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Acupuncture For Tennis Elbow

About tennis elbow

Tennis elbow (lateral epicondylitis) is characterised by pain and tenderness over the lateral epicondyle of the humerus. In the UK, the annual incidence of lateral elbow
pain in general practice is around 4/1000 to 7/1000 people.(Hamilton 1986) It is most common in people aged between 40 and 50 years (Allander 1974); for example, the
incidence is as much as 10% in women aged 42 to 46 years.(Chard 1989; Verhaar 1994) Tennis elbow is considered an overload injury, and it typically occurs after minor trauma of the extensor muscles of the forearm; tennis is a direct cause in only 5% of people with the condition.(Murtagh 1988). It is primarily a type of tendonitis though the muscles and bones of the epicondyle joint may also be involved. Pain can also occur on the inner side of the elbow, which is known as golfer's elbow. Although generally self-limiting, symptoms of tennis elbow can persist for 1.5 to 2 years or even longer in a minority of people.(Hudak 1996) The aims of conventional medical interventions are to relieve pain, control inflammation and accelerate repair in order to improve function. Treatments include corticosteroid injections, topical and oral NSAIDs, other analgesics, exercises, ultrasound, orthoses and surgery.

References

Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand
J Rheumatol 1974; 3: 145-53.
Chard MD, Hazleman BL. Tennis elbow - a reappraisal. Br J Rheumatol 1989; 28: 186-90.
Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract 1986; 36: 464-
5.
Hudak P et al. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys
Rehabil 1996; 77: 568-93.
Murtagh J. Tennis elbow. Aust Fam Physician 1988; 17: 90-1, 94-5.
Verhaar J. Tennis elbow: anatomical, epidemiological and therapeutic aspects. Int Orthop 1994; 18: 263-7.

How acupuncture can help

One systematic review concluded that acupuncture was beneficial for pain, at least in the short term, although the amount of evidence was limited (Green 2002). Two years later, a second review with more data available, found strong evidence of short-term pain relief (Trinh 2004). Most randomised controlled trials not included in these systematic reviews have compared different types of acupuncture, so can tell us little about the overall effectiveness of acupuncture for the treatment of tennis elbow.(Su 2010; Gu 2007; Xia 2004; Tsui 2002) One trial, however, compared electroacupuncture plus moxibustion with lidocaine plus prednisone treatment, and found the acupuncture treatment to be more effective.(Jiang 2005) The fact sheet on Sports Injuries has more information on other tendinopathies.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

Acupuncture may help relieve symptoms of tennis elbow, such as pain and inflammation by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and

    changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
  • delivering analgesia via alpha-adrenoceptor mechanisms (Koo 2008);
  • increasing the release of adenosine, which has antinociceptive properties(Goldman 2010);
  • modulating the limbic-paralimbic-neocortical network (Hui 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

About traditional acupuncture

Acupuncture is a tried and tested system of traditional medicine, which has been used in China and other eastern cultures for thousands of years to restore, promote

and maintain good health. Its benefits are now widely acknowledged all over the world and in the past decade traditional acupuncture has begun to feature more

prominently in mainstream healthcare in the UK. In conjunction with needling, the practitioner may use techniques such as moxibustion, cupping, massage or electroacupuncture. They may also suggest dietary or lifestyle changes. Traditional acupuncture takes a holistic approach to health and regards illness as a
sign that the body is out of balance. The exact pattern and degree of imbalance is unique to each individual. The traditional acupuncturist’s skill lies in identifying the
precise nature of the underlying disharmony and selecting the most effective treatment. The choice of acupuncture points will be specific to each patient’s needs.
Traditional acupuncture can also be used as a preventive measure to strengthen the constitution and promote general well-being.
An increasing weight of evidence from Western scientific research (see overleaf) is demonstrating the effectiveness of acupuncture for treating a wide variety of
conditions. From a biomedical viewpoint, acupuncture is believed to stimulate the nervous system, influencing the production of the body’s communication substances
- hormones and neurotransmitters. The resulting biochemical changes activate the body's self-regulating homeostatic systems, stimulating its natural healing abilities
and promoting physical and emotional well-being.

