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Tennis Elbow Everywhere! Dr A Breck McKay,* General Practitioner, Carina, Brisbane Introduction picondylitis, or more correctly epicondylalgia or tendinopathy, frequently presents to primary care physicians, who either manage it by evidenced-based methodology or respond as taught, by referring to rheumatologists or orthopaedic surgeons. The actual cause and pathophysiology are still controversial and the treatments are equally varied. 1, 2, 3 The conundrum is compounded by incorrect terminology, because there is no inflammation identifiable. It is considered a localized pain problem, rather than part of a whole body response to injury or potential injury. How can it be a whole body problem? Professor Ivan Pavlov identified the Orienting Response and conditioned reflexes in 1904-10, when he described the whole dog responses to combined internal and external stimuli.4 Dr Edward de Bono modelled the establishment of brain patterning as an explanation for how learning occurred with continuous modification, reinforcement, or removal of those patterns, as time and multiple inputs occurred.5 Melzack and Wall published the Gate Control Theory of Pain in Science in 1965 and the elucidation of the mechanisms detailing the neural and chemical pathways was summarised in The Lancet in 1999.6 McKay and Wall7 linked these concepts to explain how the whole human body responded as a single functional entity at all times and not as isolated systems, organs, or tissues which interrogative medicine has defined. McKay8 then modelled the whole body learning process as a continuum from birth to disability/death as parallel survival-function and pain pathways, with chaos theory assisting to explain how the whole body-brain function occurs and manages the complex inputs at conscious and sub-conscious levels. This allows total management of all afferents and efferents of the nervous/endocrine messaging system (Figure 1) with minimal conscious level consideration except for the most important inputs. Most of these cortical and sub-cor-

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tical efferents pass via the efferent vestibulo-autonomic postural control mechanism and affect not only the injured tissues (such as tendon attachments), but activate local tissue perfusion resulting in secondary swelling and further pain perception as “spreading pain” around the tendon attachment damage. Perhaps these efferent autonomic effects on the peripheral vascular systems give rise to the neovascular formation and neoneural budding as part of the body’s self repairing process, described by Alfredson et al9 and the referred autonomic controlled, peripheral vascular effects to disc injury as described by Takahashi et al.10, 11 These models might be used to demonstrate epicondylitis as part of a whole body response, via peripheral sensory-mechanoreceptor afferents, spinal motor reflexes and midbrain vestibulo-autonomic-postural efferents causing perceived local swelling, with changes in the muscular ability to respond as the negative feedback counters activity and results in crescendo epicondylar tenderness and arm/forearm system dysfunction, without inflammation. Such models may also show how many other clinical presentations involving muscle, tendon, fascia, or ligament attachments may be better considered as variations of the described

whole body function/response, and not the currently perceived series of localised responses.7 Anatomy and physiology… what really happens? The anatomy and physiology of tendons, ligaments, and muscles and their direct or indirect attachment to bones at the enthesis, or musculo-tendinous junction, are well detailed in anatomy and histology texts. Muscles, tendons, and ligaments can sustain high lengthwise loadings before they are damaged, but they are less able to tolerate rotational or cross directional strains.12 An actual tendon may rupture with little noticeable effect to the whole body, if supported by adjacent tendons and other tissues, but damage to the tendon attachment at the enthesis gives rise to considerable pain, with reflex whole body and autonomic vascular changes in the damaged attachments, which prevent further injury and initially facilitate repair. The mechanoreceptors, thermoreceptors and the nociceptors are concentrated in the musculo-tendinous junctions and in the periosteum at the enthesis. When muscles tighten under the influence of A-alpha nerve fibre activity, the entheses commence feedback cycles (via the A-delta and C fibres from mechanoreceptors and nociceptors) to prevent the muscle from 127

