Medical Acupuncture
A Journal For Physicians By Physicians

Volume 13 / Number 1
"Aurum Nostrum Non Est Aurum Vulgi"

Acupuncture Treatment Of Lateral
Epicondylitis In An Occupational Medicine Clinic
Christine C. Deignan, MD

ABSTRACT
Background Lateral epicondylitis ("tennis elbow") is caused by overuse of the arm in both intensity and duration. It has been suggested that acupuncture is an effective treatment for the condition.
Objective To measure the response to acupuncture in patients with lateral epicondylitis.
Design, Setting, and Patients Case series of patients referred for treatment from the Iowa Workers' Compensation system to an occupational medicine clinic.
Interventions Initial treatment of LI 4 and LR 3; at later sessions, electroacupuncture was administered. A search for trigger point areas with referred pain to the elbow was performed.
Main Outcome Measures Improvement rated as resolved, improved, or no change based on pain and functionality.
Results Of 22 patients, 19 (86%) had resolution or improvement of symptoms. There were no serious adverse events and response was not related to symptom duration.
Conclusions Acupuncture produced resolution or improvement in the symptoms of lateral epicondylitis. Future studies should include randomized controlled trials and comparison trials with surgery.
KEY WORDS
Acupuncture, Lateral Epicondylitis, Occupational Diseases, Worker's Compensation, Trigger Points

INTRODUCTION
The cause of lateral epicondylitis, "tennis elbow," is overuse of the arm in both intensity and duration. It primarily involves the origin of the extensor carpi radialis brevis, and the underside of the extensor carpi radialis longus. Activities that directly increase the tension and thus stress of the wrist extensor and supinator muscles are to blame. Grasping an object and lifting palm down will aggravate symptoms. Forceful extension of the elbow with the forearm fully pronated and the wrist palmar flexed will also aggravate symptoms.

Lateral epicondylitis is difficult to treat when seen as a work-related overuse syndrome.1,2 More than 40 different treatment methods for lateral epicondylitis have been reported in the literature.3 One study suggested that acupuncture was more effective than steroid injections for treatment of lateral epicondylitis.2 It is frequently seen in jobs requiring stressful forearm use such as carpentry, electrical line work, the operation of machines, and carrying heavy objects.4 The characteristic age of onset is between 35 and 50 years, with a median age of 42 years.5 It occurs in men and women with equal frequency.5 The annual incidence of non-sports-related lateral epicondylitis is 59 per 10,000 workers.2

Repetitive microtrauma produces initial inflammation. However, it is thought that the long-term "repair reaction" is more responsible for perpetuating symptoms.4 A unique type of granulation tissue is frequently identified at the time of surgery with the characteristic appearance of gray, homogeneous, edematous, friable tissue.6 Despite an optimal technical repair, patients frequently remain symptomatic.7 In addition, even if a surgical outcome is successful in relieving pain, it is less commonly successful in restoring function.

METHODS
All cases of lateral epicondylitis treated in our clinic with acupuncture are reported. The selection of patients for acupuncture treatment was greatly influenced by the Iowa Worker's Compensation Law.8 Approval for acupuncture treatment was necessary prior to proceeding. In Iowa, an employer is able to direct an injured worker to a care provider of his/her choice; in some cases, the possibility of acupuncture treatment caused the employer or the worker's compensation insurance company to remove the patient from our care. Cases of lateral epicondylitis that had been resistant to all previous modalities were more readily approved for acupuncture treatment by the employer or the insurance company. This produced a caseload skewed toward patients with chronic conditions. The patients were all treated by the same physician. Patient consent was obtained. Post-treatment information was obtained by the treating physician or a certified occupational health nurse contacting the patient.

TREATMENT
Treatments were done with Seirin No. 3 needles. Initial treatment of Four Gates was administered using LI 4 and LR 3. At the 3rd treatment, electrical stimulation was added at 2-4 Hz on Yin needles with ITO Electro Acupuncture IC-1107 (ITO Ltd, Tokyo, Japan). Principal meridian treatment in Tai Yin-Yang Ming was administered most often. In
addition, a search for Ah Shi points was done throughout the thoracic area, upper arm, and forearm, particularly for trigger point areas with referred pain to the elbow.9 Tendinomuscular treatment for Large Intestine was administered intermittently for acute symptomatic flares. If adequate pain relief was not obtained after 5 treatments, osteopuncture was performed.

Response to treatment was rated as "resolved" if the patient reported resolution of the pain and was able to perform all the functional tasks the job required. Response was rated as "improved" if pain complaints were under control and supplemental analgesic medica-
tion was unnecessary. The outcome was rated as "no change" if pain relief was brief and did not last for the entire period between acupuncture treatments. Notation was made regarding the need for work restrictions.