About the British Acupuncture Council

With over 3000 members, the British Acupuncture Council (BAcC) is the UK’s largest professional body for traditional acupuncturists. Membership of the BAcC guarantees
excellence in training, safe practice and professional conduct. To find a qualified traditional acupuncturist, contact the BAcC on 020 8735 0400 or visit
www.acupuncture.org.uk

Acupuncture For Tennis Elbow

The evidence

Research Conclusion
Systematic reviews (SRs)
Trinh KV et al. Acupuncture for the
alleviation of lateral epicondyle pain:
a systematic review. Rheumatology
2004; 43: 1085-90.
A systematic review that evaluated the effectiveness of
acupuncture as a treatment for lateral epicondylitis. Six
randomised controlled trials (four sham-controlled) were
included. All the studies suggested that acupuncture was
effective in the short-term relief of lateral epicondyle pain. Five of
the six studies indicated that acupuncture treatment was more
effective compared to a control treatment. The reviewers
concluded that there was strong evidence suggesting that
acupuncture is effective in the short-term relief of lateral
epicondyle pain.
Green S et al. Acupuncture for lateral
elbow pain. Cochrane Database of
Systematic Reviews 2002, Issue 1.
Art. No.: CD003527. DOI:
10.1002/14651858.CD003527.
A systematic review that included four small randomised
controlled trials. One trial found that needle acupuncture resulted
in relief of pain for significantly longer than placebo and was
more likely to result in a 50% or greater reduction in pain after
one treatment (RR 0.33, 95% CI 0.16 to 0.69). A second trial
demonstrated needle acupuncture to be more likely to result in
overall participant reported improvement than placebo in the
short term (RR = 0.09, 95% CI 0.01 to 0.64). No significant
differences were found in the longer term (after 3 or 12 months).
A third trial of laser acupuncture versus placebo demonstrated
no differences between laser acupuncture and placebo with
respect to overall benefit. A fourth trial found no difference
between Vitamin B12 injection plus acupuncture, and Vitamin
B12 injection alone. The reviewers concluded that there is
insufficient evidence to either support or refute the use of
acupuncture (either needle or laser) in the treatment of lateral
elbow pain, but that needle acupuncture is of short term benefit
with respect to pain.
Randomised controlled trials (not in the SRs)
Su X et al. Effects of
electroacupuncture of different
frequencies for treatment of patients
with refractory tennis elbow
syndrome. Zhongguo Zhen Jiu 2010;
30: 43-5.
A randomised controlled trial that assessed the different effects
of electroacupuncture of different frequencies in 85 patients with
refractory tennis elbow syndrome. The patients were allocated to
continuous wave or rarefaction wave electroacupuncture at the
same acupoints. A Visual Analogue Scale (VAS) was used to
evaluate the tenderness score. The effective rate was 82. 9% in
continuous wave group and 84. 1% in rarefaction wave group,
with no significant difference between the two groups. The
healing rate was better in rarefaction wave group (56. 8% vs.
31.7% in the continuous wave group; p<0.05). The VAS scores
were significantly reduced after electroacupuncture treatment in
both groups (both p<0.001). The researchers concluded that
rarefaction wave electroacupuncture is better than continuous
wave electroacupuncture for refractory tennis elbow syndrome.
Gu JQ, Shan YH. Therapeutic effect
of triple puncture at Tianzong (SI 11)
as main method on obstinate tennis
elbow. Zhongguo Zhen Jiu 2007; 27:
109-11.
A randomised controlled trial that compared the therapeutic
effects of triple puncture at SI11 plus routine acupuncture with
routine acupuncture alone in 62 patients with obstinate tennis
elbow. Changes in symptoms and signs were compared
between the two treatment groups. The cure rate was better in
the triple puncture group (71.9% vs. 43.3% with routine
acupuncture alone; p<0.05). The researchers concluded that
triple puncture combined with routine acupoint selection therapy
has a better therapeutic effect on obstinate tennis elbow than
routine acupuncture alone.
Jiang ZY et al. Controlled observation
on electroacupuncture combined with
cake-separated moxibustion for
treatment of tennis elbow. Zhongguo
Zhen Jiu 2005; 25: 763-4.
A randomised controlled trial that compared electroacupuncture
plus moxibustion with lidocaine plus prednisone treatment in the
treatment of 128 patients with tennis elbow. The cure rate and
the effective rate were 40.6% and 93.7% in the
electroacupuncture group, and 25.0% and 78.1% in the
conventional medicine group, respectively, with a significant
difference between the two groups in favour of acupuncture
