epicondylitis. (3)

In 2004, Trudel et al. selected in their systematic review 5 studies of level 1b and 2b evidence, with high quality scores—from 19 to 39, out of 48 studies examined. The retained works included a total of 308 patients with lateral epicondylitis, which revealed that acupuncture helps reduce the pain associated with this condition. (4)

In 2006, the treatment of epicondylitis was part of the recommendations from the systematic review of the Swedish Council on Health Technology Assessment.

*"According to high-quality evidence, acupuncture relieves chronic lower back pain more effectively than placebo…Lower back pain, lateral epicondylitis, neck and shoulder pain being alleviated as effectively as other treatments." (5)

Tangible Evidence Demonstrated by Medical Imaging

In ultrasound evaluation of the effects of acupuncture on the common extensor tendon—the area corresponding to the Ashi point (tender point) found on palpation in cases of lateral epicondylitis—Ural et al. note in the acupuncture-treated group a decrease in pressure pain, as well as a reduction in the thickness of the common extensor tendon, evidenced on ultrasound imaging. This demonstrates a correlation between clinical improvements and positive changes observed on ultrasound evaluation following acupuncture treatment. (2)

The 5 muscles forming the common extensor tendon at the elbow level: extensor digitorum, extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digiti minimi

Comparison Between Acupuncture and Corticosteroid Injections (Cortisone)

According to the retrospective cohort study by Peng et al. published in Medicine (Baltimore) in 2020, both acupuncture and corticosteroid injection are considered effective. However, 6 months after treatment, patients with chronic lateral epicondylitis treated with acupuncture obtained significant pain relief and functional improvement, judged superior to the effect of cortisone injection. (6)

The systematic review by Zhou et al., recruiting a sample of 796 individuals, reaches the same conclusion: acupuncture appears superior to medications—local anesthetics and cortisone—as well as to sham acupuncture, in the treatment of epicondylitis. (7)

Laser Acupuncture (Photobiomodulation)

Photobiomodulation, also called LLLT in English, for low level laser therapy, replaces moxibustion in an acupuncture treatment, for the purpose of administering near-infrared radiation. This constitutes laser acupuncture.

Laser (LLLT or Photobiomodulation)

According to the 3 studies selected by the meta-analysis of Chang et al. conducted in 2010, the application of laser to tender points, Ashi points, or trigger points would allow for an increase in effect size compared to application on theoretical biostimulation sites alone. (10)

The meta-analysis by Tumilty et al. (2010) highlights the importance of effective dose for obtaining a significant effect in the treatment of tendinopathies by photobiomodulation. (12)

In the multicenter double-blind clinical study, placebo-controlled, comprising 324 patients, the efficacy of laser therapy on lateral and medial epicondylitis is emphasized. The authors also note the importance of dosimetry applied in treatment, as well as the therapist's training and clinical approach, in addition to the application of said technology. (13)

Other Emerging Data

What is meant here by emerging data? The results of clinical trials conducted on small sample sizes, typically studies comprising fewer than 100 participants. Lower-level results should therefore be interpreted with caution, but these could inspire further research on the basis of new possible hypotheses, and lead to clues regarding the mechanisms involved.

Use of Electrical Stimulation on Needles (Electroacupuncture)

In the distal treatment of chronic lateral epicondylitis, the clinical trial by Tsui and Leung proposes that electroacupuncture is superior to acupuncture alone with achievement of Deqi (得氣), both in terms of pain relief and the development of maximum pain-free grip strength (pain free hand grip strength (PFG)). (8)

True Acupuncture Points vs Non-specific Acupuncture Points (Acupuncture vs Sham Acupuncture)

Fink et al. demonstrate in their clinical trial the importance of using true biostimulation sites when administering acupuncture treatment, with respect to improvement in upper limb function and reduction of pain in the same. (9)

Laser vs Shock Wave

According to Celik et al., these 2 treatments are considered useful in the treatment of epicondylitis, but only photobiomodulation (LASER) achieved improvements in elbow extension strength and shoulder flexion strength, as well as in subjective observations, in their randomized controlled trial published in 2019. An improvement in grip strength was observed in both groups, but the grip strength achieved was superior in the photobiomodulation (laser)-treated group. (11)

Laser vs Ultrasound Therapy

According to Oken et al., (2008) laser therapy would be inferior to ultrasound in reducing pain, while laser therapy would be superior to ultrasound in improving grip strength. (14)

Follow-up at 12 Weeks

Emanet et al. observed a notable effect of laser therapy 12 weeks following treatments for epicondylitis, which suggests that laser therapy continues to act favorably in improving physiological dynamics for a period of at least 9 weeks following the end of a series of 15 treatments performed over 3 weeks. (15)

SUMMARY

In clinical practice, acupuncture, laser acupuncture, or a combination of the two can be used in the treatment of epicondylitis. Give yourself the opportunity to return to work and your favorite sports activities as quickly as possible. Consult a qualified acupuncturist who uses a combination of acupuncture and laser acupuncture, or a combination of acupuncture and moxibustion (艾灸), today, in order to effectively address your acute or chronic epicondylitis condition.