RESULTS
Of the 22 patients treated with acupuncture at the occupational medicine clinic, 19 (86%) responded favorably to treatment with resolution or improvement of symptoms (Table 1). Of these, all but 1 did not return to his/her previous occupation. Six of 7 individuals who had been treated previously with a steroid injection improved or resolved with acupuncture. One individual who had been treated previously with surgery experienced resolution with acupuncture. Among the 3 individuals whose conditions failed to respond to acupuncture, 1 resolved after steroid injection, 1 received surgical intervention, and 1 was lost to follow-up. Overall, acupuncture was well tolerated; the only complication was 1 episode of needle shock.

Of patients who responded to acupuncture, only 2 required re-treatment. One patient had a tendinomuscular meridian treatment with good results, but returned 5 months later with recurrent symptoms. She then received a series of 10 treatments with resolution of symptoms, and followed up for 19 months without a recurrence. Another patient, an assembler, completed a series of 10 treatments. After 6 months, symptoms returned but were manageable with a TE band and over-the-counter analgesia, with no work restrictions.

Duration of symptoms prior to acupuncture treatment appeared to have no predictive effect for response to acupuncture. In those patients with symptoms of less than 6 months' duration, 9 of 10 responded well; 6 months or longer, 10 of 12 responded well.

CONCLUSION
In our clinic, about 10% of lateral epicondylitis cases are treated with acupuncture. Acupuncture requires increased physician time, but in contrast to surgery, does not produce any lost work days for the patient. With education of employers and insurance carriers, acupuncture should become a more attractive therapeutic option because employees are able to continue work during treatment.

The surgical treatment literature shows some striking similarities to acupuncture. Gellman2 recommends drilling a few small holes in the cortical bone to enhance blood supply and aid healing. Drilling the cortical bone is very reminiscent of osteopuncture. Nirschl6 des-
cribed the surgical appearance of the tendon overlying the lateral epicondyle as a "thick, unhappy gray tendon, weeping with edema." The area of lateral epicondylitis corresponds to the Large Intestine meridian, whose metal qualities are described as a weeping, sobbing voice with psychological characteristics of sadness or grief.10

This series was not designed as a blinded or randomized study. Further research in this area is warranted, such as a randomized controlled trial that would permit entry of appropriate cases not dependent on employer approval. Research comparing acupuncture with surgery could be performed in conjunction with an orthopedic surgeon selecting and matching cases and controls.

ACKNOWLEDGEMENTS
I wish to thank my co-workers for their assistance in the preparation of this article: Andy Rowe for the preparation of data and clinic records, Karen Dhanens, OTR/L, CHT, for her research, Ellen Heisner, RN, COHN, for her help with follow-up on cases, and Diane Deignan for her editorial assistance.

REFERENCES
1. Boyer MI, Hastings H II. Lateral tennis elbow: "is there any science out there?" J Shoulder Elbow Surg. 1999;8:481-491.
2. Gellman H. Tennis elbow (lateral epicondylitis). Orthop Clin North Am. 1992;
23:75-82.
3. Sevier TL, Wilson JK. Treating lateral epicondylitis. Sports Med. 1999;
28:375-380.
4. Geoffroy P, Yaffe MJ, Rohan I. Diagnosing and treating lateral epicondylitis. Can Fam Physician. 1994;40:73-78.
5. Morrey BF, ed. The Elbow and Its Disorders. Philadelphia, Pa: WB Saunders Co; 1993.
6. Nirschl RP. Arm Care. Arlington, Va: Med Sport Pub; 1983.
7. Katarincic JA, Weiss AP, Akelman E. Lateral epicondylitis (tennis elbow): a review. R I Med. 1992;75:541-544.
8. Iowa Workers' Compensation Commission. Workers' Compensation Guide. 5th ed. Iowa Workforce Development; 1999.
9. Travell JG, Simons DG. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. Baltimore, Md: Williams & Wilkins; 1983.
10. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995.

AUTHOR INFORMATION
Dr Christine Deignan is a specialist in Occupational Health in Bettendorf, Iowa, and practices Medical Acupuncture in a clinic and on-site in a heavy metals manufacturing plant.
Christine C. Deignan, MD
Work Fitness Center
2535 Maplecrest Rd, Suite 27
Bettendorf, IA 52722
Phone: 563-421-3680 o Fax: 563-421-3688 o E-mail: cdeignan@workfitness.com

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