(p<0.05). The researchers concluded that electroacupuncture
combined with moxibustion is an effective treatment for tennis
elbow.
Xia DB, Huang Y. Combination of Fu
needling with electric acupuncture for
tennis elbow. Di Yi Jun Yi Da Xue
Xue Bao 2004; 24: 1328-9.
A randomised controlled trial that assessed the clinical effect of
Fu needling combined with electroacupuncture in 100 patients
with tennis elbow. Patients were allocated to receive Fu
needling, electroacupuncture or a combination of the two. All
three therapies had good effects, but the combined therapy was
the most effective. The researchers concluded that Fu needling
combined with electroacupuncture may produce a higher cur
rate of tennis elbow than either of the therapies used alone.
Tsui P, Leung MC. Comparison of the
effectiveness between manual
acupuncture and electro-acupuncture
on patients with tennis elbow.
Acupunct Electrother Res 2002; 27:
107-17.
A single-blinded randomised controlled trial that compared the
relative effectiveness of manual acupuncture and
electroacupuncture in 20 patients with chronic tennis elbow.
After 6 treatments, significant differences were observed
between groups favouring electroacupuncture in relation to pain
relief (measured on a pain visual analogue scale) and pain free
hand grip strength. The researchers concluded that
electroacupuncture is superior to manual acupuncture in treating
patients with tennis elbow.
Research on mechanisms for acupuncture
Goldman N et al. Adenosine A1
receptors mediate local antinociceptive effects of acupuncture.
Nat Neurosci 2010 May 30. [Epub
ahead of print]
A study that found the neuromodulator adenosine, which has
anti-nociceptive properties, was released during acupuncture in
mice, and that its anti-nociceptive actions required adenosine A1
receptor expression. Direct injection of an adenosine A1
receptor agonist replicated the analgesic effect of acupuncture.
Inhibition of enzymes involved in adenosine degradation
potentiated the acupuncture-elicited increase in adenosine, as
well as its anti-nociceptive effect. The researchers concluded
that their observations indicate that adenosine mediates the
effects of acupuncture and that interfering with adenosine
metabolism may prolong the clinical benefit of acupuncture.
Hui K.K.-S. The salient
characteristics of the central effects
of acupuncture needling: limbicparalimbic-neocortical network
modulation. Human Brain Mapping
2009; 30: 1196-206.
A study that assessed the results of fMRI on 10 healthy adultsduring manual acupuncture at 3 acupuncture points and a sham
point on the dorsum of the foot. Although certain differences
were seen between real and sham points, the hemodynamic and
psychophysical responses were generally similar for all 4 points.
Acupuncture produced extensive deactivation of the limbicparalimbic-neocortical system. Clusters of deactivated regions
were seen in the medial prefrontal cortex, the temporal lobe and
the posterior medial cortex. The sensorimotor cortices, thalamus
and occasional paralimbic structures such as the insula and
anterior middle cingulate cortex showed activation. The
researchers concluded that their results provided additional
evidence that acupuncture modulates the limbic-paralimbicneocortical network. They hypothesised that acupuncture may
mediate its analgesic, anti-anxiety, and other therapeutic effects
via this intrinsic neural circuit that plays a central role in the
affective and cognitive dimensions of pain.
Cheng CH et al. Endogenous Opiates
in the Nucleus Tractus Solitarius
Mediate Electroacupuncture-induced
Sleep Activities in Rats. Evid Based
Complement Alternat Med 2009 Sep
3. [Epub ahead of print]
An animal study that investigated the involvement of the nucleus
tractus soliatarius opioidergic system in electroacupunctureinduced alterations in sleep, the findings of which suggested that
mechanisms of sleep enhancement may be mediated, in part,
by cholinergic activation, stimulation of the opioidergic neurons
to increase the concentrations of beta-endorphin and the
involvement of the µ-opioid receptors.
Lee B et al. Effects of acupuncture on
chronic corticosterone-induced
depression-like behavior and
expression of neuropeptide Y in the
rats. Neuroscience Letters 2009; 453:
151-6.
In animal studies, acupuncture has been found to significantly
reduce anxiety-like behaviour, and increase brain levels of
neuropeptide Y, which appear to correlate with reported anxiety.
Komori M et al. Microcirculatory
responses to acupuncture stimulation
and phototherapy. Anesth Analg
2009; 108: 635-40.
Experimental study on rabbits in which acupuncture stimulation
was directly observed to increase diameter and blood flow
velocity of peripheral arterioles, enhancing local microcirculation.