REFERENCES

(1) Pattern Differentiation of Lateral Elbow Pain in Traditional Chinese Medicine: A Systematic Review Marcus Gadau, PhD et al. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume X, Number X, 2016, pp. 1–15, Mary Ann Liebert, Inc. DOI: 10.1089/acm.2016.0098

(2) Ultrasonographic Evaluation of Acupuncture Effect on Common Extensor Tendon Thickness in Patients with Lateral Epicondylitis: A Randomized Controlled Study,Fatma Gülçin Ural et al., Randomized Controlled Trial, J Altern Complement Med., 2017 Oct;23(10):819-822. doi: 10.1089/acm.2016.0370

(3) Acupuncture for the alleviation of lateral epicondyle pain: a systematic review, K V Trinh et al. Review Rheumatology (Oxford) 2004 Sep;43(9):1085-90. doi: 10.1093/rheumatology/keh247

(4) Rehabilitation for Patients with Lateral Epicondylitis: A Systematic Review, Daniel Trudel et al., Journal of Hand Therapy, 17 (2), 243-266, doi:10.1197/j.jht.2004.02.011

(5) Review, Methods of Treating Chronic Pain: A Systematic Review, Swedish Council on Health Technology Assessment, Stockholm: Swedish Council on Health Technology Assessment (SBU); 2006 Oct. SBU Yellow Report No. 177/1+2, SBU Systematic Review Summaries, PMID: 28876750

(6) Treatment of lateral epicondylitis with acupuncture and glucocorticoid, A retrospective cohort study, Zhiyou Peng, MD, et al., Medicine (Baltimore), 2020 Feb; 99(8): e19227, doi: 10.1097/MD.0000000000019227

(7) Pain Res Manag. Effectiveness of Acupuncture for Lateral Epicondylitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Yumei Zhou et al., Published online 2020 Mar 20. doi: 10.1155/2020/8506591

(8)Comparison of the effectiveness between manual acupuncture and electro-acupuncture on patients with tennis elbow, Paul Tsui, Mason C P Leung, Clinical Trial, Acupunct Electrother Res 2002;27(2):107-17. doi: 10.3727/036012902816026040

(9) Acupuncture in chronic epicondylitis: a randomized controlled trial, M Fink et al., Clinical Trial Rheumatology (Oxford) 2002 Feb;41(2):205-9. doi: 10.1093/rheumatology/41.2.205

(10) Therapeutic Effects of Low-Level Laser on Lateral Epicondylitis from Differential Interventions of Chinese-Western Medicine: Systematic Review Wen-Dien Chang, M.S., et al. Photomedicine and Laser Surgery Volume 28, Number 3, 2010, Mary Ann Liebert, Inc. Pp. 327–336 DOI: 10.1089/pho.2009.2558

(11) Randomized Controlled Trial Photobiomodul Photomed Laser Surg 2019 May;37(5):269-275. doi: 10.1089/photob.2018.4533.

Photobiomodulation Therapy Versus Extracorporeal Shock Wave Therapy in the Treatment of Lateral Epicondylitis Derya Celikm, Bahar Anaforoglu Kulunkoglu

(12) Review Photomed Laser Surg 2010 Feb;28(1):3-16. doi: 10.1089/pho.2008.2470, Low level laser treatment of tendinopathy: a systematic review with meta-analysis, Steve Tumilty et al., 2010 Feb; 28 (1):3-16. doi: 10.1089/pho.2008.2470

(13) Clinical Trial, J Clin Laser Med Surg, Treatment of medial and lateral epicondylitis--tennis and golfer's elbow--with low level laser therapy: a multicenter double blind, placebo-controlled clinical study on 324 patients, Z Simunovic et al.,1998 Jun;16(3):145-51. doi: 10.1089/clm.1998.16.145

(14) Clinical Article, Volume 21, Issue 1, P63-68, JANUARY 01, 2008The Short-term Efficacy of Laser, Brace, and Ultrasound Treatment in Lateral Epicondylitis: A Prospective, Randomized, Controlled Trial, Öznur Öken, MD, P63-68, January 01, 2008

(15) Randomized Controlled Trial Photomed Laser Surg, Investigation of the effect of GaAs laser therapy on lateral epicondylitis, Saniye Konur Emanet,2010 Jun; 28(3):397-403. doi: 10.1089/pho.2009.2555