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pulling out of those attachments or causing further injury. This feedback or “wind up” pain6,7,13 acts on the posterior horn of the spinal cord and the afferent pathways link to the midbrain and higher centres, as well as via the direct spinal reflex pathway to the anterior horn motor cells. This results in conscious awareness of the pain, and creates autonomic efferents via the vestibulo-autonomicpostural pathways (Figure 2). The resultant vascular changes and local tissue swelling with increased pain perception at the injury site create an increasing reflex loss of function from the activation-feedback mechanisms described at the affected muscle or tissues. Ligaments across joint spaces are similarly affected when over tensioned and act by feedback to decrease any muscle activity that makes the tension worse (for example, valgus/ varus knees strain the opposite side knee ligaments, causing pain and difficulty in standing and walking). This process results in a whole body response to “epicondylitis”, which is really an epicondylalgia or enthesis dysfunction activating whole body effects and not merely localized inflammatory responses. Management needs to be directed to the mechanisms of the whole body functional response and not merely to the localised perception.7 Treatments consist of injecting local anesthetic and steroid via multiple needling of the painful area, stretching

exercises, physical therapy, or ultrasound. With the injection method, the clinically separate and combined mechanism of action of each component (needle, steroid, and local anesthetic solution) has been described by McKay previously.8 The reduced afferents to the spinal cord decrease the wind up process in the posterior horn cell layers, decreasing further afferents via the spinal pathways to the higher centres. This reduces activation of the midbrain and higher centres, and secondary efferent autonomic controls and other efferent pathway activity decreases, permitting the previous feed-back limited muscular function to restore as the tissues return to the normal state. Considering all muscle, ligament,and tendon attachments in a similar light, it is possible to extrapolate that every such tender attachment might trigger a similar wind up problem, resulting in higher centre efferents which change the local conditions with swelling and increased sensitivity. If so, then the treatment for such tender attachments might be simple tennis elbow injections to the identified enthesis or tendon attachment. These described tender points are at the entheses and are not the same as Travell and Simons Trigger Points.1 Clinical observations From the well-known classical “tennis elbow” injections coupled with the above whole-body functional analysis, the author and colleagues identified a much larger number of similar entheses and attachments and all have found that similar needling with local anesthetic/steroid injections works well. These injection and stretching protocols are known to many, and the following will not be new to some; however, the whole body explanation of what happens and why it happens may be a new concept. It may explain the whole body response to what at first appears to be a local problem. Injection sites resulting in the most spectacular results have been: 1. The coracoid process (often in conjunction with rotator cuff injections to synovial compartments); 2. Lateral processes of the cervical vertebrae at the origins of the sca-

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Tennis Elbow Everywhere! lene muscle (C 3, 4, 5, 6, 7) (Figure 3); 3. Levator scapulae insertions into the superomedial aspects of the superior angle and tip of the scapula(e) (Figure 4); 4. Attachments of the gluteus medius/ minimus to the top of the greater trochanter; 5. Medial and lateral, proximal, and distal ligaments of the knee, often on both sides (medially for valgus and laterally for varus deformity) (Figure 5); 6. Insertions of the hamstrings, both laterally and medially on the tibia, and also specifically the gracilis, sartorius and semitendinosus distal attachments to the medial aspect of the body of the tibia at the pes anserinus; 7. Ligament and tendon insertions around the ankle joints (for example, Achilles tendon, deltoid ligament, anterior talofibular, anterior inferior tibiofibular, and calcaneofibular ligaments); 8. Interspinous ligaments (ISLs) above and below the spine of any crush fracture in a vertebral body, such as occurs in osteoporosis. (The pain is not due totally to the crushed vertebral body as currently described, but is due mainly to the increased tension on the ISLs, as the spines are distracted above and below the spine of the affected vertebra. This may also explain why vertebral body cement reduces the pain of spinous distraction of the ISL). Rather than pretending to remember the anatomy, McKay examines Grant’s Atlas of Anatomy (open at the relevant pictures) with the patient to describe the injections and also to review the detailed anatomy required to be accurate with such injections. The most difficult entheses to inject are the lateral processes of the cervical spines (Figure 3), but with careful digital tip palpation lying square in the lateral position and using 25 G x 30mm needles and small volume injections (such as 0.2-0.3 ml of 0.5% lignocaine 3ml/Celestone Chronodose 1 ml), very accurate bony placement is possible. The results are most spectacular. Side effects may include a feeling of being woozy/off balance (but not vertigo per November 2005

Figure 5.