Koo ST et al. Electroacupunctureinduced analgesia in a rat model of
ankle sprain pain is mediated by
spinal alpha-adrenoceptors. Embase
Pain 2008; 135: 11-9.
An animal study that investigated the underlying mechanism of
electroacupuncture (EA) analgesia, and the effects of various
antagonists on known endogenous analgesic systems in a rat
model of ankle sprain. EA significantly improved the weightbearing capacity of the affected hind limb for 2 hours, suggesting
an analgesic effect. The alpha-adrenoceptor antagonist
phentolamine completely blocked the EA-induced analgesia,
whereas naloxone failed to block the effect. Further experiments
showed that intrathecal administration of yohimbine, an alpha2-
adrenergic antagonist, reduced the EA-induced analgesia in a
dose-dependent manner, whereas terazosin, an alpha1-
adrenergic antagonist, did not produce any effect. The
researchers concluded that the results suggest EA-induced
analgesia is mediated by alpha-adrenoceptor mechanisms and,
at least in part, mediated by spinal alpha2-adrenoceptor
mechanisms.
Zhao ZQ. Neural mechanism
underlying acupuncture analgesia.
Prog Neurobiol 2008; 85: 355-75.
Review article that discusses the various peripheral and central
nervous system components of acupuncture anaesthesia in
detail.
Zhou Q et al. The effect of electroacupuncture on the imbalance
between monoamine
neurotransmitters and GABA in the
CNS of rats with chronic emotional
stress-induced anxiety. Int J Clin
Acupunct 2008;17: 79-84.
A study of the regulatory effect of electro-acupuncture on the
imbalance between monoamine neurotransmitters and GABA in
the central nervous system of rats with chronic emotional stressinduced anxiety. The levels of serotonin, noradrenaline and
dopamine fell significantly, while GABA levels were significantly
higher in the rats given acupuncture (P<0.05, or P<0.0). The
researchers concluded that the anti-anxiety effect of electroacupuncture may relate to its regulation of the imbalance of
neurotransmitters.
Kavoussi B, Ross BE. The
neuroimmune basis of antiinflammatory acupuncture. Integr
Cancer Ther 2007; 6: 251-7.
Review article that suggests the anti-inflammatory actions of
traditional and electro-acupuncture are mediated by efferent
vagus nerve activation and inflammatory macrophage
deactivation.
Han JS. Acupuncture and
endorphins. Neurosci Lett 2004; 361:
258-61.
A literature review of studies relating to the release of
endorphins by acupuncture.
Zijlstra FJ et al. Anti-inflammatory
actions of acupuncture. Mediators
Inflamm 2003; 12: 59-69.
An article that suggests a hypothesis for anti-inflammatory action
of acupuncture: Insertion of acupuncture needles initially
stimulates production of beta-endorphins, CGRP and substance
P, leading to further stimulation of cytokines and NO. While high
levels of CGRP have been shown to be pro-inflammatory, CGRP
in low concentrations exerts potent anti-inflammatory actions.
Therefore, a frequently applied 'low-dose' treatment of
acupuncture could provoke a sustained release of CGRP with
anti-inflammatory activity, without stimulation of pro-inflammatory
cells.
Wu MT et al. Central nervous
pathway for acupuncture stimulation:
localization of processing with
functional MR imaging of the brain--
preliminary experience. Radiology
1999 ; 212: 133-41.
An experimental study using MRI to characterise the central
nervous system pathway for acupuncture stimulation, which
found that acupuncture activates structures of descending
antinocioceptive pathway and deactivates areas mediating pain
modulation.
Pomeranz B. Scientific basis of
acupuncture. In: Stux G, Pomeranz
B, eds. Acupuncture Textbook and
Atlas. Heidelberg: Springer-Verlag;
1987: 1-18.
Needle activation of A delta and C afferent nerve fibres in
muscle sends signals to the spinal cord, where dynorphin and
enkephalins are released. Afferent pathways continue to the
midbrain, triggering excitatory and inhibitory mediators in the
spinal cord. Ensuing release of serotonin and norepinephrine
onto the spinal cord leads to pain transmission being inhibited
both pre- and postsynaptically in the spinothalamic tract. Finally,
these signals reach the hypothalamus and pituitary, triggering
release of adrenocorticotropic hormones and beta-endorphin.
Terms and conditions


Terms and Conditions
The use of this fact sheet is for the use of British Acupuncture Council members and is subject to the strict conditions imposed by the British Acupuncture Council details of which can be found in the members area of its’ website www.acupuncture.org.uk.

For more information about acupuncture and how it can help relieve symptoms of tennis elbow, contact Elaine Collins at 0141 585 7904 or fill in our Contact form, and we will get back to you.