se) for perhaps 10-30 minutes after injection and occasional peripheral anesthesia along cervical dermatomes. This is uncommon with the use of small volumes of dilute injectant and repositioning the needle tip if paresthesia is elicited. Conclusions Injecting “tennis elbow” or “golfer’s elbow” (epicondylalgia) is a common general practice/primary care physician management. By understanding the anatomy, physiology, and whole body functional response7, 8 plus the mechanism of pain production and wind up,13 it is possible to use the same simple intervention at other body sites where similar “-algia” events occur. Many patients who have suffered severe musculoskeletal neck pain and migrainous headaches are often totally free after very few injections to the identified tender lateral processes and/ or the posterolateral muscle attachments of the cervical vertebra. The injections produce surprising and spectacular results. The author can attest to the simplicity and the subjective effect/ benefit having had his bilateral cervical (C4, 5, 6) vertebrae injected in October 2004. Just as any injury/nociceptive input has to be relayed through the midbrain to the cortical areas for conscious recognition, so must any resultant efferents pass through the midbrain areas and back to the periphery before any response can occur. This localizes the vestibulo-autonomic- postural mechanism at the centre of any total

body response (afferent and efferent) to any external or internal body threat, and responses rarely occur only at spinal reflex level. Ivan Pavlov identified the Orienting/ Focusing Response (1910) and the formation of conditioned reflexes in 1904, but it was the Reflex of Purpose (1916) that linked this all together. It was not until Edward de Bono described the pattern formation of brain function5 that a neuro-physiological explanation of conscious versus subconscious function was expressed fully. The advent of the fMRI and magnetoencephalogram are permitting the definition of the higher centre pathways, but the midbrain centres are too small and complex to yet be examined in such a manner. Tennis elbow or any similar strain to an enthesis or musculo-tendinous attachment can be viewed as a similar whole body response and the mechanism then becomes simplified and understood. Just as Yelland et al14 carried out double blind controlled trials of prolotherapy similar studies are needed to confirm the above observations and explanations using the Bogduk and Masters Matrix.15 Perhaps there are many other medical presentations which might be better understood and managed when considered as a whole body response, using similar simple and easier to apply protocols. Modern interrogative medicine might be missing the whole body function in many clinical presentations by con129

Tennis Elbow Everywhere! centrating on the currently interrogated detail or “wood chips” and missing the whole tree. After all, health is defined as normal. One should then ask: How is this clinical presentation different from normal? Then follow with: How can we restore health or the normal state? * mckayabATbigpond.net.au

References 1. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Part One Chapter 3: 45-102 and Part Three Chapter 33: 478. Williams & Wilkins Baltimore, 1992. 2. Wall PD, Melzack R. Tennis Elbow or Epicondylitis. In Textbook of Pain. 4th ed. Churchill Livingstone, 1999. Pp. 573, 13-92.

11. Takahashi Y et al. Neural connection between the ventral portion of the lumbar intervertebral disc and the groin skin. J Neurosurg 1996; 85(2): 323-28. 12. Wall PD, Melzack R. Ligaments and Tendons. In Textbook of Pain. 4th ed. Churchill Livingstone, 1999. Pp. 530-31. 13. The Pathophysiology of Pain. North Ryde NSW: Astra-Zeneca Pharmaceuticals Pty Ltd. 14. Yelland MJ, Glasziou PP, Bogduk N et al. Prolotherapy injections, saline and exercises for chronic low-back pain: a randomized trial. Australas Musculoskeletal Med 2004; 9(2): 80-87 (first published in Spine 2004:29(1): 9-16 ). 15. Bogduk N, Masters S. Musculoskeletal Medicine tip: The Matrix. Australas Musculoskeletal Med 2003; 8(2): 118.

3. Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine 2004; 71(5): 369-73. 4. Pavlov IP. Orienting or Focusing Response. Lectures on Conditioned Reflexes, Volume 1, Chapter XI. New York: International Publishers, 1928. Pp.133-35. 5. de Bono E. The Past Organises the Present: The Jelly Model, Short Term and Long Term Memory. The Mechanism of Mind. Simon and Schuster, 1969. Pp. 9397, 111-16. 6. The Pain Series. The Lancet 1999; 353. 7. McKay AB, Wall D. The Orienting Response and the Functional Whole Human Body. Australas Musculoskeletal Med 2003; 8(2): 86-99. 8. McKay AB. Pain and Chronic Low Back Pain: A New Model Part 1 & 2. Australas Musculoskeletal Med 2004 9(1): 14-25. 9. Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc 2003; 11(5): 334-38. 10. Takahashi Y, Hirayama J, Nakajima Y et al. Electrical stimulation of the rat lumbar spine induces reflex action potentials in the nerves to the lower abdomen. Spine 2000, 25(4): 411-17.

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